Disturbo post-traumatico da stress: fattori di ... - Marco Cannavicci

Giornale di Medicina Militare - A. 154°, Fasc. 1-2, gen. - apr. 2004
1. Introduction
Post-traumatic stress disorder: risk factors
Historically the concept of a psychogenic reaction to
stressful and traumatising events was introduced by
Bleuler in 1911. However similar concepts had already
been elaborated at the end of the last century in the definitions
of “post-traumatic neurosis” by Oppenheim (1892)
and “fright neurosis” by Kraeplin (1896). (Table 1).
The concept of “psychic trauma” originated then at
the end of the last century at the same time as events
linked with changes in technological and industrial
development. These were railway accidents, mining
accidents and those related to industrial gas, and later
the Great War with the psychic impact of new longrange
firearms. These arms brought about the appearance
of mass traumatic events.
The concept of “war neurosis” came about with the
First World War, and not by chance, the first congress
of the International Psychoanaltical Society, in Budapest
in 1924, was in fact dedicated to war neurosis.
Sigmund Freud, himself, dealing with dreams and
traumatic nightmares linked to disorders of Austrian
First World War veterans, was forced to revise his first
theory of instincts, and introduce, for example, the
psychoanalytical concept of “repitition compulsion”.
The current case histories of “Post traumatic stress
disorder” are mostly reported in North American literature,
thanks above all to the work of researchers who
collect systematic data in the event of natural catastrophes,
wars, industrial and technological disasters, etc.
There are also case histories which are less ample
but equally interesting, supplied by organisations such
as the police, military corps, fire service, Red Cross, etc.
2. Diagnostic and Clinical Criteria
Schematically the general criteria for defining “post traumatic
stress disorder” in the DSM-IV are represented by:
• persistent tendency to relive the traumatic event
through dreams, nightmares, intrusive memories
when thinking, flashbacks, etc;
• persistent avoidance of stimuli associated with the
trauma and general reactive weakening;
and protective factors
Marco Cannavicci Michele Donvito
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• persistent symptoms of increased “neuro-vegetative”
arousal.
It is possible however to recognise symptoms that
are more specific than others for differential diagnosis
of Post-traumatic stress disorder compared to other
anxiety and mood disorders, as in Table 2.
These are for example, nightmares, flashbacks,
keeping at a distance from others, loss of interest in
carrying out one’s business, avoiding things, people,
situations that recall the event.
The groups of symptoms present in the DSM-IV
cannot all be considered at the same level, in that some
symptoms or psychopathological reactions are often
the effect of the other symptoms.
Pathological avoidance (phobia), for example, has
a defensive function towards suffering that is considered
intollerable, neurovegetative hyperactivation is
a psychic correlation in reaction to the psychological
situation of avoidance.
Intrusive memories and nightmares seem to represent
instead an attempt to “reprocess” cognitively the
information linked to the event of the trauma,
moreover without success.
Table 1 - Evolution of the concept of psychic trauma.
Post-traumatic neurosis Oppenheim 1892
Fright neurosis Kraepelin 1896
War neurosis Simmel 1918
Psychogenic disorders Bleuler 1911
Reactions to events Jaspers 1913
Physioneurosis Kardiner 1941
Abnormal reactions to events Schneider 1946
Key Events Kretschmer 1966
Transitory situational disorders DSM-II 1968
Acute reactions to stress ICD-9 1978
Adaptation disorders DSM-III-R 1987
Post-traumatic stress disorder DSM-III-R 1987
Acute reaction to stress ICD-10 1989
Post-traumatic stress disorder ICD-10 1989
Adaptation disorder ICD-10 1989
Post-traumatic stress disorder DSM-IV 1996