Mohammed T. Abou-Saleh

580 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYquickly as possible, with the expectation that the trauma victimwill return to full functioning. Abreaction can be fostered throughindividual or group psychotherapy 6 .POST-TRAUMATIC STRESS DISORDERPost-traumatic stress disorder (PTSD) first appeared in DSM-IIIbut was based on older concepts tied to the history of warfare. DaCosta wrote of ‘‘irritable heart’’ following the American CivilWar. In World War I the disorder was known as ‘‘shell shock’’.Early twentieth century psychoanalytic theory called it ‘‘traumaticneurosis’’ and in World War II it was known as ‘‘traumatic warneurosis’’ or ‘‘combat neurosis’’. In DSM-I it was renamed ‘‘grossstress reaction’’, a reaction to great stress in a normal personality.During the peace time between World War II and Vietnam, thecategory was omitted from DSM-II 7 . ICD-9 defined catastrophicstress and combat fatigue as two diagnoses under the category ofacute reaction to stress.DSM-III defined intrusive re-experience of the trauma, togetherwith emotional numbing, as the central features of PTSD. DSM-III-R placed more emphasis on the avoidance of stimuliassociated with the trauma and less on numbing. DSM-IVchanged the definition of the trauma to an event where a personexperienced, witnessed or was confronted with threatened deathor serious injury or threat to physical integrity of self or others.Here, the response to the trauma involves intense fear, helplessnessor horror. Also, where DSM-III-R required eithernumbing or avoidance behavior, DSM-IV requires both 3 .ICD-10 criteria more closely resemble those of DSM-III,highlighting the restriction of emotional responsiveness. In ICD-10 the late chronic sequelae of devastating stress, i.e. thosemanifesting decades after the stressful experience, should beclassified under enduring personality change after catastrophicexperience 2 .Clinical FeaturesThe ICD-10 diagnosis of PTSD requires evidence of trauma, or aresponse to a stressful event or situation of exceptionallythreatening or catastrophic nature, likely to cause pervasivedistress in anyone. The central symptoms are repetitive andintrusive recollections (flashbacks) or re-enactment of the event inmemories, daytime imagery or dreams. The onset follows thetrauma with a latency period of a few weeks to months (rarelyexceeding 6 months). There may also be a sense of ‘‘numbness’’and emotional blunting, and avoidance of activities and situationsreminiscent of trauma.Anxiety, depression, suicidal ideation and insomnia are alsocommon in many PTSD patients, particularly with advancingage 7 . PTSD is also associated with alcohol and drug abuse,possibly reflecting attempts to cope with PTSD symptoms.Dissociative symptoms, commonly described in younger PTSDvictims, become less prevalent with increasing age 8,9 .It remains a subject of debate what factors, if any, predisposeindividuals to the development of the post-traumatic stresssyndrome. Some traumata, particularly the concentration campexperience, are so severe that symptoms are almost universal insurvivors. Because retrospective assessment of function before thetraumatic event is always colored by the response to the event,correlations are difficult to draw and empirical analyses have beeninconclusive 10 . Certain personality traits (e.g. compulsive, asthenic)and a previous history of neurotic illness may possibly lowerthe threshold for manifestation of the disorder 2 .PTSD can also develop from bereavement. A recent studysurveyed surviving spouses 2 months after their spouses’ deaths;10% of those whose spouses died after a chronic illness metcriteria for PTSD; 9% of those whose spouses died unexpectedlymet PTSD criteria; and 36% of those whose spouses died from‘‘unnatural’’ causes (suicide or accident) had PTSD 11 . PTSD canalso occur when patients have suffered the ‘‘trauma’’ of having astroke (9.8%) 12 and upon learning that they have breast cancer(3%) 13 .Although PTSD symptoms can persist for many years, withincreased frequency of symptoms towards the end of life 14 , thetypical course is one of fluctuating symptoms 15 in many cases. Onestudy, examining current PTSD symptoms in elderly World WarII and Korean War prisoners of war (POWs), suggested thatseverity of exposure to trauma and lack of post-military socialsupport were moderately predictive of PTSD. In this study, 53%of POWs met criteria for lifetime PTSD, with 29% meetingcriteria for current PTSD, but for those POWs most severelytraumatized, the lifetime PTSD rates were 83%, with currentPTSD at 59% 16 .There are two types of PTSD to which the elderly seemsusceptible: delayed-onset PTSD and chronic PTSD. In delayedonsetPTSD, patients may exhibit signs of the disorder decadesafter the trauma, and in chronic PTSD symptoms have beenpersistent since the time of the trauma.Delayed-onset PTSD is a reactivation of an old PTSD, withmany years relatively free of symptoms, or the first onset ofsymptoms years after the trauma. In some elderly World War IIveterans, media coverage commemorating the 50th anniversary ofthe end of the war triggered PTSD symptoms 17 . Commonly, guilt,distorted memory, emotional numbing, estrangement and feelingsof detachment, are seen 18 . Patients in this group can present withphysical symptoms of cardiovascular, gastrointestinal and musculoskeletaldiseases 10 . Generally, the onset of severe symptomscan be linked to a profound recent life event, such as death of awife, job retirement or loss of physical integrity from illness 18 .Most often, the contemporary precipitant reawakens emotionsand perceptions from the original trauma. Holocaust survivorsand prisoners of war have been noted to begin displayingsymptoms of PTSD after admission to nursing homes, wherethey re-experience a loss of freedom and autonomy. World War IIveterans found the loss of physical integrity due to somatic illnessparticularly upsetting, since it evoked memories of a traumaticperiod when their physical integrity was in jeopardy 9 .Differential DiagnosisAlthough adjustment disorders also occur in response to lifeevents, these events are in the normal range of human experience,unlike the extraordinary traumata responsible for PTSD. Specificfeatures of numbing and flashbacks do not occur, and adjustmentdisorders, by definition, do not last more than 6 months. Acutestress reaction is characterized by a more variable clinical picturethat resolves within days.While anxiety and depression are common features of PTSD,generalized anxiety disorder and phobic disorder have anxiety as amore specific and central symptom. Major depression is markedby deep and persistent mood disturbance, usually with loss ofreactivity; dysthymia results in chronic, indolent dysphoria. Noneof these disorders includes the specific symptom of intrusiverecollections.TherapyThe signs and symptoms of post-traumatic stress disorder includedistorted expectations and perceptions, mood disturbances,psychophysiological symptoms and social withdrawal. Thus,