Duration: 16 minutes, 03 seconds

KELLIE NEWSOME: PTSD is not the only mental illness that starts after a trauma. In this episode, you'll learn to recognize its core symptoms. Welcome to The Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. 

CHRIS AIKEN: I’m Chris Aiken, the editor-in-chief of The Carlat Psychiatry Report. 

KELLIE NEWSOME: And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue. This month, the American Journal of Psychiatry published an update on PTSD by Arieh Shalev, MD, and colleagues from NYU. It's an important topic, so we'll take a deep dive into that article in this podcast series.

CHRIS AIKEN: PTSD is part of a select club of DSM diagnoses whose criteria require an external cause. The others are acute stress disorder, which means you have PTSD-like symptoms for less than one month after a trauma, while PTSD requires more than a month, and adjustment disorder, which captures various psychological symptoms that come on after a stress. But that are not prominent or numerous enough to meet criteria for another DSM disorder. And there's another one in the newest edition of DSM, Prolonged Grief Disorder, which actually includes some PTSD-like symptoms, but centers around a sense of unresolved attachment to the deceased. But, defining these disorders by their causes has led to some confusion, most notably the tendency to diagnose any problem that happens after a trauma as PTSD. Or any psychological symptoms after bereavement as prolonged grief disorder. Not so. As we'll get into here, PTSD is a unique reaction. Trauma can cause nearly every syndrome in the DSM. Trauma can cause PTSD, but it can also cause depression, bipolar disorder, or opioid use disorder. And sometimes it can cause both. Where people will have PTSD, along with another mental illness, and both of them could have been triggered by a trauma. There is also an understandable tendency to blur the distinction between stress and trauma. Trauma is a type of stress, but it's a more specific type. And I know that trauma can be defined in many different ways, but in this podcast, I'm going to stick with the DSM definition, and Because that is the definition used in the research of PTSD, so that's what's going to guide our evidence-based care. So, in DSM, trauma is about death and dismemberment, bodily integrity, physical and sexual assault, whether you see those kinds of things happening to another or come close to it or go through it yourself. Okay, we've defined it, but there's a lot of gray areas here still. Is getting fired from your job a trauma? Because it threatens your livelihood, your ability to put food on the table, your actual life. What about surgery? What about getting diagnosed with diabetes? Or childbirth? Whether you classify childbirth as a trauma or not, there is a lot of research on this, and around 1 in 25 women meet criteria for PTSD after giving birth. Some argue that panic attacks are traumatic. After all, they involve the experience of feeling like you're gonna die. And indeed, trauma-based psychotherapies like EMDR are effective in panic disorder in controlled trials. Now, panic attacks do make people feel like they're gonna die, but in DSM's view, it is not a trauma, because it doesn't involve an actual life-threatening event. Getting back to the childbirth question, DSM doesn't take that on directly, but the text lends some clarity as it wrestles with the question of whether a medical condition could be traumatic. It says that for a medical disorder to qualify as a trauma, It has to involve a sudden catastrophic event, such as waking up during surgery or an anaphylactic shock. So, I can imagine that that could happen during childbirth, and childbirth could be traumatic in some cases. In some ways, DSM IV, the older 1994 edition, contributed to this confusion by including the reaction to trauma: intense fear, helplessness, or horror as part of the definition of a traumatic event. That led some clinicians to classify anything that causes those horrific reactions as a trauma. DSM 5 has tried to clean that up by removing any subjectivity from the definition of a traumatic event. It's worth reading the full text of DSM 5 for that criterion A, the definition of trauma. 

KELLIE NEWSOME: The patient must have had 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. 2. Witnessing in person the event as it occurred to others. 3. Learning that the traumatic event occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event must have been violent or accidental. Finally, DSM includes a fourth type of trauma that was meant to recognize first responders who collect human remains or police officers who are exposed again and again to details of child abuse. For 4., experiencing repeated or extreme exposure to aversive details of the traumatic events. 

CHRIS AIKEN: So, trauma is a potentially deadly, violent, physically dangerous event, whether it happened to you, you saw it in person, or you got shocking news about such a trauma in someone that you're close to. Finally, DSM emphasizes that if you witness the trauma, it has to be in person, unless it happened to a close loved one, or if it's a stranger, you see it again and again like a first responder in an ambulance. They have an unusual qualifier at the end that says that experiencing the trauma through video or other media could count as trauma if it's experienced again and again as part of your profession. I guess that would imply to, say, police detectives who see lots of gruesome pictures in their work and get PTSD. It's not clear why the DSM only allows that for professionals though, but in any event, they're generally trying to keep witnessing trauma to in-person witnessing, with those few exceptions, mainly when you hear about it in a loved one. And this in-person criteria was in part a response to the flood of reports of PTSD after people in the United States watched video footage of the World Trade Center's collapse over and over again after September 11th. There were about 11 million people in the U. S. who would have met criteria for PTSD, and the founders of the DSM didn't want to expand it that broad, so they cut it off that if you get PTSD from watching such news reports or watching crime documentaries. It doesn't count. Unless, if you were close to someone who died in those terrorist attacks, then of course it could count. Whew, we've gone through the weeds here, but let's get back to the big picture. Here's how you would ask about trauma in a structured clinical interview. The Mini 7. 0, which has been updated for DSM 5.

KELLIE NEWSOME: Have you ever experienced or witnessed or had to deal with an extremely traumatic event that included actual or threatened death or serious injury or sexual violence to you or someone else? For people with PTSD, the world is dangerous, uncontrollable, and unpredictable. They are hypervigilant, scanning their environment and going out of their way to avoid triggering reminders. All this effort makes them tense and exhausted. They have nightmares, flashbacks, and easily startled. Perhaps the core symptom of PTSD is re-experiencing the trauma as if it is still happening, with intense emotions and vivid perceptions. For those traumatized in a war zone, the war continues after their return to a safe environment, and there's a name for this phenomenon. Failure to update the context and integrate safety signals. Survivors of sexual assault or torture describe difficulties engaging with and trusting others. 

CHRIS AIKEN: PTSD entered the DSM in 1980. But recently discovered texts tell us that its history dates back much further, to three thousand years ago, when the earliest observations of PTSD were recorded in the Mesopotamian Empire, that we now call Iraq. Assyrian soldiers had trouble integrating back into society after returning from war. They had flashbacks, sleep problems, and depression, and they saw ghosts of the men they had killed in battle.

KELLIE NEWSOME: There are a few subtypes of PTSD to know. One is DSM's dissociative subtype, where the patient experiences depersonalization, derealization, amnesia for aspects of the trauma, or altered perception of time along with the PTSD. About 1 in 7 patients with PTSD have the dissociative subtype. Another subtype in DSM is delayed PTSD, where the symptoms start 6 months or more after a trauma. But recent studies show this is usually not the case. PTSD can come and go, often in response to stress. And most cases that look like delayed onset turn out to be due to this waxing and waning course. 

CHRIS AIKEN: There's a third subtype that's not in the DSM, but recently found recognition in ICD 11, complex PTSD. This describes people who live through extensive interpersonal trauma, like abuse, captivity, prolonged domestic violence, or torture. To make this diagnosis, the patient first has to meet criteria for PTSD. Then, on top of it, they have to meet a few criteria that describe difficulties in relationships, feeling close to others, problems in identity, like shame, and low self-worth, and problems in emotion regulation, like overreacting to everyday stress, violent outbursts, or self-destructive behaviors. If this complex PTSD is starting to sound like borderline personality disorder, you're on the right track. There is a lot of overlap here, and the studies that try to split the two apart look like efforts in splitting hairs. But in fairness, here's what those studies found. People with borderline have more frantic efforts to avoid abandonment, impulsivity, and relationship problems, and more unstable sense of self, and more aggression. While people with complex PTSD have more avoidance of trauma triggers. But these are just differences of degree. I mean, when you look at it, nearly every symptom of complex PTSD is also commonly found in borderline and vice versa. So telling the two apart with any kind of diagnostic precision would be difficult.

KELLIE NEWSOME: One of the most important symptoms in PTSD is sleep because this one will change your management. Therapy for PTSD involves learning, and sleep is where learning is consolidated. So there's a movement among some PTSD centers to treat sleep problems first, before even starting therapy, much as you would want to help a patient get sober before you worked on other stuff in therapy. Nearly everyone with PTSD has sleep problems, around 90 percent including nightmares and insomnia. The hyper-alert state continues through the night, revving up the autonomic nervous system during sleep. 

CHRIS AIKEN: That nocturnal hyperarousal might explain why sleep apnea is so common in PTSD. Somewhere between 40 to, in some studies, 80 percent of people with PTSD suffer from sleep apnea. And they don't look like stereotypical sleep apnea cases. They tend to be young and thin. No one is yet sure why there's so much overlap between PTSD and sleep apnea, but a leading theory is that this autonomic hyperarousal is causing some kind of constriction in the pharyngeal airwaves. Or possibly something going on in the CNS itself that's causing a decrease in breathing. No one's really sure, but it's a good idea to get it checked out and get some treatment started for sleep apnea because these patients are not going to recover well otherwise. And here's another thing that PTSD does to sleep, which is useful to know about and explains why those nightmares keep persisting. And why the nightmares are going to make all symptoms of PTSD worse. You see, PTSD disrupts most of the sleep stages. And, the hallmark nightmares of PTSD take place during REM sleep. The repetitive play of these terror scripts, night after night, further entrains the learned state of fearfulness, because REM sleep plays a role in the maintenance of fear memories. So if we can break those cycles of nightmares, we might break through a lot of the other PTSD symptoms. Sleep problems are one of the earliest signs of PTSD. And people with nightmares or insomnia after a trauma are at greater risk for developing the full disorder. Next week, we'll take a closer look at that. Why some people develop PTSD after a trauma and others do not?

KELLIE NEWSOME: Here's a preview of the CMA quiz for this episode. Start earning credits through the link in the show notes. 

1. What is the minimum duration of PTSD symptoms required in the DSM criteria? 

A. One week. 

B. One month. 

C. Three months. 

D. Six months.

Want more updates from the Carlat team? You may want to check out our August episode of Carlat Psychiatry News on YouTube or under the multimedia tab at the Carlat website.

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