For the diagnosis of PTSD to be made, there must be clinical evidence that the person was affected in some specified way. The first criteria for PTSD can be summarized as follows:
The person has been exposed to a traumatic event in which both of the following were present:
- The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury or a threat to the physical integrity of self or others; and,
- The involved person’s response was intense fear, helplessness, or horror.
The symptoms that are necessary for a diagnosis of PTSD to be made can be grouped into three categories.
- Re-experiencing the event
1. Re-experiencing occurs if one or more of the following happens:
- The person has recurrent and intrusive distressing recollection of the event in question. This may take the form of vivid images (i.e., believes he can see it with his eyes happening right there in his presence). However, it may not be images but “live” thoughts of what happened. It may not be any of these but perception in his mind that it is happening again.
- When the person goes to sleep, he has recurrent dreams of the traumatic event in the form of nightmares. They may wake up screaming. Many people with these symptoms will be afraid of falling asleep because they do not want to get those dreams.
- Acting or feeling as if the traumatic event was reoccurring.
This needs elaboration and examples. Many people were affected after the terrorist bomb blast in Nairobi in 1998. One such person who was referred for psychiatric care particularly remembered the loud noise of the blast. On one occasion, he was walking in the streets of Nairobi when there was a tyre burst. Immediately, he believed the terrorists had come back and had exploded another bomb. He ran around scared and screaming, “they are back, they are back!”
- There is intense psychological distress at exposure to internal or external cues (reminders) that symbolize or resemble an aspect of the traumatic event. This is best illustrated by another story by the same survivor of the bomb blast. Every time he heard the siren of an ambulance, he screamed “they have struck again and now people are being ferried to the hospital.” The reader will probably remember people who feel and behave as if a dreaded event is happening again when they see reminders of what happened.
- Physiological reactivity on exposure to internal or external cues that symbolize or resemble the event. Physiological reactivity means that the person’s bodily functions, that is, increased heart beat, increased breathing rate, and dilated eye pupils, are as would happen when a person is in real danger. These are symptoms of acute fear and fright.
Children may present re-experiencing in a different way. This takes the form of plays that mimic what they saw, happen. If they saw their father being shot with a gun, they will play a shooting game. However, they express themselves in drawings that depict what they saw.
2. Avoidance can manifest in several ways, although only a minimum of three are required to qualify for this group of symptoms:
- The person makes deliberate efforts to avoid thoughts, feelings, or conversations that are associated with the traumatic event.
- Making deliberate efforts to physically avoid activities, places, or people that remind him or her of the traumatic event.
- Inability to recall (shutting out) an important aspect of the trauma.
- Included under avoidance are several symptoms that are typical or highly suggestive of depression, but which, nevertheless, serve to protect the individual from the recollection or even thoughts or concern related to the event.
- Markedly diminished interest or participation in important activities, such as family or social activities.
- Feeling of disconnect from other people, preferring to be left alone.
- Feeling of emotional detachment from others—not able to feel for others.
- A feeling of having nothing to look forward to or expecting everything to go awry or something bad to happen.
3. Increased Arousal
For the symptoms to qualify for this group of symptoms then at least two are required out of the five listed below:
- They have persistent difficulty in falling asleep or staying asleep—When they retire to bed, they will take longer to fall asleep than they normally do or did before the traumatic event. They cope with this in several possible ways—either listen to music or read or just get out of bed and pretend to be busy. Those who smoke may find themselves smoking more or those who drink may drink more as a way of trying to relax and get some sleep. Others medicate themselves sometimes using drugs they should not use to induce sleep. It is not unusual for some to sedate themselves with cough or allergy drugs, or other medicines that a friend has told them about (read the chapter on drugs, section on nonprescribed drugs). It is dangerous to use certain types of medicines unless they are prescribed by a qualified health professional.
Beside difficulties in falling asleep in the first place, even if one ends up falling asleep in the first place, he gets inadequate sleep—they keep on waking up at the slightest noise or disturbance. It is like they are half asleep and half awake.
- They are irritable—They get upset about things that ordinarily would not upset them. These upsets are accompanied by outbursts of anger. This can be highly disruptive within family circles and with social friends, even in the work situation. If it is the father who is irritable, the families get very badly affected. He may be mistakenly thought of by the children and other family members as being uncaring or even cruel. It can be particularly painful to the children if it is the mother whom they normally associate with love, care, and tenderness, is irritable. This is particularly so if the irritability takes the form of both verbal and physical aggression. If it is a child who is irritable, then the consequence can be grave to the child, especially if it is mistaken for rudeness and insolence to the parents and other adults, such as school teachers.
Irritability in the work situation can be equally disastrous. If it is the boss who is irritable, then everybody is kept on their toes. If it is a junior person who is irritable, this could be mistaken for insubordination with serious consequences. So, watch out for irritability and handle those with this condition with understanding: talk to them; ask them to seek for help, etc.
- Difficulty in concentration—When people cannot concentrate, it means they cannot keep their mind focused on one thing at a time. It is like their minds wander off to other things instead of remaining focused on the task at hand. If you tell them your name, they will not remember it after a few seconds or minutes. If you read a newspaper, you cannot remember what you have just read. Somebody will keep his money and then forget where he kept it and instead believe it was stolen, and start accusing his friends or family members of stealing his money. If it is a child in class, he cannot follow what the teacher is saying and therefore will not remember what the teacher said. And if he is given a book to read he will not remember what he read. It is therefore not surprising that his class performance will deteriorate fast. This is particularly of great concern if important national examinations are round the corner. The unfortunate thing is that the child could be accused of not caring for his classes or performance and may get a verbal lashing from the parents or the teachers.
- Hypervigilance—This is a state of being on the alert as if anything unexpected and undesirable could happen anytime. It is not difficult to recognize a person who is in this state. He is tense and obviously not relaxed. If he sits on a chair or on a sofa, he will sit on the edge, as if in a hurry to leave. Instead of sitting in a reclining backward position, he will sit bending forward with his hands on the knees or armrest, ready to get away at the shortest notice. Instead of his forehead being smooth, it will be wrinkled.
- Exaggerated startle response—The person reacts to any external stimuli with a startle.
A slight sharp noise or a bang will set him forth in the upright position; as if afraid something terrible was just about to happen. He will breathe fast, his heart rate will increase, the pupils of his eyes will dilate and he may sweat.
It is important that the symptoms described above should occur after at least four weeks after the reference traumatic event. They could have started immediately or soon after the event, but unless four weeks are over, they do not qualify for PTSD. Alternatively, the events can occur for the first time much later after the four weeks. If they occur for the first time after six months, then it is referred to as delayed onset PTSD.
Source: Africa Mental Health Foundation