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.     

Posttraumatic Stress Disorder in the DSM-5: Group Difference Commentary

This article provides a commentary on the proposed Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 changes with respect to diagnosing posttraumatic stress disorder (PTSD) in diverse cultural groups in clinical and forensic settings. PTSD is the most common diagnosis in personal injury litigants (Koch et al. 2006). By reviewing the symptoms that have been changed in the DSM-5 draft for PTSD in terms of ethnoracial and minority–cultural factors, this article highlights the lack of data needed in the area and that the DSM project should pay more attention to such factors.     

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.     

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 Stress Disorder: Assessing Response Style and Malingering

Posttraumatic stress disorder (PTSD) may form the basis for disability or worker’s compensation claims or a personal injury lawsuit. While now achieving widespread acceptance among treating professionals and the public, PTSD is the subject of several controversies and the possibility of faking in a compensation context. There appears to be a dramatic split among mental health professionals who write primarily from a treatment or plaintiff perspective and those who take a more skeptical approach. This article reviews recent developments in the assessment of malingering, including symptom validity measures, and applies them to the assessment of PTSD. Recommendations for current practice are provided.     

Underlying Dimensions of DSM-5 Posttraumatic Stress Disorder and Major Depressive Disorder Symptoms

This study examined the relationship between the underlying latent factors of major depression symptoms and DSM-5 posttraumatic stress disorder (PTSD) symptoms (American Psychiatric Association, 2013). A nonclinical sample of 266 participants with a trauma history participated in the study. Confirmatory factor analyses were conducted to evaluate the fit of the DSM-5 PTSD model and dysphoria model, as well as a depression model comprised of somatic and nonsomatic factors. The DSM-5 PTSD model demonstrated somewhat better fit over the dysphoria model. Wald tests indicated that PTSD’s negative alterations in cognitions and mood factor was more strongly related to depression’s nonsomatic factor than its somatic factor. This study furthers a nascent line of research examining the relationship between PTSD and depression factors in order to better understand the nature of the high comorbidity rates between the two disorders. Moreover, this study provides an initial analysis of the new DSM-5 diagnostic criteria for PTSD.     

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....     

Simulating Emotional Responses in Posttraumatic Stress Disorder: An fMRI Study

This study tested the extent to which coached participants can simulate the neural responses of participants with posttraumatic stress disorder (PTSD) when they are presented with signals of fear. Functional magnetic resonance imaging (fMRI) was used to study blood oxygenation level-dependent signal during the presentations of fearful and neutral faces under both conscious and nonconscious (masked) conditions. Participants comprised 12 patients with PTSD and 12 trauma-exposed controls who were instructed to simulate PTSD. During conscious fear processing, simulators showed greater activation in the left amygdala and medial prefrontal cortex (MPFC) than PTSD participants. By contrast, during nonconscious processing, PTSD participants had greater MPFC activation than simulators. These findings suggest that coached simulators produce a profile of ‘over-responding’ to fear when controlled conscious processing is possible, but are not able to simulate the exaggerated medial prefrontal responses observed in PTSD participants under conditions of nonconscious processing.     

Posttraumatic Stress Disorder and Depression in Battered Women: The Mediating Role of Learned Helplessness

Learned helplessness (LH) may mediate the link between violence exposure and mental disorders in battered women. This study evaluated the contribution of LH to Posttraumatic Stress Disorder (PTSD) and major depression (MDD) in women with prolonged exposure to partner violence in 101 residents of shelters for battered women in Israel. DSM-IV axis-I disorders were assessed by a structured clinical interview. Self-report questionnaires evaluated exposure to violence, symptoms of PTSD and depression, LH, history of child abuse, SES and the extent of male-dominance and prejudice against women in the participants prior socialization background. LH significantly mediated the effect of violence on PTSD and depression symptoms. Male-dominated background contributed to LH. Thus, LH may increase the risk of mental disorders in battered women and should be addressed in interventions designed to reduce the burden of mental illness in this population.     

Incidence and Correlates of Posttraumatic Stress Disorder in Australian Victims of Domestic Violence

In recent years, evidence has emerged of the significant incidence of posttraumatic stress disorder (PTSD) among victims of domestic violence. The present study examined incidence and correlates of PTSD in 100 female victims of domestic violence resident in women's shelters in Adelaide, South Australia. Forty-five women were found to meet all diagnostic criteria for PTSD. Women meeting PTSD diagnostic criteria reported having experienced higher levels of violence and were more likely to report having a spouse with an alcohol problem and having believed they would be killed by their spouse than women who did not meet criteria. Diagnosis of PTSD was also associated with higher levels of anxiety and depression.     

Sexual Harassment and Posttraumatic Stress Disorder: Damages Beyond Prior Abuse

This study examined the extent to which harassment experiences correlate with posttraumatic stress disorder (PTSD) symptoms, and whether diagnosable PTSD on the basis of sexual harassment occurs after accounting for prior PTSD, prior sexual abuse, and prior psychological dysfunction. The sample consisted of a two-wave panel of 445 women who had received a domestic violence protective order from a Kentucky court. Hierarchical linear and logistic analyses confirmed that sexual harassment experiences were significantly correlated with PTSD symptoms after controlling for an extensive set of trauma variables measured in both the baseline and follow up interviews. Our findings lend further evidence that claims of PTSD from sexual harassment may be credible even if claimants have been victims of other forms of trauma.     

Co-occurrence and Correlates of Posttraumatic Stress Disorder and Major Depression in Physically Abused Women

Ninety two women presenting for treatment for marital problems and who were physically victimized by their spouses (e.g., pushing, shoving, punching) within the past year participated in this study. There were three study objectives: (1) document rates and co-occurrence of posttraumatic stress disorder (PTSD) and Major Depressive Disorder (MDD), (2) identify predictors of PTSD and depression symptom frequency/severity, and (3) systematically evaluate disorder-specific group differences in marital- and marital violence-related factors. Within the month prior to assessment, 29.8% of the sample met diagnostic criteria for PTSD and 32% for MDD. MDD and PTSD were significantly, but moderately, correlated at both the symptom and diagnosis levels. However, PTSD symptom frequency and depression symptom severity were predicted by different marital- and marital violence-related factors. PTSD symptoms were predicted by spouse's dominance/isolation tactics and intensity of husband-to-wife physical aggression while depressive symptoms were predicted by marital discord and intensity of husband-to-wife physical aggression. Comorbid women and those with PTSD only reported significantly more spousal fear and husband-to-wife physical aggression than those with MDD only or neither disorder. No group differences were found on rate of marital discord or spouse's controlling/isolating tactics. Results are discussed in terms of theoretical and treatment implications for abused women seeking treatment for marital conflict.     

Trauma and Posttraumatic Stress Disorder Among Substance-Using Women Entering Cook County Jail

In the United States, the number of incarcerated women continues to rise each year, with African American women having the highest incarceration rates. Many women enter prisons and jails with an extensive trauma history, though little is known about the percentage of these individuals suffering from posttraumatic stress disorder (PTSD) and specific trauma exposures they have had based on factors such as homelessness, degree of substance problems, and race. The present study examines a largely African American substance-using population of incarcerated women to determine the impact of various factors on specific traumas reported. We found that individuals reporting symptoms meeting criteria for PTSD had experienced the highest average number of traumas, and those who had ever been homeless also experienced many and varied trauma exposures compared with those who had never been homeless. Higher substance problems were also associated with more trauma exposure. Fewer than 10 percent of the sample met full criteria for PTSD, though those reporting having ever been homeless and those with higher substance problems were significantly more likely to meet all criteria. Results indicate a need to assess previous homelessness as a method for identifying additional trauma exposures and guiding treatment to women's specific needs and trauma profiles.     

Trauma Characteristics and Posttraumatic Stress Disorder among Adolescent Survivors of Childhood Sexual Abuse

This study examined the relationship between the characteristics of childhood sexual abuse (CSA) and the severity of consequent posttraumatic stress disorder (PTSD), depression, suicidal ideation, and substance use in a sample of 83 female adolescents aged 13–18 years seeking treatment for PTSD. Nearly two-thirds of the sample (60.7 %, n?=?51) reported the perpetrator of the CSA was a relative. A large portion (40.5 %, n?=?34) of the sample reported being victimized once, while almost a quarter of the sample reported chronic victimization (23.8 %, n?=?20). PTSD and depression scores were in the clinical range, whereas reported levels of suicidal ideation and substance use were low. The frequency of victimizations was associated with suicidal ideation. Contrary to expectation, CSA characteristics including trauma type, perpetrator relationship, and duration of abuse were unrelated to PTSD severity, depressive symptoms, or substance abuse.     

The Development of Posttraumatic Stress Disorder (PTSD) in a Sample of Child Witnesses to Mother Assault

This exploratory study examined the relationship between the development of posttraumatic stress disorder (PTSD) and a number of coping variables in child witnesses to mother assault. The sample consisted of 84 children (mean age 11 years) who had been referred from shelters for battered women and child welfare agencies. Comparisons of those who met PTSD criteria (n = 47) and those who did not meet PTSD criteria (n = 37) found significant differences on variables of age, duration, and frequency of witnessing children. Child self-report instruments indicated that the PTSD group differed significantly from the non-PTSD group on the basis of assault anxiety, depression, dissociation, anger, and negative attributions. Hierarchical multiple regression analysis indicated that factors related to negative attributions and assault variables each contributed significantly to explaining 71% of the variance of PTSD symptoms, after the variables of age and sex were controlled. Discriminant function analysis correctly classified 84.3% of the respondents. The relevance of PTSD to child witnesses is considered, along with study limitations.     

The Relationships Between Childhood Sexual Abuse,Social Anxiety,and Symptoms of Posttraumatic Stress Disorder in Women

The relationships between childhood sexual abuse, social anxiety, and symptoms of posttraumatic stress disorder were examined in a sample of 313 undergraduate women. Thirty-one percent of the women reported some form of sexual abuse in childhood. Women with a history of sexual abuse reported more symptoms of anxiety, distress in social situations, and posttraumatic stress disorder than other women. Women who experienced attempted or actual intercourse reported more avoidance than women with no history of abuse and women with exposure only, and more PTSD symptoms than all other groups of women. Women who experienced fondling reported more PTSD symptoms than women with no history of abuse. Pressure, age of onset of abuse, abuse by a family friend, and abuse by other perpetrators were all significant abuse characteristics in predicting adult social anxiety. Implications of these results for research and interventions are discussed.     

An Investigation of Posttraumatic Stress Disorder and Depressive Symptomatology among Female Victimsof Interpersonal Trauma

This study examined factors associated with PTSD-depression comorbidity among a sample of 162 adult female rape or assault victims with PTSD, as well as potential differential predictors of PTSD and depression severity. PTSD-only participants reported higher levels of childhood sexual abuse than those with comorbid PTSD and depression, and the PTSD/MDD group reported relatively more distorted trauma-related beliefs, dissociation, PTSD severity, and depression severity. Distorted trauma-related beliefs and dissociation were the strongest unique predictors of higher PTSD and depressive symptoms. Rates of PTSD and depression comorbidity did not appear to be a function of symptom overlap. Study findings suggest possible explanations for the high PTSD and depression comorbidity rates commonly found among victims of interpersonal violence. This research was supported in part by a grant to Patricia A. Resick from the National Institute of Mental Health (R02-MH51509).     

Romantic Attachment as a Moderator of the Association Between Childhood Abuse and Posttraumatic Stress Disorder Symptoms

Childhood abuse can have significant negative effects on survivors that often last into adulthood. The purpose of this study was to explore the role of romantic attachment in understanding the relationship between childhood abuse and posttraumatic stress disorder (PTSD) symptoms in adulthood. Data for this study were taken from the first wave of a five-wave longitudinal study. The sample included 120 mothers in their third trimester of pregnancy. Regression analyses were conducted in order to examine adult romantic attachment as a possible protective or vulnerability factor. Main effects of attachment anxiety and attachment avoidance on PTSD symptoms were found, such that higher levels of attachment anxiety and attachment avoidance were related to more PTSD symptoms. Attachment avoidance moderated this relationship, such that child abuse was significantly related to greater PTSD symptoms in those with high attachment avoidance. Implications for attachment-based interventions are discussed.