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.     

The Delayed and Cumulative Consequences of Traumatic Stress: Challenges and Issues in Compensation Settings

Delayed onset posttraumatic stress disorder has been a challenging issue in medico-legal settings. Prospective studies have done much to characterise the validity of this construct and the prevalence in various populations. The delayed impact of these events places significant challenges on a plaintiff in establishing a causal link to some distal exposure. Furthermore, the literature highlights that depression is a frequent independent outcome from posttraumatic events, independent of the frequent comorbidity for posttraumatic stress disorder. To date, there has been little examination of the commonality of the underlying mechanisms of aetiology between depression and posttraumatic stress disorder. The concepts of sensitisation and kindling have been extensively discussed as underlying mechanisms relevant to a range of psychiatric disorders. This idea of increasing sensitisation of individuals who have multiple traumatic stress exposures is of critical importance to understanding the shared aetiology of major depressive disorder and posttraumatic stress disorder. Furthermore, the neural circuitry involved in these conditions particularly involves the amygdala, medial prefrontal cortex and anterior cingulate. Given the shared aetiological mechanisms, it is probable that the delays in treatment which have been demonstrated to be important factors for decreasing the probability of a full treatment response in depression are equally relevant to posttraumatic stress disorder. This raises important issues about the liability of employers particularly in the emergency services for vetting individuals where there is a foreseeable risk. A further challenge in litigation settings is the increasing body of evidence linking posttraumatic stress disorder and depression to cardiovascular disease and hypertension.     

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.     

Work Impairment and Disability in Posttraumatic Stress Disorder: A Review and Recommendations for Psychological Injury Research and Practice

Work impairment and disability are common consequences of posttraumatic stress disorder (PTSD), as reflected by significant rates of sickness absence, failure to return to work, and reduced work performance. Within the psychological injury field, the issue of work impairment and disability in PTSD often arises in workers’ compensation and disability insurance claims and in personal injury litigation. In this context, clinical and forensic practitioners are faced with challenges in rendering expert opinions on diagnosis, causality, prognosis, and recommendations for treatment and rehabilitation. To promote understanding of this important, yet understudied area, there are three aims of this paper: first, to review the current literature on work impairment and disability associated with PTSD; second, to draw on this literature to present a biopsychosocial framework of work impairment and disability in PTSD; and third, to offer suggestions for improving the assessment and management of PTSD-related work impairment and disability.     

Sexual Harassment, PTSD, and Criterion A: If It Walks Like a Duck …

Sexual harassment and posttraumatic stress disorder (PTSD) are two topics that generate heated debate in the social science literature. When the two are combined in the civil litigation context, the intensity of the debate is heightened by the adversarial context of the courts. The current paper examines research on both sexual harassment and PTSD separately, before addressing the issues that arise for psychologists and psychiatrists who serve as expert witnesses in sexual harassment litigation. Proposed resolutions of controversies are offered that attempt to expand the knowledge base for expert witnesses on the topic of sexual harassment as well as work within the current Diagnostic and Statistical Manual (DSM-IV-TR; American Psychiatric Association 2000) framework of PTSD.     

Posttraumatic Stress Disorder and Comorbidity: Untangling the Gordian Knot

The high rates of psychiatric comorbidity for individuals with posttraumatic stress disorder (PTSD) have long been noted. The conceptual, clinical and aetiological relationships between PTSD and other disorders are so interwoven and multi-determined that understanding and treating posttraumatic psychopathology can feel like trying to untangle the legendary Gordian knot. This paper examines the varying streams of research seeking to better understand this extensive comorbidity. These streams of research include examination of the bi-directional relationships in the development of PTSD and key mood, anxiety and substance use disorders; the study of the shared manifest and common higher order features across these disorders and investigations of underlying biopsychosocial vulnerabilities. Finally, the paper examines the preliminary findings emerging using the new DSM-5 criteria for PTSD and queries whether these revised criteria will address the issue of comorbidity and assist in untangling the knot of posttraumatic comorbidity.     

Posttraumatic anger, recalled peritraumatic emotions, and PTSD in victims of violent crime

A mixed cross-sectional and longitudinal design was employed to explore the association between posttraumatic anger and posttraumatic stress disorder (PTSD; symptoms) in victims of civilian violence. It was speculated that this relationship is mainly due to concurrent recalled peritraumatic emotions. Such emotions may be interpreted to result from anger-rooted threat perceptions and to share similarities with posttraumatic intrusion symptoms. In addition, predictors of PTSD maintenance were investigated. Cross-sectional data indicated that posttraumatic anger and several indices of PTSD were highly interconnected. Recalled peritraumatic emotions partly accounted for the relation between posttraumatic anger and posttraumatic intrusions (n = 177). Only posttraumatic intrusions were associated with PTSD symptom persistence at follow-up (n = 56). Findings were discussed in light of study limitations and directions for future research.     

Self-worth as a mediator between attachment and posttraumatic stress in interpersonal trauma

It is well documented that most trauma survivors recover from adversity and only a number of them go on to develop posttraumatic stress disorder (PTSD). In addition, survivors of interpersonal trauma (IPT) appear to be at heightened risk for developing PTSD in comparison to survivors of noninterpersonal trauma (NIPT). Despite a robust association between IPT exposure and attachment disruptions, there is a dearth of research examining the role of attachment-related processes implicated in predicting PTSD. Using a sample of college undergraduates exposed to IPT and NIPT, this study explores the mediating effect of self-worth in the relationship between attachment and PTSD. It is hypothesized that insecure attachment will be related to posttraumatic symptomatology via a reduced sense of self-worth in IPT survivors but not in NIPT survivors. Mediation analyses provide support for this hypothesis, suggesting the importance of considering negative cognitions about the self in therapeutic interventions, particularly those offered to IPT survivors.     

Partner's stake in conformity and abused wives' psychological trauma

This study investigates the potential buffering effect of help-seeking in the association between intimate partner assault and women's psychological trauma, and how this, in turn, may depend on the partner's stake in conformity. The sample consists of 374 women reporting the experience of domestic violence from a current intimate partner, drawn from the larger survey Violence and Threats of Violence Against Women and Men in the United States, 1994-1996. Help-seeking did not appear to buffer the impact of assault severity, contrary to expectation. However, the partner's stake in conformity did condition the effect of his or her having been arrested. Victims had higher levels of posttraumatic stress disorder (PTSD) when police arrested partners of average or below-average stake in conformity. But victims of partners characterized by higher than average stake in conformity did not show elevated PTSD due to their partners having been arrested. On the other hand, PTSD was higher among women experiencing more emotional abuse from the partner.     

Gender Differences in PTSD in Israeli Youth Exposed to Terror Attacks

Differences between boys' and girls' exposure to terror and posttraumatic symptoms were examined in a sample of 2,999 Israeli adolescents. Gender differences were also assessed regarding perceived social support, religious beliefs, and ideological commitment. Results indicate that girls reported more posttraumatic symptoms than boys, although boys reported twice the rate of very severe symptoms. Differences were also found between boys and girls in levels of fear, religiosity, ideological commitment, and social support, but not regarding exposure. Path analysis revealed that gender is not a direct predictor of posttraumatic stress disorder (PTSD); however, it does have an indirect effect, especially through fear, which was the best predictor of PTSD. Social extrinsic religiosity and ideological intolerance were positive predictors of PTSD. The study concludes that gender differences in PTSD are largely the result of differences in levels of fear and are not due to differences in political ideology, religiosity, or social support.     

Re-examination of the Controversial Coexistence of Traumatic Brain Injury and Posttraumatic Stress Disorder: Misdiagnosis and Self-Report Measures

The coexistence of traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD) remains a controversial issue in the literature. To address this controversy, we focused primarily on the civilian-related literature of TBI and PTSD. Some investigators have argued that individuals who had been rendered unconscious or suffered amnesia due to a TBI are unable to develop PTSD because they would be unable to consciously experience the symptoms of fear, helplessness, and horror associated with the development of PTSD. Other investigators have reported that individuals who sustain TBI, regardless of its severity, can develop PTSD even in the context of prolonged unconsciousness. A careful review of the methodologies employed in these studies reveals that investigators who relied on clinical interviews of TBI patients to diagnose PTSD found little or no evidence of PTSD. In contrast, investigators who relied on PTSD questionnaires to diagnose PTSD found considerable evidence of PTSD. Further analysis revealed that many of the TBI patients who were initially diagnosed with PTSD according to self-report questionnaires did not meet the diagnostic criteria for PTSD upon completion of a clinical interview. In particular, patients with severe TBI were often misdiagnosed with PTSD. A number of investigators found that many of the severe TBI patients failed to follow the questionnaire instructions and erroneously endorsed PTSD symptoms because of their cognitive difficulties. Because PTSD questionnaires are not designed to discriminate between PTSD and TBI symptoms or determine whether a patient's responses are accurate or exaggerated, studies that rely on self-report questionnaires to evaluate PTSD in TBI patients are at risk of misdiagnosing PTSD. Further research should evaluate the degree to which misdiagnosis of PTSD occurs in individuals who have sustained mild TBI.     

Assessment of Stress and Resiliency in Emergency Dispatchers

Although they are technically the first responders on most critical incidents, emergency dispatchers have received a modicum of attention from researchers and clinicians. The purpose of the present study was to evaluate job-related stress, psychological distress, posttraumatic stress disorder (PTSD), stress resiliency, and posttraumatic growth in this high-risk group. These areas were evaluated via an assessment battery administered to 90 emergency dispatchers working in a law enforcement agency. Results showed that dispatchers experienced an average amount of occupational stress, with 24% of the current sample reporting significant job stress. Between 13.34 and 15.56% reported symptoms consistent with a PTSD diagnosis, and 16.67% indicated sub-threshold PTSD symptomatology. The findings revealed that, overall, dispatchers experience occupational stress, psychological distress, and sub-threshold PTSD at similar or higher rates compared to police officers. Further, dispatchers reported posttraumatic growth at an average rate, also similar to that reported by police officers. Clinical implications of the results are discussed. Suggestions for directions that future research might take are offered.     

Structural validity of the posttraumatic stress disorder checklist among college students with a trauma history

The authors conducted confirmatory factor analyses to test three-factor and four-factor models of posttraumatic stress disorder (PTSD) using the PTSD Checklist with college students reporting a traumatic event history. The authors found support for the three-factor DSM-IV-based PTSD diagnostic model including reexperiencing, avoidance/numbing, and hyperarousal symptom factors, with slightly better support for a four-factor model separating the avoidance and numbing factors. Results further attest to the PTSD Checklist's construct validity, and to research finding that PTSD avoidance and numbing constructs are distinct.     

Domestic Predation of an Elder: A Fatal Dog Attack Case

We present the case of a 91‐year‐old woman lived alone at her home with two domestic dogs, that is,, a Labrador Retriever and a Staffordshire Bull Terrier and found dead. The investigation of the scene revealed that the Bull Terrier's jawbone and chest were covered with blood. The autopsy revealed multiple, histologically confirmed, life‐threatening skin and bone lacerations without scavenging marks. The punctures and tearing of each of the wounds on the skin were compatible with bites. A left humeral fracture and multiple fractures of the right facial bones were observed. The death was attributed to external hemorrhages due to several dog bites. A veterinary physical and behavioral examination indicated that the Bull Terrier was involved in the attack. A domestic predation hypothesis was deemed here most likely due to the presence of food supplies at the scene, the dog's previous history of attack, and the breed of the dog.     

Posttraumatic Stress Disorder in DSM-5: New Criteria,New Measures,and Implications for Assessment

The diagnostic criteria for posttraumatic stress disorder (PTSD) were substantially revised for Diagnostic and Statistical Manual of Mental Disorders—5th edition (DSM-5). This in turn necessitated revision of DSM-correspondent assessment measures of PTSD. We describe the various changes to the PTSD diagnostic criteria and the corresponding changes to National Center for PTSD measures. We also discuss the implications of the new criteria for assessment of trauma exposure and PTSD. Although the DSM-5 version of PTSD departs significantly in some respects from previous versions, we conclude that there is fundamental continuity with the original DSM-III conceptualization of PTSD as a chronic, debilitating mental disorder that develops in response to catastrophic life events.     

The Dissociative Subtype of Posttraumatic Stress Disorder: Forensic Considerations and Recent Controversies

Psychological Injury and Law - This article provides an overview of the evidence concerning the dissociative subtype of posttraumatic stress disorder (PTSD) and its relevance in forensic contexts....     

Sexual Harassment Litigation: a Road to Re-victimization or Recovery?

Various aspects of the judicial process have been hypothesized as damaging to sexual harassment plaintiffs, though limited research has been conducted that actually examines this hypothesis. We examined data from a large sample of women who participated in a class action lawsuit alleging workplace sexual harassment and discrimination (n?=?1218) and another sample of similarly situated women who opted out of litigation (n?=?465, non-litigants). We then followed the litigants for 5 years. This study takes an initial look at some of the variables theorized to play a role in the psychological outcomes of both harassment and subsequent litigation. Both the severity of harassment and participation/persistence in the litigation process were related to psychological outcomes at each of three assessments across a 5-year period; the frequency and severity of harassment, as well as plaintiffs’ cognitive appraisals of their situation, appeared to have the strongest relationship to psychological harm. Results of multivariate analysis of covariance (MANCOVA) revealed that participation and persistence in litigation played a consistent role in psychological outcomes across time, over and above the impact of harassment itself. However, litigation did not appear to be the cause of psychological outcomes as posttraumatic stress disorder (PTSD) symptomatology, in particular, was the result of the original harassment experience.     

PTSD及其法医学相关问题

随着国外对PTSD(posttraumatic stress disorder)的深入研究以及中国心理卫生事业与法医学事业的发展,相关领域的学者开始从事这一方面的研究并取得了不少成就。本文结合国内外的一些理论研究与实践成果,对PTSD的概念、诊断与鉴别以及相关法医学问题作一综述和探讨。     

Neuropsychological and Psychological Aspects of Malingered Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) is an anxiety disorder that is frequently encountered in litigation, and as such, there is an increased risk for poor effort on cognitive tests, symptom exaggeration, or frank malingering. These are particularly problematic for accurate diagnosis. This article is divided into four sections. First, we address why individuals malinger PTSD as well as the challenges in detecting an invalid PTSD symptom presentation. Second, we discuss issues of cognitive functioning in PTSD and then the prevalence of and common patterns of poor effort on neuropsychological testing among individuals feigning PTSD. Third, we discuss psychological functioning in PTSD and then the prevalence and patterns of functioning on psychological measures of malingering in this population. Finally, recommendations for detecting invalid PTSD symptom presentations are provided.     

Beyond PTSD: mental health consequences of violence against women: a response to Briere and Jordan

This article proposes that we move beyond posttraumatic stress disorder (PTSD) in our conceptualization of traumatic stress responses of victimized women exposed to serial forms of unrelenting violence, such as intimate partner violence and stalking. It is argued that the traditional PTSD framework is ill fitting in the context of some forms of violence against women (VAW), and these limits have consequences for developing appropriate interventions for some victimized women. The article further suggests going beyond PTSD by developing a more nuanced understanding of the ways in which PTSD and other mental health symptoms contribute to the vast array of deleterious personal, societal, and economic costs of VAW.