Posttraumatic Stress Disorder and Removal from Home as a Primary, Secondary, or Disclaimed Trauma in Maltreated Adolescents

Posttraumatic stress disorder (PTSD) is common among maltreated youth but it remains unclear as to whether removal from home is as traumatizing as the maltreatment. This study examined 250 maltreated adolescents aged 11–17?years who were grouped on the basis of whether they (1) endorsed removal from home as their primary traumatic event, (2) endorsed removal from home as a secondary traumatic event, but not their primary traumatic event, or (3) did not endorse removal from home as traumatic. PTSD diagnoses as well as symptoms of PTSD, dissociation, depression, posttraumatic cognitions, and anger expression were measured. Adolescents who endorsed removal from home as their primary traumatic event reported significantly lower levels of PTSD and related symptoms than adolescents in the other groups. The findings are discussed within the context of transactions surrounding removal from home and support previous work that PTSD is a critical concern regarding many maltreated youth.     

Disorders of extreme stress (DESNOS) symptoms are associated with type and severity of interpersonal trauma exposure in a sample of healthy young women

Childhood abuse and other developmentally adverse interpersonal traumas may put young adults at risk not only for posttraumatic stress disorder (PTSD) but also for impairment in affective, cognitive, biological, and relational self-regulation ("disorders of extreme stress not otherwise specified"; DESNOS). Structured clinical interviews with 345 sophomore college women, most of whom (84%) had experienced at least one traumatic event, indicated that the DESNOS syndrome was rare (1% prevalence), but DESNOS symptoms were reported by a majority of respondents. Controlling for PTSD and other anxiety or affective disorders, DESNOS symptom severity was associated with a history of single-incident interpersonal trauma and with more severe interpersonal trauma in a dose-response manner. Noninterpersonal trauma was associated with elevated prevalence of PTSD and dissociation but not with DESNOS severity. Study findings indicate that persistent posttraumatic problems with self-regulation warrant attention, even in relatively healthy young adult populations.     

The PTSD Stressor Criterion as a Barrier to Malingering: DSM-5 Draft Commentaries

This commentary focuses on the proposed changes to the trauma stressor criterion for PTSD for DSM-5, specifically its likely impact on malingering. PTSD is particularly susceptible to malingering because the diagnosis relies so heavily on a patient’s subjective symptoms. Because the traumatic event that is the trigger of the PTSD syndrome is generally based on objective fact and thus often easily corroborated, this element of the diagnosis is usually more challenging to malinger than subjective reports of symptoms. Therefore, one of the main gateways for limiting the misuse of the PTSD diagnosis in forensic settings is the criterion defining the range of qualifying traumas. Proposed changes to criterion A of PTSD in the draft include modifying the types of qualifying trauma by replacing “threat to physical integrity” with “sexual violation,” and clarifying the modes of exposure by replacing the phrase “confronted with” with two criterion: “learning that the event occurred to a close relative or close friend” and “experiencing repeated or extreme exposure to aversive details of the event.” Each of these changes has the potential to significantly broaden the range of qualifying stressors and consequently expand the potential pool of individuals who might be in a position to malinger the disorder. Given the likelihood that the DSM-5 field trials will be unable to provide information relevant to assessing the impact of making these changes in forensic settings, it would be prudent to resist the inclination to tinker with the wording unless other mechanisms are available to ensure that the wording changes do more good than harm.     

Acute stress disorder as a predictor of post-traumatic stress disorder in physical assault victims

The authors' objective was to examine the ability of acute stress disorder (ASD) and other trauma-related factors in a group of physical assault victims in predicting post-traumatic stress disorder (PTSD) 6 months later. Subjects included 214 victims of violence who completed a questionnaire 1 to 2 weeks after the assault, with 128 participating in the follow-up. Measures included the Harvard Trauma Questionnaire, the Trauma Symptom Checklist, and the Crisis Support Scale. Twenty-two percent met the full PTSD diagnosis and 22% a subclinical PTSD diagnosis. Previous lifetime shock due to a traumatic event happening to someone close, threats during the assault, and dissociation explained 56% of PTSD variance. Inability to express feelings, hypervigilance, impairment, and hopelessness explained another 15% of PTSD variance. The dissociative, the reexperiencing, the avoidant, and the arousal criteria of the ASD diagnosis correctly classified 79% of the subsequent PTSD cases.     

Signs and symptoms of post-traumatic stress disorder in children

Summary Post-traumatic Stress Disorder in children is a complex interaction of cognitive, affective, and physiological responses to an event that is outside the range of usual human experience and would be markedly distressing to almost anyone. Traumatic stress reactions in children are conscious and unconscious efforts to assimilate an overwhelming event and have been identified in the past as panic reaction, acute grief hysterical reaction, and physical shock. PTSD in children is complicated by multiple issues of developmental stages, family dynamics, physical maturity, genetic predisposition, and cognitive skills. Characteristic symptoms of PTSD which must persist for more than one month include re-experiencing (flashbacks, nightmares); avoidance; numbing of general responsiveness; and persistent autonomic arousal. Children exhibit characteristic PTSD symptoms, but research suggests four criteria specific to traumatized children independent of chronological age and the course of the disorder: 1) visualized and repeatedly perceived memories; 2) repetitive behaviors; 3) trauma-related fears; 4) altered attitudes about life and future orientation. These four criteria appear to remain clustered together in childhood trauma victims even when other diagnosis would appear more appropriate. PTSD in children encompasses a complex spectrum of diagnosis and remains technically intricate for the mental health professional.     

Posttraumatic Stress Disorder: Protective and Risk Factors in 18 Survivors of a Plane Crash

The aim of this study is to identify protective and risk factors related to the development of posttraumatic stress disorder (PTSD) on a sample of survivors from a single plane crash. Eighteen survivors were examined 6 months following the event. The subjects all underwent psychiatric interviews, Clinician‐Administered PTSD Scale structured interviews, personality and cognitive tests. Only 38.9% of them presented with all of the symptoms of PTSD; 22.2% showed no symptoms for PTSD; remaining survivors exhibited emotional/affective symptoms related to the event. In addition to the severity of the traumatic event itself, other risk factors identified were the loss of a relative, the manifestation of depressive symptoms, and the severity of physical injuries sustained. Low levels of hostility and high levels of self‐efficacy represented protective factors against developing PTSD.     

One Quintillion Ways to Have PTSD Comorbidity: Recommendations for the Disordered DSM-5

Galatzer-Levy and Bryant (Perspect Psychol Sci 8:651–662, 2013) have calculated the number of ways that Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association, 2013) posttraumatic stress disorder (PTSD) symptoms can be combined as over 600,000. They concluded that the amount is astounding and the category is rendered amorphous. PTSD often occurs in the context of polytrauma or comorbidity. The epidemiological literature indicates that the most common comorbid conditions in cases of PTSD include major depressive disorder (MDD), chronic pain, neurocognitive disorder due to traumatic brain injury (e.g., mild), and alcohol use disorder, with premorbid personality disorder possible, as well (which we consider as exacerbated due to the traumatic incident at issue, as in borderline personality disorder). We calculated the possible symptom combinations for each of these disorders and then in comorbid combination with PTSD (e.g., PTSD with MDD, but also when all six conditions are present). The number of symptom combinations in full polytrauma involving all six conditions listed is truly astounding, over one quintillion. Also, we reviewed the range of PTSD comorbidities, which adds to the symptom heterogeneity in cases. We make recommendations to prioritize symptoms in disorders as primary (e.g., unique, marker), secondary (e.g., core essential), and tertiary (e.g., common, cross-diagnostic). The latter tertiary type of symptoms in a disorder, if any, should be kept apart in its own criterion. This approach might help make the next version of the DSM more clinically useful both to clinicians and to court.     

Acute dissociative responses in law enforcement officers involved in critical shooting incidents: the clinical and forensic implications

The authors examine the prevalence of acute traumatic dissociative responses in a group of 115 law enforcement officers involved in critical incidents. Law enforcement officers were retrospectively surveyed for the presence of dissociative symptoms at the time of the critical incident, as well as for the presence of acute stress symptoms and posttraumatic stress symptoms. Results show that 90% of the officers reported experiencing a dissociative response during the critical incident. Thirty percent meet the Dissociative Criterion B of acute stress disorder under the DSM-IV. The mean number of dissociative symptoms in this group was two and one-half. In addition, 19% of the law enforcement officers reported varying forms of memory impairment for details of the incident. There were no reports of amnesia for the entire event. The clinical, forensic, and legal implications of these preliminary findings are discussed in this paper.     

Environmental Considerations for Trauma‐Responsive Juvenile and Family Courts: A Review of the Literature with Recommendations for Practice

Juvenile and family courts serve some of our most vulnerable populations, many of whom have experienced some traumatic event. People suffering with posttraumatic stress disorder (PTSD) are known to be more sensitive to environmental stimuli, and many of the environmental conditions within courts can be challenging for those suffering traumatic stress. Trauma‐responsive practices help foster conditions of healing, which can benefit both the court user and those who work within the court. Research reviewed in this article demonstrates the likelihood of negative behavioral and emotional responses to specific environmental factors for people suffering PTSD and other stress reactions, and offers recommendations to minimize environmental stressors.     

Toward a Typology of High-Risk Major Stressful Events and Situations in Posttraumatic Stress Disorder and Related Psychopathology

The diagnosis of posttraumatic stress disorder (PTSD) was introduced in 1980 with the publication of the Diagnostic and Statistical Manual of the American Psychiatric Association, Third Edition (DSM-III). DSM-III put forward a novel syndrome consisting of intrusive, avoidance/numbing, and arousal symptoms as distinctive psychopathology following exposure to traumatic events. The traumatic stressors, although expanded in later editions published in 1987 (DSM-III-R) and 1994 (DSM-IV), focus on life-threatening events and situations. However, at least 12 studies, most of them recent, have found associations between the PTSD symptoms and the PTSD symptom syndrome with stressors, such as unemployment and divorce that would not qualify, even in the broadened DSM-IV diagnosis, as traumatic stressors. These findings challenge the basic assumption on which the PTSD diagnosis is based, the assumption that exposure to life-threatening stressors is the primary cause of a unique set of stress response symptoms. The purpose of this paper is to show how to confront this challenge by developing a typology of stressful situations and events that can be tested systematically for their relation to the PTSD symptom syndrome and other relevant variables. The typology includes but is not limited to the types of situations and events defined as "traumatic" in the DSMs.     

Life Stressors and Posttraumatic Stress Disorder in a Seriously Mentally Ill Jail Population,

Inmates represent a vulnerable population with increased rates of trauma and posttraumatic stress disorder (PTSD). However, little is known about the rates of trauma and PTSD among male inmates with acute psychiatric illness. This prospective, randomized study was conducted to assess the current rates of trauma and PTSD in this population. The sample consisted of 48 patients admitted to a hospital jail psychiatry service in New York City. Subjects were administered the Life Stressor Checklist‐Revised and the Structured Clinical Interview for DSM‐IV‐TR Disorders, PTSD Module (SCID‐I). The rate of PTSD diagnosis via SCID‐I was 46.2% as compared to 2.1% diagnosis via clinical interview. All participants reported a history of at least one stressful and/or traumatic event, and many of these events occurred during incarceration. These results demonstrate that a great deal of trauma and PTSD goes unrecognized and untreated in this population, indicating the need for more effective treatment interventions.     

The Future of Posttraumatic Stress Disorder in the DSM

Posttraumatic stress disorder (PTSD), added to the DSM nosology in 1980, has become a widely used and studied psychiatric diagnosis—though it has also been the subject of much criticism and controversy. In this paper, we review and discuss a number of issues related to the future of PTSD within the DSM, including the conceptual basis of the disorder, summary of proposed changes to DSM-V, the empirical basis for or against specific disorder criteria, forensic implications, and conclusions and recommendations regarding the future of the disorder in DSM. Overall, the current proposed changes for DSM-V represent a modest improvement over DSM-IV criteria, though they are incremental and relatively minor in nature. As such, they are unlikely to have a meaningful impact on prevalence rates, treatment approaches, or forensic applications of the disorder—and the disorder, as defined, remains problematic in many ways. The empirical data on latent structure of responses to traumatic and general life stressors seem to indicate that perhaps PTSD should be replaced by a dimensional general stress response disorder within the DSM system.     

Community violence and PTSD in selected South African townships

Given the high rates of crime in South Africa's townships, nonpolitical violence out-side the home and its psychological impact on women were investigated within two samples, the primary a help-seeking sample and the secondary a community sample. In the help-seeking sample, two thirds of the women reported having experienced several traumatic events outside the home. Those women displayed a median of 9 PTSD (post-traumatic stress disorder) symptoms, with nearly half meeting all criteria for PTSD. In the community sample, 40 women of color were interviewed at a community festival for women, and again two thirds reported having experienced several traumatic events outside the home during the previous year. These women displayed a median of 8.8 PTSD symptoms, with none meeting all criteria for PTSD. South Africa's distinctive culture of violence is discussed as context for understanding issues of community violence and PTSD among women in its minority townships.     

Post-traumatic stress disorder (PTSD): what we have learned and what we still have not found out

This article discusses the biomedical and the social constructionist models applied to response to trauma, presents the prevalence and the etiology of post-traumatic stress disorder (PTSD), and describes its biological and psychological correlates in children and adults. It concludes that future research might benefit from investigating factors that may protect people who have been exposed to an event likely to be traumatic from presenting with PTSD symptoms, and factors that may affect the longitudinal course of PTSD and treatment effectiveness.     

Community violence victimization and symptoms of posttraumatic stress disorder: the moderating effects of coping and social support

This study tested the relationship of community violence (CV) victimization to severity of posttraumatic stress disorder (PTSD), and the roles of coping style and perceived social support in moderating that relationship. Three-hundred seventy-two men and women (age 18 to 22 years) self-reported on CV exposure, traumatic experiences, PTSD symptoms, perceived support from family and friends, and coping strategies. Results indicated that high CV victimization, high disengagement coping (i.e., avoidant styles), and low perceived social support from family and friends significantly predicted increased PTSD scores. Significant moderating effects indicated that the relationship between victimization and heightened PTSD severity was stronger at high levels of perceived friend support and disengagement. Thus, the protective function of friend support seemed to break down at increasing levels of victimization, whereas, as expected, avoidant styles of coping increased the risk for negative outcome. Findings are discussed in terms of event controllability, negative social reactions, and coping resources.     

Evaluating the Reliability of Expert Evidence in Compensation Procedures: Are Diagnosticians Influenced by the Narrative Fallacy when Assessing the Psychological Injuries of Trauma Victims?

The current study investigated whether mental health practitioners are influenced by the narrative fallacy when assessing the psychological injuries of trauma victims. The narrative fallacy is associated with our tendency to establish logical links between different facts. In psychodiagnostic assessments, this tendency may result in overdiagnosis of mental disorders when psychological symptoms can be attributed to a traumatic event. Consequently, legal decision makers may be at risk of awarding compensation for psychological injuries which are not severe enough to justify financial reimbursement. To explore this topic, we asked Dutch mental health practitioners whether they would assign a diagnosis of mental disorder to fictitious symptoms of psychological injury. Each participant was presented with two vignettes. The first vignette described symptoms in terms of a generalized anxiety disorder; the second in terms of a major depressive episode. The vignettes varied in the cause (trauma versus cause not specified) and severity (near threshold of DSM diagnosis versus below threshold of DSM diagnosis) of the symptoms. Results indicated that participants more often assigned a diagnosis of mental disorder if the psychological symptoms had been caused by a traumatic event than if that had not been the case. Further analysis of the data suggested that this difference was due to the high numbers of assigned diagnoses of posttraumatic stress and acute stress disorder in the trauma conditions. It was speculated that participants filled in missing information to justify the assignment of such diagnoses, for example by imagining symptoms of intrusion and avoidance.     

Posttraumatic Stress Disorder: Current Concepts and Controversies

The diagnosis of posttraumatic stress disorder (PTSD) sometimes is raised in compensation claims, in tort settings, and in other medical–legal settings. Accordingly, health-care and legal professionals working in these areas need to be familiar with the current findings and controversies concerning the disorder. The purpose of this article is twofold. First, we review the most important findings concerning the clinical features, etiology, and treatment of PTSD. Second, we examine six major controversies concerning the disorder that are relevant to psychologists and other medical–legal practitioners: (a) the issue of what qualifies as a traumatic stressor, (b) the question of whether traumatic stress causes brain damage, (c) the validity of the concept of delayed-onset PTSD, (d) the recovered memory controversy, (e) the question of whether PTSD can arise when the person has no memory of the trauma (e.g., due to concussion), and (f) issues concerning PTSD malingering. Throughout this article we offer recommendations for psychological and other medical–legal practice in relation to the evaluation of PTSD claims.     

Impact of Common Mental Health Disorders on Cognition: Depression and Posttraumatic Stress Disorder in Forensic Neuropsychology Context

The assessment and diagnosis of posttraumatic stress disorder (PTSD) and depression in forensic evaluations may lack an acknowledgement of the neurocognitive impact of these disorders and how they interact with other causative factors, such as traumatic brain injury (TBI), pain or fatigue. Both PTSD and depression have a complex, growing and consolidating neuroscientific and neuropsychological evidence base, and both can affect neuropsychological test results. In forensic neuropsychological assessments, they are often considered to be confounding factors in evaluating TBI and neurodegenerative disorders but not a source of cognitive impairment in their own right. Yet, an accurate neuropsychological assessment of both cognition and affect is vital to causality determination, prognosis and treatment planning. To complicate matters, selective brain injuries, contingent on the location of injury, can produce symptoms of depression that also affect the neurocognitive profile. Therefore, behavior can overlap not only due to overlapping or comorbid diagnoses, but also due to similar neuroanatomical correlates of both conditions. This paper focuses on reviewing and integrating the available empirical evidence from neuroscience and neuropsychology regarding the cognitive impact of PTSD and depression. Our critical review will emphasize the implications of the more recent evidence for forensic assessment determinations regarding causality, diagnosis, and the impact on function, prognosis and treatment. Hence, electronic search engines, PubMed, PsycINFO, and Google Scholar (up to January 2018) were screened and reviewed both for the neuroscience and neuropsychological literature related to depression and PTSD.     

Military combat, posttraumatic stress disorder, and criminal behavior in Vietnam veterans

Although data are inconclusive, popular perception has linked military combat, posttraumatic stress disorder (PTSD), and criminal behavior. This paper discusses the multifactorial elements of this association that include both conscious and unconscious parameters of psychologic functioning. Testimony on combat-related PTSD has been presented in the courtroom to support veterans' claims of not guilty by reason of insanity (NGRI) and diminished capacity and for consideration during judicial sentencing. Because there is a known connection between the degree of combat involvement and PTSD, verification through collateral sources of the veteran's report of combat experiences is an important component of forensic assessment. The DSM-III-defined diagnosis of PTSD and the presence of a dissociative state have particular relevance in NGRI determinations. In other aspects of the judicial process demonstration of the absolute presence or absence of PTSD is often irrelevant and should be replaced by efforts to establish plausible links between provable combat experiences and the circumstances of the crime.     

Assessing Trauma-Related Dissociation in Forensic Contexts: Addressing Trauma-Related Dissociation as a Forensic Psychologist,Part II

Chronic dissociative reactions and dissociative disorders can occur following traumatic events and are associated with suffering and impaired functioning. Therefore, trauma-related dissociation could be part of the claims made in civil actions or contribute to mitigation or an insanity defense in criminal actions. Dissociative reactions to trauma, including dissociative disorders, are more common than most mental health professionals realize. Unfortunately, few professionals have training in the assessment of dissociation, and forensic experts may be unaware of research indicating that standard interpretations of well-regarded assessment instruments can result in inaccurate determinations of symptom exaggeration in cases with dissociation. This paper is the second paper of a two-part series that aims to expand assessors’ knowledge about trauma-related dissociation (TRD) and enhance their ability to assess and present information about dissociation. In this article, we focus on the forensic assessment of TRD and discuss: dissociative symptoms; complex trauma; trauma-related disorders; an approach to assessment of TRD; trauma-related reactions that can impede the detection of TRD; and differential diagnosis of genuine versus feigned dissociation. In addition, we review research related to the validity and appropriate interpretation of the following measures in use with persons with TRD: Dissociative Experiences Scale, Multiscale Dissociation Inventory, Somatoform Dissociation Questionnaire, Trauma Symptom Inventory-2, Multidimensional Inventory of Dissociation, Structured Clinical Interview for Dissociative Disorders-Revised, Minnesota Multiphasic Personality Inventory-2, Personality Assessment Inventory, Structured Interview of Reported Symptoms, Test of Memory Malingering, and the Gudjonsson Suggestibility Scale.