Post-traumatic stress disorder (PTSD) was first introduced into the Diagnostic and Statistical Manual (DSM) of the American Psychological Association in 1980. Since then, the diagnostic guidelines have been reviewed multiple times, and the understanding of risk factors, neurobiological consequences and psychological symptoms has improved dramatically.

While many still connect the diagnosis with veterans returning from war, the majority of cases are diagnosed in survivors of sexual assault. This reflects changes in the diagnostic criteria as former versions only included traumatic events that were life threatening for the patient.

The current diagnostic manual (DSM‑5) lists several ways of experiencing trauma that can lead to the development of PTSD, including the direct experience of a traumatic event, witnessing an event where the victim is someone else but the patient was present, learning about a traumatic event that concerned a close family member or friend and lastly, experiencing repeated exposure to details of traumatic events (e.g. because work exposes one to these details).¹

COVID and PTSD symptom groups

The three symptom categories of PTSD, according to the current International Classification of Diseases 11th revision (ICD‑11), are re‑experiencing, avoidance and sense of threat.² The DSM‑5 includes a fourth one, namely negative changes in mood or cognition. The diagnosis must be connected to an event or a series of traumas, which is an important difference to diagnoses, such as depression.

As a result of COVID‑19, frontline medical workers and other first responders have been in the spotlight when discussing possible psychiatric sequelae of the pandemic, including PTSD, as their exposure to trauma and death has been extremely high for an extended period of time under intense circumstances.

It is important to keep in mind that not everyone exposed to trauma will develop PTSD. Studies show that about 20% of trauma survivors meet the criteria,³ although these numbers vary for different trauma categories. For rape, the number is as high as 49%.⁴

Possible risk factors for PTSD include having had an episode of another psychiatric condition such as depression, and a genetic predisposition.⁵ However, in the aftermath of SARS, increased PTSD diagnoses in medical staff were observed⁶ and should be expected in some members of this specific target group because of the COVID‑19 pandemic.

Media outlets have also suggested that other vulnerable groups were displaying PTSD symptoms while social distancing, or after a COVID‑19 infection; however, these claims need to be taken with a grain of salt. The pandemic was and still is a very burdensome time for almost everyone for a plethora of reasons. An increase in symptoms, such as avoidant behavior and intrusive memories, as well as changes in mood are to be expected in times like these and not everyone reporting some symptoms will meet the clinical diagnosis of PTSD. Many might rather display a case of adjustment disorder, or just a normal response to a very extraordinary and stressful time that will leave no damaging and lasting effects on their mental health.

Adjustment disorder, PTSD and cPTSD

The differences between adjustment disorder and PTSD are the onset and duration and the number and severity of symptoms experienced. PTSD usually occurs with a delay after the traumatic event and can be experienced for a long period of time (onset is commonly within three months, and symptoms must be present for at least one month). In contrast, adjustment disorder can be diagnosed right after the event has happened and can be diagnosed for any level of stressor (including stressors not meeting the PTSD criteria, e.g. losing a job).

Adjustment disorder can also be diagnosed in cases where the symptom profile does not meet that of PTSD. An example is grief after a loved one has died that exceeds the usual grieving process but does not meet the criteria for persistent complex bereavement disorder. The duration of adjustment disorder is limited to six months, after which another diagnosis should be considered.

In the ICD‑11, the diagnosis of complex PTSD (cPTSD) was introduced. Although this debilitating disorder is not included in the DSM‑5, it has been on the map for many professionals for years. Many patients suffering from cPTSD are individuals who had to endure violence and abuse over a long period of time, often starting in childhood. The symptoms of these patients tend to have a slightly different and more far‑reaching impact on their daily functioning and cognition.

Along with the burdensome core symptoms of PTSD mentioned above, cPTSD is characterised by additional symptom clusters, namely affect dysregulation (poor ability to manage emotional responses), negative self-concept and difficulties in relationships.⁷ In many cases, the trauma was experienced during a formative time in life when self-image and attachments to primary caretakers are formed. If trauma occurs in this vulnerable time, it impacts the way someone approaches interpersonal relationships and thus develops attachment and coping strategies. Many people who endured severe and prolonged trauma in their early years struggle as adults to find healthy ways of connecting to others and forming relationships built on trust to form secure bonds.

This group of patients also experiences more severe somatic symptoms compared to those with PTSD alone. Of course, prolonged trauma can also happen to survivors of trauma experienced in adulthood – cPTSD can develop at any age after repeated trauma exposure. Many studies suggest that trauma related to cPTSD alters biological processes, such as the stress response and the nervous system reactivity, exacerbating the symptoms connected to increased arousal and hypervigilance by burdening the body in a systemic way over a long period of time.⁸

Treatment of PTSD

In the past, many psychiatrists and therapists believed that prolonged exposure therapy, in which the memories of the trauma are discussed in a safe setting to decrease the emotional response, is the best way to treat PTSD. However, many patients who experienced multiple traumas or over a longer period of time cannot access the memories, or only parts of them, due to the brain trying to compartmentalise these moments as a coping mechanism. The most common treatments for these patients are cognitive behavioural therapy (CBT) and eye movement desensitization and reprocessing (EMDR).

Some patients are prescribed pharmaceuticals, such as antidepressants to target symptoms connected to hyperarousal and changes in mood, but most patients do not experience significant relief by taking them. Some patients suffer from severe night terrors or sleep issues. Alpha blockers are sometimes prescribed and seem to help with sleep issues, but a large group of patients is still not getting any symptomatic relief from pharmaceutical interventions. However, novel drug treatments – such as experimental treatments with MDMA and ketamine – are entering general practices and hospitals, but both are recommended to be used in combination with cognitive behavioural therapy.⁹

For veterans suffering from PTSD, virtual reality exposure therapy (VRET) is a promising new treatment approach, that has been shown to be as effective as other therapeutic measures, such as CBT and exposure therapy, for both PTSD symptom severity and also depressive symptoms, in this particular patient group.¹⁰

Lastly, transcranial magnetic stimulation (TMS) has been found to be effective in patients with PTSD. This non‑invasive treatment, also used for major depression, can inhibit or excite neurons in the brain by using an external magnet on the scalp of patients.¹¹

Awareness is key

Clearly, PTSD is a debilitating disorder that a small amount of people develop after experiencing a traumatic event. The variation in combinations of symptoms experienced by patients, together with their diverse responses to treatments, underlines the fact that this disorder is complex and affects many aspects of a patient’s life. New treatment options are emerging but for many patients complete remission is not achieved.

The current pandemic could lead to an increase in diagnoses for certain occupational groups, but awareness of the disorder could help vulnerable individuals to reach out for treatment in an early phase of the disorder, possibly preventing a chronic course of illness.

Nevertheless, an increase in PTSD both in underwriting and claims assessment should be expected for certain occupations and individuals who have experienced severe trauma during the pandemic. It is therefore important to be aware of the clinical picture of PTSD and adjacent diagnoses, to differentiate between people displaying symptoms but staying subclinical and those affected by PTSD or other trauma-related disorders. The reported treatment and course of illness together with the clinical history can give important hints about the prognosis of such cases, ultimately enabling underwriters and claims assessors to handle such complex cases successfully and with the care they require.

June 27 is National PTSD Awareness Day, many useful resources can be found on the American Psychological Association website.

Endnotes

1. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC.
2. World Health Organization (2020). International Statistical Classification of Diseases and Related Health Problems (11th ed.).
3. Avigail Moor & Moshe Farchi (2011) Is Rape-Related Self Blame Distinct From Other Post Traumatic Attributions of Blame? A Comparison of Severity and Implications for Treatment, Women & Therapy, 34:4, 447‑460.
4. Ibid.
5. Pitman, R. K., Rasmusson, A. M., Koenen, K. C., Shin, L. M., Orr, S. P., Gilbertson, M. W., Milad, M. R., & Liberzon, I. (2012). Biological Studies of Post-Traumatic Stress Disorder. Nature reviews. Neuroscience, 13(11), 769–787.
6. Wu, K. K., Chan, S. K., & Ma, T. M. (2005). Posttraumatic Stress after SARS. Emerging Infectious Diseases, 11(8), 1297‑1300.
7. See endnote 2.
8. Herringa RJ. Trauma, PTSD, and the Developing Brain. Curr Psychiatry Rep. 2017 Aug 19;19(10):69. Doi: 10.1007/s11920-017-0825-3. PMID: 28823091; PMCID: PMC5604756.
9. (In Dutch) Krediet, E., Bostoen, T., Breeksema, J., van Schagen, A., Passie, T., & Vermetten, E. (2020). Reviewing the Potential of Psychedelics for the Treatment of PTSD. The International Journal of Neuropsychopharmacology, 23(6), 385–400.
10. (In German) Kothgassner, O. D., Goreis, A., Kafka, J. X., Van Eickels, R. L., Plener, P. L., & Felnhofer, A. (2019). Virtual Reality Exposure Therapy for Posttraumatic Stress Disorder (PTSD): A Meta-Analysis. European Journal of Psychotraumatology, 10(1), 1654782. https://doi.org/10.1080/20008198.2019.1654782
11. Rossi S, Cappa SF, Ulivelli M, De Capua A, Bartalini S, Rossini PM. rTMS for PTSD: Induced Merciful Oblivion or Elimination of Abnormal Hypermnesia? Behav Neurol. 2006;17(3‑4):195‑9. doi: 10.1155/2006/793256. PMID: 17148840; PMCID: PMC5471538.