What is PTSD?

Key points

• PTSD is caused by exposure to a traumatic event or series of events

• The symptom picture lasts for more than one month

• PTSD can affect anyone in society, not just combatants

• PTSD is a normal reaction to an abnormal event(s)

Todd: There has been a slow evolution of names and diagnoses for soldiers with Post-Traumatic Stress Disorder (PTSD) since World War I; initially combatants were diagnosed with 'shell shock', so named as it was believed to have been a result of concussion from the impact of artillery shells. During the modern conflicts of the 20th Century the symptom picture progressed along with the change in designation, with terms such as 'battle fatigue', 'combat stress' and the more general 1950s definition of 'gross stress reaction'.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the go-to manual for most psychiatrists, psychologists, and general practitioners when diagnosing mental health disorders. The manual is currently in its Fifth Edition and each edition is designated by Roman Numerals, such as DSM II or DSM IV. In between publishing new editions, the American Psychiatric Association has also printed Text Revisions (TR) – as an example, DSM III TR. However, the current edition is designated by numerals: DSM 5. This rationale sounds a lot like something the Army would do. This is not an attempt to teach you to suck eggs, but I feel it is important to be on the same page as our treating clinical support team. Therefore the majority of statements referenced within this chapter will be from the extant DSM 5.

Before we tackle PTSD, it is pertinent to identify what encompasses trauma from a clinical perspective. A traumatic stressor is defined within the DSM 5 as any event (or events) that may cause or threaten death, serious injury, or sexual violence to an individual, a close family member, or a close friend. Traumatic events include, but are not limited to, exposure to war as a combatant or civilian, threatened or actual physical assault, threatened or actual sexual violence, being kidnapped, being taken hostage, terrorist attack, torture, natural or man-made disasters, and severe motor accidents. This is only a part of the diagnostic definition, in addition there are eight criteria that incorporate the symptom picture and lead to a formal diagnosis. Each element will be discussed in turn.

The essential feature of PTSD is the development of characteristic symptoms following exposure to one or more traumatic events. The clinical presentation varies. In some individuals, fear-based re-experiencing, emotional, and behavioural symptoms may predominate. The DSM refers to a few mood states of which you may not be familiar with: anhedonia and dysphoria. Anhedonia is defined as the inability to experience pleasure or have any fun. Dysphoria is regarded as a feeling of uneasiness, discomfort, anxiety, or anguish. It is at this point that it should be noted that in previous editions of the DSM, PTSD was characterised as an anxiety disorder, however it is now placed between trauma and stress-related disorders.

Before we start analysing the diagnostic features and criteria, I want to reinforce that it is not just service personnel who may develop PTSD, indeed it can affect anyone from every walk of life. My personal experience is one of a military background, which has a unique organisational culture and operating environment. Similarly, so do the emergency services, first responders, and the personnel of border protection agencies. Hence, my focus within the handbook will be upon the effects of PTSD within the service culture.

The initial part of the definition of a traumatic stressor is quite clear: exposure to actual or threatened death, serious injury, or sexual violence. It is easy for one to identify or acknowledge triggers from the previous statement, particularly for military personnel during their operational service. However, with first responders these waters are somewhat muddied and it may not be easy to identify one specific trigger. Indeed, the PTSD may have developed as a result of an accumulation of numerous traumatic incidents that led to the development of the disorder.

The last part of the initial descriptor is something that requires further discussion: to an individual, a close family member, or a close friend. Having previously mentioned that the service culture is unique, I would now suggest that in terms of relationships it is akin to family. The majority of my military tenure was within infantry and special operations units; very close-knit teams particularly at lower levels, where groups comprised a small number of personnel. As with most families, these men and women may not all like each other, but they know the most intimate details about their team members, and the bond between them is extremely strong. These bonds are forged during initial training, mission rehearsal exercises, and reinforced during operational deployments. Notably, it is the latter part of the aforementioned definition that may often be overlooked with regard to the development of PTSD: exposure of a traumatic event to a close family member, or a close friend.

Diagnostic Criteria

In the section below, I have summarised the eight diagnostic criteria (A-H) that describe the full symptom picture. Some are quite detailed and others are very simple. Further, some of the elements require two or more of a specific criterion to be present before a diagnosis is confirmed. Leaving this part to the clinicians, I will describe or extrapolate upon the statements within the DSM 5 to give you a greater understanding of the components within the criteria as they have affected me.

A) Exposure to trauma

While deployed to Malaysia, I was involved in a fatal motor vehicle accident. Five of my soldiers were killed and many others seriously injured. My ultimate task was recovery of the bodies back to Australia,...