Psychiatry - July 2008 - (Page 43)

serious lethality intent, work disability or substantial limitation, or any disorder that resulted in 30 or more days out of role in the year. Moderate cases were defined by suicide gesture, plan, or ideation, at least moderate work limitation due to a mental or substance disorder, or any disorder with at least moderate role impairment in two or more domains of the Sheehan Disability Scale, which assesses disability in work role performance, household maintenance, social life, and intimate relationships. All other cases were classified as mild.2 Complex PTSD is characterized by all of the symptoms associated with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) definition of PTSD but also more pronounced problems with emotional regulation, self-image, preoccupation with the relationship to the perpetrator (e.g., preoccupied with revenge fantasies), and interpersonal and occupational relationships, including repeated search for a rescuer. See Table 1 for DSM-IV-TR diagnostic criteria for PTSD. The diagnosis and treatment of PTSD in children provides its own special challenges. Children are apt to display symptoms of PTSD in ways that are different from adults, but common presentations include repetitive play and nightmares. Children who are traumatized are at particular risk for lasting neurobiological changes, including impairments in the corpus callosum, left neocortex, hippocampus, and amygdala.3 Depending on the circumstances, child trauma survivors may or may not have a chance to develop appropriate object relations and a schema of the world being safe. This predisposes them to a host of comorbid axis I and II disorders, as well as PTSD subsequent to traumas later in life (Table 2).4 With regard to treating children with PTSD, evidence is even more sparse, although there is some evidence in favor of trauma-focused 43 TABLE 1. Diagnostic criteria for 309.81 posttraumatic stress disorder A. The person has been exposed to a traumatic event in which both of the following were present: 1. 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 2. The person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior. B. The traumatic event is persistently reexperienced in one (or more) of the following ways: 1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed. 2. Recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content. 3. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur. 4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event 5. Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following: 1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma 2. Efforts to avoid activities, places, or people that arouse recollections of the trauma 3. Inability to recall an important aspect of the trauma 4. Markedly diminished interest or participation in significant activities 5. Feeling of detachment or estrangement from others 6. Restricted range of affect (e.g., unable to have loving feelings) 7. Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span) D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following: 1. Difficulty falling or staying asleep 2. Irritability or outbursts of anger 3. Difficulty concentrating 4. Hypervigilance 5. Exaggerated startle response E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month. F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify if: Acute: if duration of symptoms is less than three months Chronic: if duration of symptoms is six months or more Specify if: With Delayed Onset: if onset of symptoms is at least six months after the stressor [JULY] Psychiatry 2008 43

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Psychiatry - July 2008 Editor's Message Editorial Advisory Board Contents PsychRx Letters to the Editor Reliability of Diagnoses: Do Psychiatrists Use Structured Interviews In Real Clinical Settings? Trend Watch: Use of Atypical Antipsychotics in the Elderly Review: The Struggle for Mental Healthcare in New Orleans-One Case at a Time Psychotherapy Rounds: Psychotherapeutic and Adjuntive Pharmacologic Approaches to Treating Posttraumatic Stress Disorder Original Research: Baseline Dissociation and Prospective Success in Special Forces Assessment and Selection Commentary: Performance-Enhancing Drugs: Where Should the Line Be Drawn and By Whom? Commentary: Psychiatric Diagnosis and the Pathlogist's View of Schizophrenia Journal Watch Classified Advertising Information for Authors

Psychiatry - July 2008

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