Diagnosis and prevalence of posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) is a condition that develops after a single or repeated traumatic psycho-emotional impact on an individual’s psyche. The diagnosis of PTSD was first formulated in 1980 by the American Psychiatric Association.

In 2018, the journal MMR (Medical Military Research) published the article “Posttraumatic stress disorder: from diagnosis to prevention” (Xue-Rong Miao et al), which presented the results of an analysis of more than 3000 PubMed publications related to PTSD. The study presented the current understanding of posttraumatic stress disorder associated with military trauma. The findings published in the article represent a substantial contribution to the contemporary interdisciplinary understanding of posttraumatic stress disorder.

Definition and Differential Diagnosis of PTSD

Today, posttraumatic stress disorder is defined as a chronic disabling psychiatric syndrome associated with significant functional impairment. The etiology and manifestations of the syndrome are not always clear, making diagnosis challenging. According to the DSM (Diagnostic and Statistical Manual), PTSD is classified according to 20 symptoms in four clusters:

• intrusion;
• active avoidance;
• negative alterations in cognitions and mood;
• alterations in arousal and reactivity.

Current PTSD diagnosis is based on criteria related to exposure to a stressor and is determined by the presence of a combination of the following symptoms:

• one intrusion symptom;
• one active avoidance symptom;
• two negative alterations in cognitions and mood;
• two symptoms of alterations in arousal and reactivity with functional impairment lasting for at least one month.

The current International Classification of Diseases (ICD-11) proposes a substantially different diagnostic approach based on six symptoms in three clusters:

• constant re-experiencing of the traumatic event;
• avoidance of traumatic reminders;
• sense of threat.

To establish the diagnosis, at least one symptom from each cluster must be present and persist for several weeks after exposure to the stressor.

Both diagnostic guidelines, ICD-11 and DSM, emphasize the importance of the presence of a traumatic factor and the duration of exposure to the stressor, which distinguish PTSD from other disorders with similar symptoms, such as:

• anxiety disorder;
• adjustment disorder;
• obsessive-compulsive disorder;
• personality disorder.

Despite numerous studies aimed at defining diagnostic criteria for posttraumatic stress disorder, it remains unclear which type and degree of stress exposure can cause PTSD. For example, fear associated with combat trauma is considered a sufficient stressor capable of causing PTSD. However, other stressors, such as feelings of shame and guilt, have also been found to correlate with the causes of PTSD development. These stressors are typical of wartime conditions and are associated with routine human behavior and the actions of military personnel with established moral and ethical beliefs. In addition, family members of military personnel exposed to stressors may also become susceptible to the development of PTSD. Mental health education and prevention programs before military events have been found to be insufficient to prevent or mitigate the impact of wartime stressors. Most research in this field focuses on identifying and systematizing diagnostic criteria and verifying the diagnosis of PTSD.

More relevant information is available via Treatment and prevention strategy of posttraumatic stress disorder

Prevalence of PTSD

The reported prevalence of PTSD ranges from 5.4% to 16.8% among military personnel and veterans, which is almost twice as high as in the civilian population. In recent years, an increase in PTSD prevalence in the population has been observed in association with the rise in global terrorism and military conflicts. Most current studies primarily investigate groups of military personnel and veterans, although PTSD can occur in any population at any stage of life. Manifestations of PTSD among children and adolescents remain insufficiently studied.

In most studies, the prevalence of PTSD among male military personnel (13%) is slightly higher than the corresponding rate among female military personnel (11%). However, women have a higher rate of sexual trauma. After returning to civilian life, 44%–72% of veterans experience high levels of stress. Many veterans with PTSD demonstrate difficulties with emotional regulation and self-control after returning home. More than 80% of patients with PTSD have one or more comorbid conditions. The coexistence of PTSD with traumatic brain injury (TBI) is 48%. In addition, PTSD is frequently accompanied by cognitive impairment.

Additional relevant facts are available via Psychedelic-assisted therapy for PTSD

What mechanisms underlie the development of posttraumatic stress disorder?

What strategies are used in the treatment and prevention of PTSD?

Read about this in our article “Treatment and Prevention Strategy for Posttraumatic Stress Disorder”.

References

Miao XR, Chen QB, Wei K, Tao KM, Lu ZJ. Posttraumatic stress disorder: from diagnosis to prevention. Mil Med Res. 2018;5(1):32. Published 2018 Sep 28. doi:10.1186/s40779-018-0179-0

Author: Olena Vyrva, MD

Questions & Answers

Q1. How do the DSM and ICD-11 approaches to PTSD diagnosis differ?
The DSM approach described in the article includes 20 symptoms across four clusters, whereas ICD-11 uses six symptoms across three clusters. ICD-11 requires at least one symptom from each cluster to persist for several weeks after exposure to the stressor.

Q2. What prevalence of PTSD is reported among military personnel and veterans?
The article reports a prevalence of 5.4%–16.8% among military personnel and veterans. It also notes rates of 13% among male and 11% among female military personnel in most studies.