**2. Historical background**

Reports of battle-associated stress reactions appeared as early as the 6th century BC. One of the first descriptions of PTSD was made by the Greek historian Herodotus. In 490 BC

Post Traumatic Stress Disorder – An Overview 5

Posttraumatic Stress Disorder Checklist(PCL), Acute Stress Disorder Scale (ASDS), Acute Stress Checklist for Children (ASC-Kids), Child PTSD Symptom Scale (CPSS) and Reactions to Research Participation Questionnaires for Children and Parents (RRPQ-C and RRPQ-P)[4,5,6]. All these might be used prior to or as a complement to the clinical interview. Such measures are used most frequently in research settings, some might be used clinically to provide additional sources of documentation, and others might be given to veterans at a health facility prior to their first interview with health professional. Screening tools can be useful in initiating a conversation about exposure to traumatic events or possible PTSD symptoms. However, as noted by Briere (2004) "no psychological test can replace the focused attention, visible empathy, and extensive clinical experience of a well-trained and seasoned trauma clinician [7]." Working in Vietnam war-zone, veterans have developed both psychometric and psycho physiologic assessment techniques that have proven to be both reliable and valid. Other investigators have modified such assessment instruments and used them with natural disaster victims, rape/incest survivors, and other traumatized

PTSD has been criticized from the perspective of cross-cultural psychology and medical anthropology, because it has usually been diagnosed by clinicians from Western industrialized nations working with patients from a similar background. . Despite these criticisms, PTSD is a real time mental disorder with devastating clinical, physical, social and economic consequences for sufferers. Though clinicians from developing countries continue to diagnose PTSD using diagnostic systems developed in industrialized countries, the major clinical features appear to be uniform across cultures. Major gaps remain in our understanding of the effects of ethnicity and culture on the clinical phenomenology of posttraumatic syndromes. We have only just begun to apply vigorous ethno cultural research strategies to delineate possible differences between Western and non-Western societies regarding the psychological impact of traumatic exposure and the clinical manifestations of

The United Nations' World Health Organization publishes estimates of PTSD impact for each of its member states; the latest data available are for 2004. The age-standardiseddisability adjusted life-year (DALY) rates for PTSD, per 100,000 inhabitants, in 10 most

The National Comorbidity Survey has estimated that the lifetime prevalence of PTSD among adult Americans is 7.8%, with women (10.4%) twice as likely as men (5%) to have PTSD at some point in their lives. In the United States, 60% of men and 50% of women experience a traumatic event during their lifetimes. The rate is highest for soldiers. The United States Department of Veterans Affairs estimates that 830,000 Vietnam War veterans suffered symptoms of PTSD. The National Vietnam Veterans' Readjustment Study (NVVRS) found 15.2% of male and 8.5% of female Vietnam Vets to suffer from PTSD. Life-Time prevalence of PTSD was 30.9% for males and 26.9% for females. For soldiers who fought in the Iraq war in 2008, the prevalence of PTSD was 13.8%. The National Survey of Adolescents, which included a household probability sample of 4,023 adolescents between the ages of 12 and 17, found that using accepted diagnostic criteria for PTSD, the six-month

prevalence was estimated to be 3.7% for boys and 6.3% for girls [8].

cohorts.

such exposure.

**3. Epidemiology and prevalence** 

ranking countries is as table 1.

Herodotus described, during the Battle of Marathon, an Athenian soldier who suffered no injury from war but became permanently blind after witnessing the death of a fellow soldier. In the early 19th century military medical doctors started diagnosing soldiers with "exhaustion" after the stress of battle. This "exhaustion" was characterized by mental shutdown due to individual or group trauma. Soldiers during the 19th century were not supposed to be scared or show any fear in the midst of battle. The only treatment for this "exhaustion" was to bring the afflicted back for a bit for a short term therapy and then send them back into battle. During the intense and frequently repeated stress, the soldiers became fatigued as a part of their body's natural shock reaction. According to Stéphane Audoin-Rouzeau and Annette Becker, "One-tenth of mobilized American men were hospitalized for mental disturbances between 1942 and 1945, and after thirty-five days of uninterrupted combat, 98% of them manifested psychiatric disturbances in varying degrees."

Previous diagnoses now considered historical equivalents of PTSD include railway spine, stress syndrome, shell shock, battle fatigue, or traumatic war neurosis. Although PTSD-like symptoms have also been recognized in combat veterans of many military conflicts, the modern understanding of PTSD dates from the 1970s, largely as a result of the problems that were still being experienced by US military veterans of the war in Vietnam. In its initial DSM-III (formulation 1980), a traumatic event was conceptualized as a catastrophic stressor that was outside the range of usual human experience. The framers of the original PTSD diagnosis had in mind events such as war, torture, rape, the Nazi Holocaust, the atomic bombings of Hiroshima and Nagasaki, natural disasters (such as earthquakes, hurricanes, and volcano eruptions) and human-made disasters (such as factory explosions, airplane crashes, and automobile accidents). They considered traumatic events as clearly different from the very painful stressors that constitute the normal vicissitudes of life such as divorce, failure, rejection, serious illness and financial reverses. (By this logic adverse psychological responses to such "ordinary stressors" would, in DSM-III terms, be characterized as Adjustment Disorders rather than PTSD.) This dichotomization between traumatic and other stressors was based on the assumption that although most individuals have the ability to cope with ordinary stress, their adaptive capacities are likely to be overwhelmed when confronted by a traumatic stressor.

The DSM-III diagnostic criteria for PTSD were revised in DSM-III-R (1987) and DSM-IV (1994) [2]. A very similar syndrome is classified in ICD-10 [3]. Since 1980 there has been a great deal of attention devoted to the development of instruments for assessing PTSD. Although an optimal evaluation of a patient for PTSD consists of a face-to-face interview by a mental health professional trained in diagnosing psychiatric disorders, several instruments are available to facilitate the diagnosis and assessment of posttraumatic stress disorder (PTSD). These include screening tools, diagnostic instruments, and trauma and symptom severity scales. For example, there are brief screening tools, such as the 4-item Primary Care PTSD Screen, developed by the Department of Veterans Affairs National Center for Posttraumatic Stress Disorder; self-report screening instruments, such as the Posttraumatic Diagnostic Scale; and structured or semi-structured interviews, such as the Clinician-Administered PTSD Scale (CAPS), the Structured Clinical Interview for DSM-IV (SCID), the Diagnostic Interview Schedule for DSM-IV (DIS-IV), and the Composite International Diagnostic Interview (CIDI), Acute Stress Disorder Interview (ASDI),

Herodotus described, during the Battle of Marathon, an Athenian soldier who suffered no injury from war but became permanently blind after witnessing the death of a fellow soldier. In the early 19th century military medical doctors started diagnosing soldiers with "exhaustion" after the stress of battle. This "exhaustion" was characterized by mental shutdown due to individual or group trauma. Soldiers during the 19th century were not supposed to be scared or show any fear in the midst of battle. The only treatment for this "exhaustion" was to bring the afflicted back for a bit for a short term therapy and then send them back into battle. During the intense and frequently repeated stress, the soldiers became fatigued as a part of their body's natural shock reaction. According to Stéphane Audoin-Rouzeau and Annette Becker, "One-tenth of mobilized American men were hospitalized for mental disturbances between 1942 and 1945, and after thirty-five days of uninterrupted combat, 98% of them manifested psychiatric disturbances in varying

Previous diagnoses now considered historical equivalents of PTSD include railway spine, stress syndrome, shell shock, battle fatigue, or traumatic war neurosis. Although PTSD-like symptoms have also been recognized in combat veterans of many military conflicts, the modern understanding of PTSD dates from the 1970s, largely as a result of the problems that were still being experienced by US military veterans of the war in Vietnam. In its initial DSM-III (formulation 1980), a traumatic event was conceptualized as a catastrophic stressor that was outside the range of usual human experience. The framers of the original PTSD diagnosis had in mind events such as war, torture, rape, the Nazi Holocaust, the atomic bombings of Hiroshima and Nagasaki, natural disasters (such as earthquakes, hurricanes, and volcano eruptions) and human-made disasters (such as factory explosions, airplane crashes, and automobile accidents). They considered traumatic events as clearly different from the very painful stressors that constitute the normal vicissitudes of life such as divorce, failure, rejection, serious illness and financial reverses. (By this logic adverse psychological responses to such "ordinary stressors" would, in DSM-III terms, be characterized as Adjustment Disorders rather than PTSD.) This dichotomization between traumatic and other stressors was based on the assumption that although most individuals have the ability to cope with ordinary stress, their adaptive capacities are likely to be overwhelmed when

The DSM-III diagnostic criteria for PTSD were revised in DSM-III-R (1987) and DSM-IV (1994) [2]. A very similar syndrome is classified in ICD-10 [3]. Since 1980 there has been a great deal of attention devoted to the development of instruments for assessing PTSD. Although an optimal evaluation of a patient for PTSD consists of a face-to-face interview by a mental health professional trained in diagnosing psychiatric disorders, several instruments are available to facilitate the diagnosis and assessment of posttraumatic stress disorder (PTSD). These include screening tools, diagnostic instruments, and trauma and symptom severity scales. For example, there are brief screening tools, such as the 4-item Primary Care PTSD Screen, developed by the Department of Veterans Affairs National Center for Posttraumatic Stress Disorder; self-report screening instruments, such as the Posttraumatic Diagnostic Scale; and structured or semi-structured interviews, such as the Clinician-Administered PTSD Scale (CAPS), the Structured Clinical Interview for DSM-IV (SCID), the Diagnostic Interview Schedule for DSM-IV (DIS-IV), and the Composite International Diagnostic Interview (CIDI), Acute Stress Disorder Interview (ASDI),

degrees."

confronted by a traumatic stressor.

Posttraumatic Stress Disorder Checklist(PCL), Acute Stress Disorder Scale (ASDS), Acute Stress Checklist for Children (ASC-Kids), Child PTSD Symptom Scale (CPSS) and Reactions to Research Participation Questionnaires for Children and Parents (RRPQ-C and RRPQ-P)[4,5,6]. All these might be used prior to or as a complement to the clinical interview. Such measures are used most frequently in research settings, some might be used clinically to provide additional sources of documentation, and others might be given to veterans at a health facility prior to their first interview with health professional. Screening tools can be useful in initiating a conversation about exposure to traumatic events or possible PTSD symptoms. However, as noted by Briere (2004) "no psychological test can replace the focused attention, visible empathy, and extensive clinical experience of a well-trained and seasoned trauma clinician [7]." Working in Vietnam war-zone, veterans have developed both psychometric and psycho physiologic assessment techniques that have proven to be both reliable and valid. Other investigators have modified such assessment instruments and used them with natural disaster victims, rape/incest survivors, and other traumatized cohorts.

PTSD has been criticized from the perspective of cross-cultural psychology and medical anthropology, because it has usually been diagnosed by clinicians from Western industrialized nations working with patients from a similar background. . Despite these criticisms, PTSD is a real time mental disorder with devastating clinical, physical, social and economic consequences for sufferers. Though clinicians from developing countries continue to diagnose PTSD using diagnostic systems developed in industrialized countries, the major clinical features appear to be uniform across cultures. Major gaps remain in our understanding of the effects of ethnicity and culture on the clinical phenomenology of posttraumatic syndromes. We have only just begun to apply vigorous ethno cultural research strategies to delineate possible differences between Western and non-Western societies regarding the psychological impact of traumatic exposure and the clinical manifestations of such exposure.

#### **3. Epidemiology and prevalence**

The United Nations' World Health Organization publishes estimates of PTSD impact for each of its member states; the latest data available are for 2004. The age-standardiseddisability adjusted life-year (DALY) rates for PTSD, per 100,000 inhabitants, in 10 most ranking countries is as table 1.

The National Comorbidity Survey has estimated that the lifetime prevalence of PTSD among adult Americans is 7.8%, with women (10.4%) twice as likely as men (5%) to have PTSD at some point in their lives. In the United States, 60% of men and 50% of women experience a traumatic event during their lifetimes. The rate is highest for soldiers. The United States Department of Veterans Affairs estimates that 830,000 Vietnam War veterans suffered symptoms of PTSD. The National Vietnam Veterans' Readjustment Study (NVVRS) found 15.2% of male and 8.5% of female Vietnam Vets to suffer from PTSD. Life-Time prevalence of PTSD was 30.9% for males and 26.9% for females. For soldiers who fought in the Iraq war in 2008, the prevalence of PTSD was 13.8%. The National Survey of Adolescents, which included a household probability sample of 4,023 adolescents between the ages of 12 and 17, found that using accepted diagnostic criteria for PTSD, the six-month prevalence was estimated to be 3.7% for boys and 6.3% for girls [8].

Post Traumatic Stress Disorder – An Overview 7

of PTSD include experiencing or witnessing an event perceived as life-threatening such as accidents, terminal illnesses, or employment in occupations exposed to war (such as soldiers) or disaster (such as emergency service workers). Traumatic events that may cause PTSD symptoms to develop include violent assault, kidnapping, sexual assault, torture, being a hostage, prisoner of war or concentration camp victim, experiencing a disaster, violent automobile accidents or getting a diagnosis of a life-threatening illness. Children or adults may develop PTSD symptoms by experiencing bullying or mob violence. Preliminary research suggests that child abuse may interact with mutations in a stress-related gene to increase the risk of PTSD in adults[9]. Multiple studies show that parental PTSD and other posttraumatic disturbances in parental psychological functioning can, despite a traumatized parent's best efforts, interfere with their response to their child as well as their child's response to trauma[10,11]. Parents with violence-related PTSD may, for example, inadvertently expose their children to developmentally inappropriate violent media due to

Military experience as risk factors for the development of PTSD include coming from an unstable family, being punished severely during childhood, childhood anti-social behavior and depression as pre-military factors, war-zone exposure, peri-traumatic dissociation, depression as military factors and recent stressful life events and depression as post-military factors[14]. Certain protective factors against PTSD in war-conditions include high school degree or college education, older age at entry to war, higher socioeconomic status, and positive paternal relationship as pre-military protective factors and social support at homecoming and current social support as post-military factors[15]. Research also indicates the protective effects of social support in averting and recovery from PTSD[16]. There may also be an attitudinal component; for example, a soldier who believes that they will not sustain injuries may be more likely to develop symptoms of PTSD than one who anticipates the possibility, should either be wounded[15]. Likewise, the later incidence of suicide among those injured in home fires above those injured in fires in the workplace suggests this

Posttraumatic stress responses have been documented in children who have suffered traumatic loss of their parents, siblings, and peers[17,18,19,20]. Results from a study indicated that knowing someone who was injured or killed, female gender, and bombrelated television viewing or other media exposure were associated with the most severe psychological reactions. Bereaved youths who suffered severe loss (e.g. a parent, sibling, close relative, or friend) as a result of the bombing were more likely to report posttraumatic

Although most people (50-90%) encounter trauma over a lifetime, only about 8% develop full PTSD[21]. Vulnerability to PTSD presumably stems from an interaction of biological diathesis, early childhood developmental experiences, and trauma severity. Predictor models have consistently found that childhood trauma, chronic adversity, and familial stressors increase risk for PTSD as well as risk for biological markers of risk for PTSD after a traumatic event in adulthood[22]. This effect of childhood trauma, which is not well understood, may be a marker for both traumatic experiences and attachment problems. Proximity to, duration of, and severity of the trauma also make an impact; and interpersonal traumas cause more problems than impersonal ones[21]. People vary in susceptibility to PTSD. Genetic factors may play a significant role in susceptibility. Women develop PTSD at about twice the rate as men, even for the same crimes[21]. Individuals with a prior trauma history or multiple traumas are at increased risk[21]. A premorbid psychiatric history also

stress symptoms than did children who did not experience this degree of loss.

their need to manage their own emotional dysregulation[12,13].

possibility.


Table 1.
