Written by Jeannie Singleton, MSW, LSW on September 04, 2019
Startle response, nightmares, sleep problems, hypervigilance, intrusive recollections, and flashbacks are some of the most common signs and symptoms of posttraumatic stress disorder, also commonly known as PTSD. Symptoms of PTSD are often disruptive and make it difficult for individuals, and oftentimes their family members, to get through what used to be normal daily activities.
It has been reported that approximately one third of survivors with a major burn injury experience PTSD after discharge.Fortunately, significant advances have been made in the research and treatment of PTSD, and it is my hope that this three part series will help shed some light on the subject.
This first article will shed light on some basic information on PTSD, including its history and how it is diagnosed. The second article will focus on treatment, and the third article will discuss the impact that PTSD has on individuals and families.
As a medical social worker assigned to the only burn center in Hawaii, I am often asked by patients and family members what causes PTSD and what can be done to treat it. When looking back through history, it’s clear that post-traumatic stress disorder has been around for a very long time, although it’s been referred to by a variety of names.
For example, in the American Civil War the term “soldier's heart” was used to describe what soldiers experienced after participating in the Battle at Antietam where 15,000 soldiers were killed in one hour. Soldiers suffering from psychiatric breakdown “were put on trains with no supervision, the name of their home town or state pinned to their tunics; others were left to wander about the countryside until they died from exposure or starvation.”
In World War I, soldiers displaying signs of PTSD were often described as suffering from “gas neurosis,” “trench neurosis,” or “shell shock.” World War II, Korea, and Vietnam soldiers exhibiting symptoms of PTSD were told that they were experiencing combat psychosis/neurosis or combat/battle fatigue.
According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)3, in order for an individual to be diagnosed with PTSD that person must meet certain diagnostic criteria, which is described briefly and generally below:
Directly experiencing the event
Witnessing, in person, the event as it occurred to others
Learning about a violent or accidental event that occurred to a significant individual
Experiencing repeated/extreme exposure to averse details of traumatic events (does not include electronic media/pictures, unless work related)
There are numerous ways that an individual can be exposed to a traumatic event, such as:
Traumatic events can be caused by crime victimization (assault, rape, child abuse)
Natural or manmade disasters (tsunamis, earthquakes, fires)
Sudden life-threatening illness
Once it has been established that a person meets criterion A, the next step is to look at criterion B, which is the re-experiencing of symptoms. In order to meet diagnostic criteria, an individual must experience at least one of the following:
Recurrent, involuntary, intrusive thoughts/memories of the trauma
Recurrent distressing dreams of the event
Reliving the experience as if it were recurring (flashbacks)
Intense emotional distress after exposure to trauma reminders
Intense physical reactions to trauma reminders
Assuming that the individual has met criteria A and B, we would move on to check if that person also meets criteria C, D, and E before saying that this individual has PTSD.
Criterion C focuses on the avoidance symptoms, which means that an individual must experience at least one of the following:
Effortful avoidance of thoughts/feelings associated with the trauma
Avoidance of situations, activities, or places that remind one of the traumas
Criterion D addresses negative changes to thoughts/mood and an individual must experience at least two of the following:
Can’t remember important aspects of the trauma
Persistent, exaggerated negative beliefs about the self, others, and the world
Persistent, distorted thoughts about the cause of the trauma that leads to self/other blame
Persistent negative emotional state
Decreased interest in significant activities
Feelings of detachment from others
Persistent inability to experience positive emotions
Criterion E focuses on increased arousal symptoms, and an individual must experience at least 2 of the following to meet criteria:
Irritability or anger outbursts
Reckless or self-destructive behavior
Exaggerated startle response
Problems falling or staying asleep
It is important that an individual who is concerned they may have PTSD see a provider who is familiar with PTSD and who can complete a good assessment.
Some of the important things that a provider should look for when completing an assessment is the ability to link the symptoms directly back to the trauma, particularly the re-experiencing of symptoms.
It is also important that there is an assessment of prior functioning—symptoms that existed at a similar level prior to the trauma. For instance, being angry would not count toward the PTSD diagnosis if the individual has a prior history of anger management problems.
Another thing to keep in mind when undergoing assessment for symptoms of PTSD is the importance of working with a behavioral health provider or clinician who is familiar with PTSD, rather than trying to self-diagnose. This is important because what an individual reports experiencing can be different than the clinical interpretation of the symptom.
For example, it is normal to have an occasional nightmare or a bad trigger moment, everyone does even without trauma, but a good assessor will be able to contextualize the symptoms and detect changes in functioning, which is key to diagnosis.
Accurately diagnosing PTSD can be difficult because there is a significant overlap between PTSD and other mental health diagnoses. For example, there is a significant overlap of negative changes in mood/cognition and depression symptoms, and personality disorders can display many of the criteria D and E symptoms.
Although all the reasons listed above are good reasons for having a solid assessment completed, I believe the most important reason is because PTSD treatments will simply not be effective if the individual is not experiencing PTSD. We will explore this topic more in part 2 of this series where we will look into what is being done to successfully treat post-traumatic stress disorder.
1. Fauerbach JA, McKibben J, Bienvenu OJ, et al. Psychological distress after a major burn injury. Psychosom Med. 2007:69:473–482.
2. Bentley S. A short history of PTSD: From Thermopylae to Hue soldiers have always had a disturbing reaction to war. VVA Veteran. March/April 2005.
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association;2013.
Jeannie Singleton is a licensed medical social worker currently working in the burn center and ICU unit at Straub Medical Center. Her prior experience includes working in child welfare services, adult mental health and substance abuse, and the Veterans Administration. Jeannie received her certification in cognitive processing therapy for PTSD while working with veterans in the traumatic stress recovery program.