PSYC 2490 Study Guide - Summer 2018, Comprehensive Midterm Notes - Mental Disorder, Syndrome, Psychiatry
12 Oct 2018
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Department
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PSYC 2490
MIDTERM EXAM
STUDY GUIDE
Fall 2018
CASE #4
POSTTRAUMATIC STRESS DISORDER (PTSD) HAS A LONG MILITARY HISTORY:
Historically, in DSM-III and DSM-IV, we considered PTSD to be an anxiety disorder
because it begins with a fear-provoking situation. Avoidant behaviours, common to
anxiety disorders, are evident. The individual anxiously avoids both thoughts about the
event and situations that remind them of the event. PTSD also involves the strong
autonomic nervous system arousal that is also common to panic attacks and phobias.
Your textbook discusses PTSD as essentially an anxiety disorder in Chapter 5.
However, in ICD-10, PTSD is listed as under the category of Reaction to severe
stress, and adjustment disorders, which is distinguished from panic, phobias, and
general anxiety disorders. OCD is also listed separately from anxiety disorders
DSM-5 has altered its chapters to be more consistent with ICD-10, thus also separating
PTSD and OCD into distinct chapters. Why? Firstly, PTSD is a reaction to a severe
traumatic event, and thus it is distinguished by being a reaction to severe stress. Trauma
can either be a single event (such as severe accident or natural disaster) or a prolonged
stress (such a prolonged military tour of duty in a war zone). Secondly, PTSD has
aspects of being a dissociative disorder, reflecting a disrupted memory processing. We
will study dissociative disorders in Unit 4. Thus DSM-5 places PTSD in between the
chapters on Anxiety Disorders and Dissociative Disorders, indicating its linkage to both.
The importance in DSM-5 of where chapters are placed is a theme that we will see is
repeated when we study mood disorders (Unit 5).
Furthermore, when we study the history of PTSD in the military, we will find that it initially
resembled a somatic symptom disorder (DSM-5), also called somatoform (ICD-10); also
found in our course in Unit 4 along with dissociative disorders. Somatoform or somatic
symptom refers to an expression of emotional stress or conflict as a physical symptom.
CRITICAL POINT: HISTORY WILL TEACH US THAT PTSD CONTAINS ELEMENTS OF 3
CATEGORIES OF MENTAL DISORDERS: ANXIETY, DISSOCIATIVE, AND SOMATIC
SYMPTOM DISORDERS. THIS ILLUSTRATES THAT OUR DIAGNOSTIC CATEGORIES
ARE NOT DISTINCT, BUT OVERLAP CONSIDERABLY WITH MANY COMMON
SYMPTOMS.
HISTORY OF POSTTRAUMATIC STRESS DISORDER
Military reactions to war trauma and stress are integral to the history of the PTSD
diagnosis. Our current understanding of PTSD is in large part as a result of the problems
in the 1970s that were being experienced by Vietnam veterans. Vietnam was a difficult
experience for American soldiers and airmen as they were fighting a prolonged losing
battle in Asian jungles, constantly in danger and with many casualties. Further
complicating the experience, many at home in the USA (and in other countries such as
Canada) perceived this as illegitimate war, and there were many public protests against
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it. This made the experience of returning Vietnam veterans quite unlike WWII veterans.
WWII veterans were treated as heroes from a legitimate war to keep the world free;
Vietnam vets experienced shame. As a result, there was a high rate of mental disorders
experienced in Vietnam veterans. Veterans of the Vietnam War lobbied for help with a
common set of nervous symptoms. It was during the period after Vietnam, in the late
1970s, that those treating Vietnam veterans came to propose the diagnosis of PTSD,
which was formally recognized as a disorder in DSM-III, published in 1980.
Since then, the term PTSD has been extended far beyond the military, to accidents,
natural disasters, and crime victims. Our case study book chapter provides as example
of PTSD due to a subway train accident. PTSD may be experienced by victims, or for
example, by ambulance or emergency workers attempting to rescue or treat victims.
PTSD is not restricted to the direct victim but can be experienced by many individuals
witnessing or involved in the event.
Actually, a form of non-military PTSD was well recognized in Britain and elsewhere over
a hundred years ago. Like our case study involving a train collision, in the late 1800s and
early 1900s there were some horrendous collisions due to brake failures and head on
collisions (fortunately this is much more rare today). Some victims of these train
accidents were psychiatrically diagnosed with what was called traumatic
neurasthenia (Rivers, 1922). Neurasthenia still exists as a diagnostic category in ICD-
10, but not DSM. Neurasthenia has many somatic and anxiety symptoms such as
fatigue, feelings of muscular aches and pains, dizziness, tension headaches, sleep
disturbance, an inability to relax, and stomach upset. Thus traumatic neurasthenia from
1900 train wrecks was a mixture of anxiety and somatic symptom disorders, and
obviously has many similarities to the current PTSD diagnosis.
PTSD IN THE MILITARY
The military has a particular concern about PTSD. Data from the recent Iraq and
Afghanistan wars indicates that PTSD in soldiers runs as high as 15%. In several
Canadian cities, the Canadian military funds PTSD treatment centres for the Canadian
military and RCMP personnel and families. It is called an Operational Stress
Injury Clinic, named in this manner to denote that it treats stress due to military or police
“operations.” In Winnipeg, the OSI Clinic is located at Deer Lodge Centre and employs
several clinical psychologists.
Much can be learned about PTSD by considering the history of soldiers in war and their
reactions to severe conditions and trauma. Soldiers’ extreme emotional reactions to
severe trauma are nothing new. In recorded history, reports of battle stress or battle
fatigue can be found in writings as early as 500 B.C. For example, in 490 BC the Greek
historian Herodotus described how during the Battle of Marathon, an Athenian soldier
who had suffered no injury from that battle had became permanently blind after
witnessing the death of a fellow soldier. This symptom of psychologically caused
blindness is technically more of a somatic symptom “conversion disorder” than PTSD
(chapter 7, p.137), but as we have already noted PTSD likely has both dissociative and
somatoform aspects in addition to anxiety.
In a 1871 study of 300 veterans if the American Civil War, Jacob Da Costa, an American
physician who taught at Jefferson University, described common symptoms of fatigue,
shortness of breath, palpitations, sweating, and chest pain. He called it irritable heart,
but it came to be known as “soldier’s heart” or Da Costa's syndrome. These symptoms
are very similar to the traumatic neurasthenia from train wrecks.
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Document Summary
Posttraumatic stress disorder (ptsd) has a long military history: Historically, in dsm-iii and dsm-iv, we considered ptsd to be an anxiety disorder because it begins with a fear-provoking situation. Avoidant behaviours, common to anxiety disorders, are evident. The individual anxiously avoids both thoughts about the event and situations that remind them of the event. Ptsd also involves the strong autonomic nervous system arousal that is also common to panic attacks and phobias. Your textbook discusses ptsd as essentially an anxiety disorder in chapter 5. However, in icd-10, ptsd is listed as under the category of reaction to severe stress, and adjustment disorders, which is distinguished from panic, phobias, and general anxiety disorders. Ocd is also listed separately from anxiety disorders. Dsm-5 has altered its chapters to be more consistent with icd-10, thus also separating. Firstly, ptsd is a reaction to a severe traumatic event, and thus it is distinguished by being a reaction to severe stress.
