PTSD

Jayvant Makwana
Clinical Psychologist
A. Exposure to actual or threatened death, serious injury, or sexual violence in
one (or more) of the following ways:

1. Directly experiencing the traumatic event(s).

2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the traumatic event(s) occurred to a close family member
or close friend. In cases of actual or threatened death of a family member
or friend, the event(s) must have been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of the
traumatic event(s) (e.g., first responders 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 pictures, unless this exposure is work related.
 B. Presence of one (or more) of the following intrusion
symptoms
associated with the traumatic event(s), beginning after the
traumatic event(s) occurred:
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
Note: In children older than 6 years, repetitive play may occur in which themes or aspects of
the traumatic event(s) are expressed.

2. Recurrent distressing dreams in which the content and/or affect of the dream are related to
the traumatic event(s).
Note: In children, there may be frightening dreams without recognizable content.

3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the
traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most
extreme expression being a complete loss of awareness of present surroundings.)
Note: In children, trauma-specific reenactment may occur in play.

4. Intense or prolonged psychological distress at exposure to internal or external cues that

symbolize or resemble an aspect of the traumatic event(s).
5. Marked physiological reactions to internal or external cues that symbolize or resemble an
aspect of the traumatic event(s).
C. Persistent avoidance of stimuli associated with the traumatic
event(s), beginning after the traumatic event(s) occurred, as
evidenced by one or both of the following:

1. Avoidance of or efforts to avoid distressing

memories, thoughts, or feelings about or closely
associated with the traumatic event(s).
2. Avoidance of 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 alterations in cognitions and mood associated with
the traumatic event(s), beginning or worsening after the traumatic
event(s) occurred, as evidenced by two (or more) of the
following:
1. Inability to remember an important aspect of the traumatic event(s) (typically due to
dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).

2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the
world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My
whole nervous system is permanently ruined”).

3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s)
that lead the individual to blame himself/herself or others.

4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).

5. Markedly diminished interest or participation in significant activities.

6. Feelings of detachment or estrangement from others.

7. Persistent inability to experience positive emotions (e.g., inability to experience happiness,

satisfaction, or loving feelings).
 E. Marked alterations in arousal and reactivity associated with the
traumatic event(s), beginning or worsening after the traumatic
event(s) occurred, as evidenced by two (or more) of the following:

1. Irritable behavior and angry outbursts (with little

or no provocation) typically expressed as verbal or
physical aggression toward people or objects.
2. Reckless or self-destructive behavior.
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems with concentration.
6. Sleep disturbance (e.g., difficulty falling or staying
asleep or restless sleep).
F. Duration of the disturbance (Criteria B, C, D,
and E) is more than 1 month.
G. The disturbance causes clinically significant
distress or impairment in social, occupational, or
other important areas of functioning.
H. The disturbance is not attributable to the
physiological effects of a substance (e.g.,
medication, alcohol) or another medical
condition.
 Case Study
Mr. A. was a married accountant, the father of two, in his early 30s. One
night, while out running an errand, he was attacked by a group of young
men. They forced him into their car and took him to a deserted country
road. There they pulled him from the car and began beating and kicking
him. They took his wallet, began taunting him about its contents (they had
learned his name, his occupation, and the names of his wife and children),
and threatened to go to his home and harm his family. Finally, after
brutalizing him for several hours, they tied him to a tree. One man held a
gun to his head.
Mr. A.begged and pleaded for his life; then the armed assailant pulled the
trigger. The gun was empty, but at the moment the trigger was pulled, Mr.
A. defecated and urinated in his pants. Then the men untied him and left
him on the road. Mr. A. slowly made his way to a gas station and called the
police. [One of the authors] was called to examine him and did so at
intervals for the next 2 years. The diagnosis was PTSD.
Mr. A. had clearly experienced an event outside the range of normal human experience and was
reexperiencing the event in various ways: intrusive recollections, nightmares, flashbacks, and
extreme fear upon seeing groups of tough-looking young men. He was initially remarkably numb
in other respects: He felt estranged and detached. He withdrew from his family, lost interest in his
job, and expected to die in the near future. Mr. A. also showed symptoms of increased
physiological arousal. His sleep was poor, he had difficulty concentrating, and he was easily
startled. When
Mr. A. first spoke about his abduction in detail he actually soiled himself at the moment he
described doing so during the original traumatic experience. Mr. A. received treatment from a
psychiatrist for the next 2 years. This consisted of twice-weekly individual psychotherapy as well
as antidepressant medications. A focus of the therapy was the sense of shame and guilt Mr. A. felt
over his behavior during his abduction. He wished he had been more stoic and had not pleaded
for his life. With the help of his therapist, Mr. A. came to see that his murderous rage at his
abductors was understandable, as was his desire for revenge. He was also able to accept that his
response to his experience was likely similar to how others might have responded if faced with
the same circumstances. By the end of treatment Mr. A. was almost without symptoms, although
he still became somewhat anxious when he saw some groups of young men. Most important, his
relationship with his wife and children was warm and close, and he was again interested in his
work.