Trauma-Related Disorders and Recommended Treatment Clinical Presentation of Trauma-Related Disorders and Recommended Treatments

On January 13, 2015, Andrew Brannan, a 66-year-old Vietnam veteran was executed in Georgia for killing police officer Kyle Dinkheller in 1998 (Hoffman, 2015). At the time, Brannan had been living in a bunker on his mother's property without water or electricity and had stopped taking his medications. According to the Veterans Administration (VA), he was 100% disabled due to combat-related post-traumatic stress disorder (PTSD). He also suffered from bipolar disorder, had lost two brothers to a military plane crash and suicide, and lost a father to cancer. Veterans groups, death penalty critics, and mental health advocates, all petitioned the Georgia Supreme Court for a stay of execution unsuccessfully. The veterans groups were particularly interested in preventing the death of yet another veteran who developed severe psychiatric problems while serving his or her country.

Trauma in general has affected a substantial portion of the estimated 2.6 million military personnel who have served in Iraq and Afghanistan (Ruiz, 2013). Over a million have suffered non-lethal injuries and approximately one sixth will receive a diagnosis of PTSD (Dursa, Reinhard, Barth, & Schneiderman, 2014). These figures should not be surprising given that 60 to 90% of all service members who have served in Afghanistan and Iraq have been ambushed, shot at, survived rocket or mortar attacks, or know someone who was killed or seriously injured in combat (VAHC, 2014). An unknown number have also been exposed to sexual harassment and assault.

Even if combat exposure is excluded, the American public is no stranger to trauma. As Jones and Cureton (2014) point out, close to 80% of all individuals seeking mental health services in the U.S. have suffered a traumatic event. From their perspective, trauma exposure has reached epidemic levels as the United States entered the first part of the 21st century. Among the most common sources of trauma exposure is school and community violence. Jones and Cureton (2014) also argue that trauma-induced mental health problems are among the most controversial diagnostically, second only to dissociative identity disorder. This is reflected in the substantial changes that have been made to the diagnostic boundaries, symptoms, assumptions, and clinical utility associated with a diagnosis of PTSD in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM). To better understand how trauma affects mental health, recent research publications and expert opinions concerning the epidemiology, etiology, diagnosis, and treatment of PTSD, and its related disorders, will be critically reviewed here.

Trauma Epidemiology

Recent estimates suggest the prevalence of PTSD among past and current service members who saw combat in Afghanistan and Iraq is approximately 15.7%, compared to 10.9% among service members never exposed to combat (Dursa et al., 2014). By comparison, the 12-month prevalence for PTSD was 1.8 and 5.2% among civilian adult men and women, respectively; whereas, the lifetime prevalence of PTSD among adult men and women is 3.6 and 9.7%, respectively (Gradus, 2014). These rates have been stable since the early 90s, but based on these statistics, simply serving in the military without combat exposure increases the risk of developing PTSD substantially.

PTSD prevalence rates, however, tends to hide important considerations from a clinical perspective. According to a recent study, American civilians least likely to seek mental health services for trauma in Southern California are male, African-American, poor, and lack mental health literacy (Ghafoori, Barragan, & Palinkas, 2014). More troubling was the finding that the higher the number of trauma exposures the less likely mental health services will be accessed. The most common traumatic events reported included physical assault and abuse, mugging, robbery, being threatened with a weapon, or being involved in a life-threatening accident. Interestingly, study participants with a history of sexual assault were more likely to have sought mental health services. In terms of mental disorder diagnosis, between 40 and 50% of study participants met the criteria for PTSD, generalized anxiety disorder (GAD), and/or depression. Reported symptoms included emotional pain, avoidance, irritability, sadness, anxiety, hopelessness, and depression. The psychosocial effects included unemployment, economic stress, and social...

Among the reasons given for not seeking treatment was anxiety over unwanted side effects of medication and having to revisit the traumatic event(s).
Etiology and Diagnosis

Trauma- and stressor-related disorders is an umbrella classification for any psychological disorder where a diagnosis requires trauma exposure or severe stress as part of the etiology (APA, 2013, p. 265). This includes PTSD, acute stress disorder, reactive attachment disorder, disinhibited social engagement disorder, and adjustment disorders. Individuals can react to traumatic or extremely stressful events in a variety of ways, besides clinically severe anxiety or fear, such as anhedonia, dysphoria, anger, aggression, and/or dissociation. The current PTSD diagnostic criteria for anyone over the age of 6 includes direct or secondhand exposure to a traumatic event, avoidance behaviors, negative affect and behaviors, sleep problems, impaired social or occupational functioning, and/or intrusive memories, dreams, somatic reactions, or reliving of the event (APA, 2013, pp. 271-280). Secondhand exposure for anyone over the age of 6 is limited to witnessing an unnatural or threatened death, serious injury, medical catastrophe, war, disasters, or sexual assault involving another person, or learning of a close family member or friend experiencing unnatural death, serious injury, sexual assault, disaster, or suicide. Exposure to trauma through news and electronic media is excluded diagnostically, unless the exposure is required by work-related obligations. When a child 6-years of age or younger is exposed to trauma indirectly the person traumatized must be a caregiver to meet PTSD diagnostic criteria. A diagnosis of PTSD is appropriate when symptoms last for more than a month and cannot be attributed to a medical condition or pharmacological agents (APA, 2013, pp. 271-280). A PTSD diagnosis may earn a qualifier if manifestation of symptoms is delayed for months or accompanied by dissociative symptoms.

The traumas experienced directly that can trigger PTSD symptoms include combat, actual or threatened physical assault, actual or threatened sexual violence, kidnapping/hostage/prisoner of war, torture, severe automotive accident, or exposure to a terrorist attack, natural disaster, or man-made disaster (APA, 2013, p. 274). More specifically, diagnostically-relevant traumas include criminal victimization, rape, abusive sexual contact, sexual harassment, sexual trafficking, and experiencing sudden, catastrophic medical events, such as waking during surgery or anaphylactic shock. In children, merely experiencing developmentally-inappropriate sexual events in the absence of violence or injury can elicit clinically-relevant symptoms. When the trauma is inflicted intentionally by another person the symptoms are often severe and long-lasting. Obvious examples if the intentional infliction of trauma would be torture and sexual assault.

PTSD Clinical Presentation

The traumatic events that can lead to a diagnosis of PTSD are quite diverse, as are the diversity of clinical presentations. Among the most prominent features are intrusive memories, dreams, somatic symptoms, and flashbacks (APA, 2013, pp. 275-276). During flashbacks, a person may enter a limited or complete dissociative state, lasting from a few seconds to days, and engage in behaviors more appropriate for the relived event. Unfortunately, flashbacks can be nearly as traumatic as the real event and lead to prolonged states of distress and arousal. Flashbacks are often triggered by an otherwise innocuous event. Examples include combat veterans hearing a car backfire or a hurricane survivor walking outside on a windy day. Triggering events also include somatic sensations. For example, a physical assault victim with a traumatic brain injury may re-experience the assault should they begin to feel dizzy.

To avoid being re-traumatized by flashbacks, trauma victims quickly learn behaviors intended to avoid triggering situations and events (APA, 2013, pp. 275-276). This leads to the development of a repertoire of avoidance behaviors, which is one of the diagnostic criteria for PTSD. These behaviors include deliberate attempts to minimize exposure to thoughts, feelings, memories, discussions, activities, objects, situations, or individuals that might trigger a flashback, which explains why individuals with low mental health literacy fail to take advantage of mental health services when made available (Ghafoori et al., 2014). Negative cognitions become more prominent and can include inaccurate generalizations about society, others, or self, such as always having bad judgment, authority figures can never be trusted, or all men are sexual predators (APA, 2013, pp. 275-276). Inaccurate attributions may become entrenched in a trauma victim's thought processes and can include beliefs, for example, that sexual victimization could have been avoided if the victim had behaved differently. Other cognitive manifestations of trauma include dissociative amnesia, poor concentration, memory impairments, and sleep problems due to elevated arousal. Depersonalization and derealization may be evident, which are dissociative states in relation to the victim's body or reality, respectively. In children, cognitive alterations may include loss of language ability, while some adult trauma victims may experience auditory hallucinations and paranoia. Victims that experience prolonged, severe, repetitive exposures to trauma, such as childhood sexual assault or torture, will have difficulty regulating emotions, developing and maintaining stable relationships, and/or avoiding dissociative states. Such victims have been suggested to be suffering from what the World Health Organization considers to be complex PTSD (CPTSD) (Wolf et al., 2015).

Negative cognitions often co-occur with negative mood alterations and…