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The Stressor Criterion in PTSD: Notes on the Genealogy of a Problematic Construct

Authors:

Abstract

After a brief historical overview of the genealogy of the stressor criterion in the Diagnostic and Statistical Manual (DSM), a clinical example is drawn upon to indicate that there is evidence suggesting that low-magnitude stressors are also capable of producing PTSD symptoms. The diathesis-stress model and the kindling model are discussed as providing possible explanations for this.
The Stressor Criterion in PTSD: Notes on
the Genealogy of a Problematic Construct
GUNTER H. SEIDLER, Privatdozent Dr. Med*#
FRANK E. WAGNER, Ph.D.**
After a brief
historical
overview of the genealogy of the stressor criterion in
the Diagnostic and Statistical Manual (DSM), a clinical example is drawn
upon to indicate that there is evidence suggesting that low-magnitude
stressors
are also
capable
of producing PTSD symptoms. The diathesis-stress
model and the kindling model are discussed as providing possible explana-
tions for this.
INTRODUCTION
Posttraumatic stress disorder (PTSD) was first included in the third
edition of the Diagnostic and Statistical Manual of Mental
Disorders
(DSM-
III) (American Psychiatric Association, 1980) as "posttraumatic stress
disorder, acute" (308.30) and "posttraumatic stress disorder, chronic or
delayed" (309.81). These definitions described the symptoms frequently
occurring after experience of an extremely stressful event. At present
PTSD is one of the few psychiatric diagnostic categories in the DSM that
traces the etiology of a symptom or set of symptoms back to a preceding
event. The necessary condition for PTSD diagnosis is "exposure to an
extreme traumatic stressor" (DSM-IV, 309.81 [American Psychiatric As-
sociation, 1994]). However, as things stand, there are no established norms
or standards for making a distinction between an event that represents an
extremely traumatic stressor and one that does. Naturally, if an event is not
classified as traumatic in accordance with the DSM, then by definition, the
diagnosis of PTSD is ruled out. The question here is whether there may be
events that, in isolated cases, lead to PTSD although they do not qualify as
stressors on the basis of the DSM-IV definition. In fact, there are indica-
tions that low-magnitude stressors, defying accurate classification in terms
*Director of the Psychotraumatology Department, Psychosomatics Division, Hospital for Psycho-
somatic and General Clinical Medicine; **Hospital for Psychosomatic and General Clinical Medicine.
Mailing address: #ThibautstraBe 2, D-69115 Heidelberg, Germany, e-mail: guenter_seidler@
med.uni-heidelberg.de or guenter.seidler@urz.uni-heidelberg.de
AMERICAN JOURNAL OF PSYCHOTHERAPY, Vol. 60, No. 3,
2006
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AMERICAN JOURNAL OF PSYCHOTHERAPY
of the DSM, can indeed produce PTSD symptoms (Spitzer, Abraham,
Reschke, Michels, Siebel, and Freiberger, 2000). Bryant (1996) reports on
a lawsuit in which the plaintiff claimed to be suffering from the symptoms
of PTSD because of his exposure to nuclear tests taking place in Mara-
lingua in the 1950s. As the author indicates, it would, on the one hand, be
possible to argue that a nuclear test does not represent a stressor of
adequate magnitude because (a) it is foreseeable and (b) precautions
would be taken to ensure that no safety hazards would ensue. On the other
hand, one might argue equally well that observation of the devastation
caused by the nuclear blast and knowledge of the radioactive fallout
produced by it do, in fact, represent subjective threats to a person's safety,
and thus the test can legitimately be classified as a stressor. Bryant
concludes that if PTSD is to be diagnosed as the outcome of an event,
there is a need to clarify the conditions determining the connection
between an event and the harm done to a person. Ultimately, the difficul-
ties lie in defining what constitutes a traumatic event for a given individual
and in establishing the line of demarcation between such an event and a
non-traumatic stressor (see also Dobson and Marshall, 1996).
In the next section we provide a brief overview of the development of
the event criterion (A-criterion) in PTSD from DSM-III to DSM-IV, and
we discuss the problems the criterion poses with reference to a clinical
example. Subsequently, we discuss factors that explain why PTSD can be
triggered by low-magnitude stressors, without the involvement of an
extreme stressor.
BRIEF HISTORICAL OVERVIEW OF THE GENEALOGY OF THE
A CRITERION IN THE DSM
For a comprehensive overview of the historical development of the
PTSD construct, we refer the interested reader to the article by Wilson
(1995).
According to DSM-III (1980), a qualifying stressor was one "that
would evoke significant symptoms of distress in almost everyone." (p. 238).
In terms of its operationalization potential this definition was extremely
vague, and significant diagnostic problems ensued in clinical practice.
In the DSM-III-R (American Psychiatric Association, 1987, 309.89) an
attempt was made to specify the stressor criterion more precisely. The
event in question must be one
. . .that is outside the range of usual human experience and that would be
markedly distressing to almost anyone, e.g. serious threat to one's life or
physical integrity; serious threat or harm to one's children, spouse, or other
close relatives and friends; sudden destruction of one's home or commu-
262
The Stressor Criterion in PTSD
nity; or seeing another person who has recently been, or is being, seriously
injured or killed as the result of an accident or physical violence.
The intention behind this definition was to indicate that the event must
be outside the range of "ordinary" stress, occupying an extreme position
on the stress continuum. The more stressful and threatening the event, the
greater the likelihood that PTSD would ensue. It was left to the clinician
to decide whether an event was one that would be experienced by "almost
anyone" as extremely distressing. It is hardly surprising that clinicians
frequently came to different conclusions on this point. Although DSM-III
and DSM-III-R attempt to provide an objective stressor definition, the
clinical verdict was the result of the clinician's subjective assessment of
what he/she considered to be the objective features displayed by the
stressor.
The DSM-IV (APA, 1994) stressor definition differs markedly from
earlier definitions. The focus shifts from an objective traumatic event to the
subjective response of the person affected. The A-criterion was divided
into an objective part, describing the traumatic event and a subjective part,
chronicling the individual's response to that event. The response of the
individual was taken to be the expression of the significance accorded to
the event, i.e. the perception of the event as a threat to life and limb.
Accordingly, the DSM-IV stipulates that the following criteria must be
fulfilled for the diagnosis of PTSD:
"(1) the person experienced, witnessed, or
was
confronted with an event or
events that involved actual or threatened death or serious injury, or a threat
to the physical integrity of self or
others;
(2) the person's response involved
intense fear, helplessness, or horror" (pp. 427-428).
But more than the mere addition of a criterion (the A2-criterion)
pertaining to the individual's response, the former event criterion (now the
Al-criterion) is expanded with a view to covering a broader range of
traumatic events. Events affecting other persons (death, injury, threat)
were classed as potentially traumatic events; in earlier DSM versions these
had not been deemed sufficient to warrant a PTSD diagnosis. In a
retrospective study, Breslau and Kessler (2001) investigated this two-part
criterion using a major representative sample. The Al-criterion was op-
erationalized to include 19 representative traumatic events, five of which
were added as the result of the extension of the stressor criterion and
included learning about traumatic events to a close relative or friend as
well as learning about the sudden death of a loved one. On average, each
person in the sample reported 4.3 traumatic events, 1.6 of which referred
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AMERICAN JOURNAL OF PSYCHOTHERAPY
to events that were newly included in DSM-IV. This suggests that the
population's total life experience that can be used to diagnose PTSD has
increased materially by 59%. Although the addition of the A2-criterion
had a restrictive effect, the net effect of the extension of the stressor
component (Al) plus the newly introduced subjective component (A2),
amounted to over 20% increase in comparison with the total number of
qualifying events listed in DSM-III-R. In other words, the extension of the
stressor category in DSM-IV caused an increase of over 20% in the
number of traumatic events acknowledged as liable to trigger PTSD. Of all
the PTSD cases, 38% were attributable to the five new event types
included in DSM-IV, with most PTSD caused by the death of a friend or
close relative. However, the newly included traumatic events were less
likely to cause PTSD than the narrower list of stressors in previous DSM
editions. Also, the duration of PTSD triggered by these newly included
events was shorter than that caused by the events experienced personally.
In a longitudinal study, Brewin, Andrews, and Rose (2000) undertook
an investigation of the A2-criterion. In this study, the majority of the
individuals in the test group who developed PTSD symptoms after an
event involving violence responded that they had experienced at least one
trauma-related emotion specific to the A2-criterion (89%). The responses
"fear" and "helplessness" were more frequent than "horror." The authors
note that while the A2-criterion applied to most of the victims of violence
who developed PTSD symptoms, a small number of individuals displayed
no intense emotions during the trauma and thus did not fulfill the
A2-criterion. Accordingly, these persons did not meet the terms of
DSM-IV definition for PTSD, whereas they did qualify in terms both of
DSM-III-R and of International Statistical Classification of Disease and
Related Health Problems 10 (ICD-10, F43.0, World Health Organization,
1992).
In contrast to the DSM-IV, ICD-10 takes its bearings from the
DSM-III-R, defining PTSD as "a delayed and/or protracted response to a
stressful event or situation (either short or long-lasting) of an exceptionally
threatening or catastrophic nature which is likely to cause pervasive
distress in almost anyone." The issue of the discrepancy between DSM-IV
and ICD-10 in the diagnosis of PTSD is addressed in detail in the studies
by Andrews and Slade (2002), Andrews, Slade, and Peters (1999), and
Peters, Slade, and Andrews (1999).
With regard to the Al-criterion, it is certainly true that many traumatic
events that would not have qualified for inclusion in the DSM-III-R can be
classified as such with reference to DSM-IV. Despite the extension in the
range of potential traumatic events, the question still remains whether
264
The Stressor Criterion in PTSD
there may be other events that can also trigger PTSD, although they fail to
fulfill the Al-criterion established in DSM-IV. This issue is also important
in connection with the calculation of event prevalence rates. The more
potential stressor events there are, the higher the prevalence of PTSD will
supposedly be in the population as a whole. Breslau et al. (2002, p. 9^)
refer to a number of earlier studies reporting a lifetime prevalence rate of
40%-60%
regarding the confrontation with a traumatic event, whereas a
more recent study based on the DSM-IV stressor definition identified a
lifetime prevalence of 90% (Breslau et al., 1998). Accordingly, in the
course of their lives the majority of people are confronted with at least one
event that can be classified as "traumatic" on the basis of DSM-IV.
CLINICAL CASE DESCRIPTION
It is, however, evident that events not classifiable as traumatic in the
sense of the DSM-IV can still evoke PTSD symptoms. In the following we
discuss this problem using an example from our clinical practice.
A young woman (28 years old) turned to the outpatient section of our
psychotraumatology department for advice and assistance. She is em-
ployed for the municipal office for public order, where she has been
entrusted with the task of ensuring that cyclists do not ride their bicycles
through the pedestrian zones in the city. While she was on the job, a
cyclist, approaching from behind her, dealt her a light blow to the head
with his fist.
The patient presented with no neurological symptoms (nor any symp-
tom that could be described in neurological terms); there was no indication
of concussion. However, when she came to us five weeks after the event,
she displayed all the symptoms of PTSD (re-experiencing the trauma in
thoughts and feelings, avoidance of stimuli that aroused recollections of
the trauma, symptoms of hyperarousal). The diagnosis was made first
clinically, then was fuUy substantiated using self-rating measures. The
following instruments were used: Impact of Event Scale (revised) (IES-R;
Weiss & Marmar, 1997; German version by Maercker & Schiitzwohl,
1998),
the Fragebogen zu dissoziativen Symptomen [Questionnaire on
Dissociative Symptoms] (FDS; Freyberger, Spitzer, & Stieglitz, 1999); the
German version of the Peritraumatic Dissociative Experiences Question-
naire (PDEQ; Marmar, Weiss, & Metzler, 1997); the Symptom Checklist
(SCL-90-R; Derogatis, 1977; German version by Franke, 1995); and the
Posttraumatic Diagnostic Scale
(PDS-d-1;
Ehlers, Steil, Winter, & Foa,
1996),
including its modified form for the second measurement timepoint,
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AMERICAN JOURNAL OF PSYCHOTHERAPY
the Posttraumatic Diagnostic Scale (In-Course) (PDS-d-2) (Ehlers, Steil,
Winter, & Foa, 1996).
The anamnestic exploration revealed that the patient was born before
her parents married. They married after the birth of a second little girl.
When the patient was five years old, her mother was diagnosed as
schizophrenic, while her father developed alcoholism. The patient's par-
ents divorced when she was ten. It was around this time that the patient's
mother inflicted life-threatening knife injuries on her father's new partner.
Although the patient did not witness this event, she constantly suffered
from her mother's unpredictability, mood-swings, arbitrary impulses, and
bouts of physical and verbal aggression.
When the patient was 17 years of age, she became pregnant from a
drug-dependent partner. She reported that this partner "kicked the baby
out of her belly" in the fourth month of pregnancy, after which she and her
partner separated. Two years later, the patient again became pregnant and
had another miscarriage, again in the fourth month of the pregnancy.
During this period, the young woman the woman attended evening
classes and graduated from high school. After graduation she began
training to become an interpreter. During a holiday in England, she was in
a car accident, suffering multiple pelvic and femoral fractures. Subsequent
financial problems forced her to terminate her training. She then applied
for a post with the municipal office for public order in her native city, and
she was employed. It was in the exercise of her duties that the traumatic
event occurred.
DISCUSSION
In this case, the diagnosis of a posttraumatic stress disorder would only
be justifiable if one is prepared to make a number of concessions with
regard to the event criterion as stipulated both by ICD-10 and by DSM-IV.
In the latter case the concessions would apply both to the Al- and the
A2-criteria. In affective terms the patient had merely responded to her
condition with annoyance, saying: "I don't understand why I can't come to
terms with this, much worse things have happened to me in the past!"
Thus,
we noted that there had been a series of events in her life, at least
two of which fulfilled the Al- and A2-criteria for PTSD as set out in
DSM-IV. However, there had not been a manifestation of posttraumatic
stress disorder subsequent to those events. Our investigation produced no
indications of a marked dissociative propensity on the patient's part
(although we must bear in mind the problems involved in retrospective
data collection). However, it appeared as if the event in the pedestrian
266
The Stressor Criterion in PTSD
zone sufficed to trigger PTSD. It seems that sometimes several factors can
add up and one of these becomes "just the last straw." A relatively minor
incident may trigger memories from previous traumas (domestic violence
episodes, in this case). It became apparent that in diagnosing PTSD, a
cross-sectional approach is not sufficient and needs to be complemented
by a longitudinal approach (stress events, traumatic events, etc.).
THE STRESS-DIATHESIS MODEL AND THE "KINDLING"
PHENOMENON
The fact is, only a small percentage of people exposed to traumatic
events subsequently develop PTSD. In the last few years scientists have
attempted to identify factors with special significance for the development
of PTSD. Central to this research is the identification of predictors.
Alongside event factors associated with the trauma, protective factors and
risk factors are regarded as possible predictors for development of a
posttraumatic disorder. These include the psychiatric history of the indi-
vidual and his/her family, genetic factors, family members with PTSD, or
some other anxiety disorder, early traumatization, social environment,
gender, and personality factors. The question of whether an event will lead
to PTSD cannot be regarded independent of these factors.
This research on predictors relates to PTSD in its present, conceptu-
alized form, i.e. including the current definition of the A-criterion. The
statement we are making in this article is that PTSD can develop even if the
A-criterion is not fulfilled. It is worth noting that a change in the
conceptualization of the criterion would merely shift the predictor issue to
a different plane.
For all that, a combination of the predictor issue with a critical
discussion of the A-criterion definition does appear plausible. It involves
the conceptualization of a dialectical relationship between the event
criterion and existing psychological features of the individuals affected.
Harvey and Yehuda (1999) discuss stress-diathesis models of PTSD.
Such models draw upon the notion of diathesis, or a specific "vulnerabil-
ity," in an attempt to explain the development of different mental disor-
ders in different people exposed to the same stressors. The assumption
underlying these models is that vulnerability (as a disposition or weakness
caused by a variety of factors) and the effect of stressors complement one
another in causing a disorder to manifest. Accordingly, a disorder is the
result of the interaction between dispositional and environmental factors.
Seen thus, neither a traumatic event in itself nor the existence of risk
factors is sufficient in triggering PTSD. Basing the development of PTSD
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AMERICAN JOURNAL OF PSYCHOTHERAPY
on a stress-diathesis model, it is conceivable that, in the case of a highJy
vuhierable person, so-called Jow-magnitude stressors can indeed Jead to
the development of PTSD sytnptoms. This means that in vuInerabJe
persons the threshold for the development of PTSD is lower than in other
individuaJs.
RecentJy, the "Jcindling" phenomenon has also been discussed as a
further explanation for the deveJopment of PTSD. The term "JiindJing" is
a metaphor for this process. Setting fire to a Jog with one match is a
difficult undertaking, but if the log is surrounded by small pieces_ of
brushwood it will catch fire much more readily. Kindling was first de-
scribed by Goddard, Mclntyre, and Leech (1969). To study learning
behavior in rats, the researchers subjected the brains of a number of these
rodents to electric stimulation. In
itseJf,
the stimulation was much too
slight to cause a seizure. But after the rats had been treated with this
Jow-JeveJ electric stimulation over a period of weeks, seizures did occur
spontaneously. Obviously, the brains of these rats had been sensitized to
the stimulus. Even after a period of months without any further stimula-
tion, one of the rats had seizures after reintroduction of stimulation of the
same kind. Goddard et aJ. (1969) appJied this model to the origination of
epileptic seizures and established that repeated, low-level electric stimu-
lation can lead to a distinctive cerebral seizure. After a number of
repetitions of the electrical impulses, seizures began to spontaneously
manifest. Alongside electric kindling, chemical kindling can also lead to
seizures and bebavior changes, notably after stimulation with cocaine and
amphetamines (Post & Kopanda, 1976).
Post, Ballenger, Rey, and Burney (1981) proposed the application of
the kindling model to affective disorders. They described a stress-diatbesis
model in which certain life events, after one or more episodes of such a
disorder, would exert an increasing influence in the limbic system and
make way for new episodes. By applying this model to PTSD, it is
conceivable that an event that does not fulfill the A-criterion might kindle
limbic nuclei leading to some of the behavioural changes seen in the
disorder, provided numerous other stress situations that had sensitized the
system. What we bave here is a progressive vulnerability of tbe brain. In
tbe further course of events, stressors of an increasingly low magnitude
suffice to trigger tbe corresponding symptoms. In psycbobiological terms,
kindling can be explained as follows: a stressor leads to an increase in the
hypothalamic peptide hormone CRH (corticotropin-releasing hormone),
which directly stimulates noradrenergic neurons in the locus ceruleus.
This,
in turn, leads to increased sensitivity in the limbic nuclei. In this way
268
The Stressor Criterion in PTSD
repeated stress episodes can "kindle" limbic nuclei and sensitize them to
new stressors (see Hageman, Andersen, & Jorgensen, 2001, p. 415).
CONCLUSION
Thus the stress-diathesis model gravitates around a discrepancy be-
tween "threatening situation factors and individual ability to come to terms
with them," without enlarging on the causes for inadequate coping poten-
tial vis-a-vis a given event, while the kindling model is based on the
cumulative effect of low-magnitude stress events. The first of these models
is relational, dynamic, and also dialectical, which in our view increases its
appeal, as long as "event" is understood as a factor in a process that cannot
be described without reference to that process. The second model is more
static and positivist (because it postulates the reality of "events" as entities
in themselves), but it has the advantage of being easier to operationalize.
The stress-diathesis model can provide a plausible explanation to why one
person is more likely to develop PTSD than another; the kindling model
can tell us why, say, the sixth (possibly low-magnitude) event in a series has
triggered PTSD, whereas the earlier events in the same series have not.
Against the background of these explanatory models, it is readily
conceivable that low-magnitude stressors that do not qualify for inclusion
in DSM-IV (such as mobbing at work or the sudden loss of one's job) may
trigger a posttraumatic stress disorder in an individual with a history of
prior traumatization. This may be true even if these low-level stressors are
compounded with a further stressful even that might in itself be classified
as low-magnitude.
Acknowledgment: The research on which this article is based was supported by the Hopp
Foundation (Heidelberg, Germany).
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... It is also possible that there are historical factors that should be considered in terms of these losses. As noted, Yellow Horse Brave Heart (2003) Alternatively, these results may support a diathesis-stress model of PTSD (McKeever & Huff, 2003;Seidler & Wagner, 2006. The diathesis stress model proposes that there are risk factors associated with the development of PTSD symptoms. ...
... The diathesis stress model proposes that there are risk factors associated with the development of PTSD symptoms. These factors include psychiatric history of the family, genetics, environment, gender, as well as personality factors (Layne et al., 2008;McKeever & Huff, 2003;Seidler & Wagner, 2006). As noted previously, the historical experience of American Indians has been referred to as genocide (Cohen, Dekel, Solomon, & Lavie, 2003;Dasberg, 2001;La American Indian adolescents 54 Capra, 1994;Yellow Horse Brave Heart & DeBruyn, 1998), and it is plausible that through these past experiences, there were individuals who developed PTSD. ...
... As noted previously, the historical experience of American Indians has been referred to as genocide (Cohen, Dekel, Solomon, & Lavie, 2003;Dasberg, 2001;La American Indian adolescents 54 Capra, 1994;Yellow Horse Brave Heart & DeBruyn, 1998), and it is plausible that through these past experiences, there were individuals who developed PTSD. In the diathesis-stress model this may put immediate and extended family members at risk of pathology, even cross generationally (Layne et al., 2008;McKeever & Huff, 2003;Seidler & Wagner, 2006). The historical experiences may have created a predisposition to PTSD, and the current losses may serve as a trigger to the development of PTSD symptoms. ...
... A number of cases have been reported whereby PTSD symptoms have been experienced as a result of traditionally defined ''non-traumatic'' or ''life events.'' For example, in response to miscarriage, spousal affair (Helzer, Robins, & McEvoy, 1987), marital disruption and collapse of adoption arrangements (Burstein, 1985), non-serious nor lifethreatening physical assault (Seidler & Wagner, 2006), work-related stressors, caring for a chronically ill loved one (Scott & Stradling, 1994), and loss of cattle due to foot and mouth disease (Olff, Koeter, Van Haaften, Kersten, & Gersons, 2005). ...
Article
Considerable controversy exists with regard to the interpretation and definition of the stressor “A1” criterion for Post Traumatic Stress Disorder (PTSD). At present, classifying an event as either traumatic (satisfying DSM-IV Criterion-A1 for PTSD), or non-traumatic (life event) is determined by the rater's subjective interpretation of the diagnostic criteria. This has implications in research and clinical practice. Utilizing a sample of 860 Australian adults, this study is the first to provide a detailed examination of the impact of event categorization on the prevalence of trauma and PTSD. Overall, events classified as non-traumatic were associated with higher rates of PTSD. Unanimous agreement between raters occurred for 683 (79.4%) events. As predicted, the categorization method employed (single rater, multiple rater-majority, multiple rater-unanimous) substantially altered the prevalence of Criterion-A1 events and PTSD, raising doubts about the functionality of PTSD diagnostic criteria. Factors impacting on the categorization process and suggestions for minimizing discrepancies in future research are discussed.
... Also, the BTQ measures how many different types of event one has experienced, but not the total number of traumatic events experienced. Some have suggested a kindling effect exists in which experiencing prior trauma increases the impact of each additional trauma (Seidler & Wagner, 2006). It is certainly possible that having experienced multiple events (particularly the same event repeatedly) could increase the centrality of the event and change one's schemas about the self and world in dramatic ways. ...
Article
Ehlers and Clark (2000) developed a cognitive model of posttraumatic stress disorder (PTSD) symptom maintenance which implicated the role of posttraumatic cognitions and aspects of the trauma memory in maintaining symptoms via an increased sense of current threat. The aim of the current study was to empirically test a variant of this model using path analysis. Participants in the current study were 514 undergraduates at a midwestern university who reported experiencing at least one traumatic event. Path analyses examined various models of the possible relationships between one's posttraumatic cognitions and the centrality of the traumatic event to the sense of self (considered an aspect of memory integration) in predicting current level of PTSD symptoms. Results indicate that both event centrality and posttraumatic cognitions are unique and independent predictors of current symptom level. Overall, the results of this study support aspects of Ehlers and Clark's cognitive model of PTSD; cognitive appraisals of the self and centrality of the event were highly related to levels of distress. However, the current study suggests that overly integrated trauma memories may lead to greater distress and not poorly integrated ones as suggested by Ehlers and Clark.
... It is well known that psychological stress plays an important role in the development of various psychopathologies, including post-traumatic stress disorder, depression, and anxiety (Blake, 2001;McFarlane et al., 2005;Seidler and Wagner, 2006;Shields, 2006). For over a decade now, research has employed challenge tests in order to assess reactive endogenous activity of the hypothalamic-pituitaryadrenal (HPA) axis in order to delineate reactivity to stress in humans. ...
Article
The present study assessed the modulating effect of education level on cortisol reactivity to the Trier Social Stress Test (TSST) in a sample of 101 middle-aged adults (22 males, 79 females) between the ages of 50 and 65. The TSST involves a public speech and mental arithmetic task in front of an audience. No previous studies have assessed whether education level can have an impact on cortisol reactivity to this psychosocial stressor. It is plausible that greater exposure to academia may impact how one perceives and responds to the demands of the speech and arithmetic task. Should education have an impact on cortisol reactivity to the TSST, future studies will be required to control for this factor in order to reduce both statistical error and false interpretations. In addition to completing the TSST, participants were administered a battery of neurocognitive tests and personality questionnaires, including a report on education level (i.e. number of years total and degree: High School, Junior College, Technical, University). Results showed that adults with post-secondary education above Junior College tended to secrete higher cortisol levels overall, as measured by total area under the curve. However, it was the group with lower educational attainment who showed a greater stress response specific to the TSST, as measured by percentage increase in cortisol from pre- to post-TSST. Analyses also found that higher educated adults performed better than their less educated peers on verbal fluency. Considering that the TSST is an oral task, it is suggested that middle-aged individuals with a lower level of education may find the TSST more stressful due to lower verbal capacity, which may lead to an increased cortisol response to the TSST when compared to individuals with a higher level of education.
Article
Traumatic life events can result in severe psychiatric conditions among which posttraumatic stress disorder (PTSD) is the most prevalent. Due to high comorbidity with other psychiatric diagnoses, PTSD treatment is challenging. In older adults, the presentation of PTSD symptoms is especially complicated because of even higher comorbidity, higher rates with other mental disorders, and cognitive and somatic conditions. Eye movement desensitization and reprocessing (EMDR) is an evidence-based treatment for trauma in younger adults. There is limited empirical research on the treatment effects of EMDR in older adults. Moreover, the impact of successful EMDR treatment on the comorbid disorders, especially personality and cognitive dysfunctions, is unclear. In this case report, EMDR treatment effects for late-onset PTSD with comorbid borderline and avoidant personality disorders, as well as cognitive disorders and multiple somatic problems, will be presented in an older woman.
Article
Introduction There has been a tendency in the more recent revisions of the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association (APA) and in studies of posttraumatic stress disorder (PTSD) to expand somewhat haphazardly the DSM-III formulation of Criterion A traumatic events. This formulation has evolved from events that are “outside the range of usual human experience” and that “would evoke symptoms in almost everyone” (APA 1980, p. 236), to a much wider range and variety of stressful events that many of us experience at one time or another, such as learning about the unexpected death of a loved one (APA 1994). The purpose of this chapter is to set forth how the field might develop a more rigorous Criterion A definition. Background During World War II, a view developed that psychological symptoms related to combat experiences were normal responses to abnormal situations and were transient unless treated in ways that increased secondary gain (e.g., Wessely 2005). A separate diagnostic category was created for these situationally specific phenomena, and combat-related psychopathology was included in gross stress reaction under transient situational personality disturbance in DSM-I (APA 1952).
Article
Criterion AThe Evolution of Criterion ADSM-IIIDSM-III-RDSM-IVContentious Aspects of Criterion AUnderstanding Why PTSD Symptoms May Occur After Non Criterion a EventsImplications for the ClinicianConclusion
Article
Female-identified transgender youth (FIT youth) have a male birth sex but identify as female, placing them outside of socially acceptable standards and increasing the challenges of adolescence. They face numerous potential sources of stress and have a higher likelihood of experiencing negative mental health outcomes due to lack of support, lack of perceived safety, and limited access to resources and like peers. Fortunately, there are protective factors and intervention strategies that help buffer against negative mental health outcomes. Intervention is encouraged to build on these factors and is likely to be most effective when applied at the individual, family, and school levels.
Article
High-magnitude stressors and posttraumatic stress disorder (PTSD) are frequently in psychiatric patients. In contrast, the role of low-magnitude stressors has rarely been studied. We assessed a consecutive series of 78 psychiatric inpatients taking part in our psychotherapy programme for potentially traumatic events and PTSD with a structured interview. All participants completed self-report questionnaires on PTSD-symptomatology, dissociative and general psychopathology (DES, SCL-90). A distressing event was reported by 48 patients (61.5%) and 27 (34.6%) met the diagnostic criteria for PTSD. Of these, 16 reported a low-magnitude stressor, while 11 had experienced a high-magnitude stressor. There were no significant differences in PTSD symptoms, dissociative and general psychopathology between patients with PTSD due to a minor trauma and those with a major trauma. Our preliminary findings suggest that low-magnitude stressors can also lead to PTSD. We discuss the possible implications with regard to psychotherapy. Copyright © 2000 John Wiley & Sons, Ltd.
Article
Bryant (1996) outlined a recent Federal Court case where an applicant claimed to be suffering from posttraumatic stress disorder (PTSD) following exposure to atomic testing in Maralinga. In his paper, Bryant (1996) discusses the legal definition of a stressor, highlighting the ambiguity which remains in the DSM-IV definition of the stressor criterion (American Psychiatric Association, 1994). In this comment, our aim is not to question Bryant's argument concerning the ambiguity of the stressor criterion, but to question the view that there might be some way of objectifying the definition of a stressor in the diagnosis of PTSD, thereby standardising the diagnosis. Our perspective on the PTSD diagnosis is necessarily biased by our experience as clinicians and researchers in the field of war-related trauma. Although PTSD has been conceptualised as an anxiety reaction that follows in the wake of exposure to an extreme event, there may not be a discrete class of stressors that cause PTSD. In supporting this view, we argue that the etiology of PTSD is multidimensional. It follows that PTSD cannot be understood in terms of a cause-effect type relationship between the stressor and symptoms, as is required for the assessment of compensation/litigation claims in the courtroom setting.
Article
Post-traumatic Stress Disorder (PTSD) is a psychiatric diagnosis that links a stressor to an anxiety reaction. It is increasingly the subject of compensation claims in Australian courts. A recent Federal Court decision ruled against an applicant's claim for PTSD arising from exposure to atomic testing in Maralinga in 1957. The legal definition of stressor is discussed in the context of this case and of recent developments in diagnostic criteria of PTSD. Forensic psychologists need to be aware that ambiguities still exist in the definition of stressor, and that a legal definition has yet to be stipulated in Australian courts.