Entitlement Eligibility Guidelines

Post-traumatic Stress Disorder

Definition

Post-Traumatic Stress Disorder (PTSD) is classified as acute, chronic, and with delayed onset. For pension purposes, acute PTSD, i.e. when duration of symptoms is less than 3 months, will not be pensioned.

The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders 4th edition (DSM-IV) has defined PTSD as a psychiatric condition if it meets the following 6 criteria:

1. The person has been exposed to a traumatic event in which:
   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; and
   2. The person's response involved intense fear, helplessness, or horror; and
2. The traumatic event is persistently re-experienced in one or more of the following ways:
   1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions;
   2. Recurrent distressing dreams of the event;
   3. Acting or feeling as if the traumatic event were recurring (including a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awaking or when intoxicated);
   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; and
3. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before 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); and
4. 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; and
5. Duration of the disturbance (indicated by the relevant symptoms set out in paragraphs (b), (c) and (d)) is more than one month; and
6. The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning.

Diagnostic Standard

A diagnosis from a qualified medical practitioner or a psychiatrist or a registered/licensed psychologist is required. The diagnosis is made clinically. Supporting documentation should be as comprehensive as possible and should satisfy the requirements for diagnosis as outlined in the DSM-IV diagnostic criteria.

Anatomy and Physiology

PTSD is a condition that can develop as a result of an individual's exposure to an extremely traumatic stressor, especially if the individual response involves intense fear, helplessness, or horror. The disorder may be particularly severe or long-lasting when the stressor is of human design (e.g. torture, rape), and trust is lost. Trauma may be personal trauma or witnessed trauma, examples of which are as follows:

• The direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity; or
• Witnessing an event that involves death, injury or threat to the physical integrity of another person.

Such personal trauma events include, but are not limited to:

• Military combat
• violent personal assault (sexual assault, physical attack, robbery, mugging)
• being kidnapped
• being taken hostage
• a terrorist attack
• torture
• incarceration as a prisoner of war or in a concentration camp
• being required to exhume a dead body or body parts
• natural or man-made disasters
• severe automobile accidents, of a nature which meets the above-noted criteria or equivalent

Witnessed events include, but are not limited to:

• observing serious injury or unnatural death of another person due to violent assault
• accident
• war
• disaster
• unexpectedly witnessing a dead body or body parts

Studies indicate that the prevalence of PTSD for at risk populations (e.g. Vietnam veterans, rape victims, Rwandan peacekeepers, and Armenian children after an earthquake) ranges from 14 - 75%. It is considered that the wide range of prevalence rates reflects the variety of measurement criteria used to diagnose PTSD.

Epidemiological studies show that PTSD often remains chronic, with a significant number of persons remaining symptomatic several years after the event.

The disorder cannot exist unless the individual has been exposed to a traumatic stressor with a particular set of properties. While trauma is a necessary factor, few would consider it to be sufficient to cause PTSD. The relative importance of the traumatic event, predisposing factors, and environmental factors shortly before or after the trauma must all be considered in understanding the etiology of PTSD. In most instances, occurrence of the disorder represents the outcome of an interaction amongst these three groups of factors.

Predisposing factors include the identification of genetic vulnerability to the development of PTSD. Because of different reactions to the same traumatic event, it cannot be said that psychological models alone fully account for the development of PTSD. Other than genetics, premorbid vulnerability factors include a prior history of psychiatric disorder, a family history of psychiatric disorder, a pre-existing personality disorder or traits, poor peer and social support, and a prior history of trauma. Normal adaptive mechanisms for processing life experiences may eventually become overwhelmed by psychological trauma, if the trauma is sufficiently severe.

There are 3 psychological theories of PTSD, which are briefly described as follows:

1. Psychodynamic Theory
   • When faced with an overwhelming traumatic experience, the mind mobilizes defences in order to survive. In order to make sense of the trauma, the survivor develops intrusive and avoidance symptoms, and through the use of repetition and compulsion attempts to master the memories. This is adaptive in Adjustment Disorder and Acute Stress Disorder, but in PTSD the process is overwhelmed and symptoms persists.
2. Cognitive/Behavioural Theory
   • Fears associated with PTSD develop through classical conditioning, i.e. an unconditioned stimulus produces an unconditioned response which becomes associated with a conditioned stimulus. For example, a person is robbed in an elevator by a man in a yellow raincoat. The robbery (unconditioned stimulus) produces fear (unconditioned response), and the sight of a yellow raincoat (conditioned stimulus) becomes associated with the same fear. These new, classically-condition fears are maintained through operant conditioning. Escape or avoidance behaviours are reinforced by their anxiety-relieving effects. Over time, increasing numbers and types of stimuli may become elicitors of anxiety, and symptoms of PTSD are maintained.
3. Cognitive Network Theory
   • Original traumatic events conflict with prior beliefs. For example, a person who grows up to believe that women and children are to be protected may find this principle challenged when placed in a combat situation.

New information that is congruent with prior beliefs about self or the world is assimilated quickly and without effort because the information matches current schemas. When schema-discrepant effects occur, as in trauma, individuals must reconcile the effect with their beliefs about themselves and the world. Accordingly, their schemas must be altered or accommodated to incorporate this new information. Because of the strong effect associated with the trauma, this process is often avoided. Thus, rather than accommodating beliefs to incorporate the trauma, victims may distort the trauma to ensure that their beliefs remain in tact.

PTSD has been shown to have a number of unique biological features, separate from other mental disorders. These include changes to the hypothalmic-pituitary axis (which regulates the body's response to stress), decreased cortisol levels, and higher glucocorticoid receptor sensitivity. These factors demonstrate that the body's response to traumatic stress in PTSD differs from other mental health disorders. Despite exposure to the same trauma, it is only those who suffer from PTSD who undergo biological changes in response to the trauma. Subsequent stressors may also contribute to biological alterations.

Clinical Features

For pension purposes, PTSD is classified as "chronic" or "with delayed onset". Chronic PTSD is used when symptoms last 3 months or longer. PTSD of delayed onset is used when at least 6 months have passed between the traumatic event and onset of symptoms.

To make a diagnosis of PTSD for pension purposes, it is required that symptoms last for a minimum period of 3 months and that the disturbance causes an impairment or clinically significant distress.

The characteristic symptoms of PTSD are as follows:

• Re-experiencing the traumatic event,
• Avoidance of stimuli associated with the event,
• Numbing of general responsiveness,
• Increased arousal.

1. Re-experiencing the traumatic event

   The traumatic event can be re-experienced in a variety of ways. Commonly, the person has recurrent and intrusive recollections of the event or recurrent distressing dreams during which the event is re-experienced. In rare instances there are dissociative states lasting from a few seconds to several hours or even days, during which components of the event are relived and the person behaves as though experiencing the event at that moment. There is often intense psychological distress when the person is exposed to a situation that resembles an aspect of the traumatic event or that symbolizes the traumatic event, e.g. an anniversary of the event.

2. Avoidance of stimuli

   There is persistent avoidance of any stimuli associated with the traumatic event or a numbing of general responsiveness that was not present before the trauma. The person commonly makes deliberate efforts to avoid thoughts or feelings about the traumatic event and about activities or situations that arouse recollections of it. This may include psychogenic amnesia for an important aspect of the traumatic event.

3. Numbing of general responsiveness

   Diminished responsiveness to the external world, referred to as "psychic numbing" or "emotional anesthesia", usually begins soon after the traumatic event. A person may complain of feeling detached or estranged from others, that he or she has lost the ability to become interested in previously enjoyed activities, or that the ability to feel emotions of any type, especially those associated with intimacy, tenderness and sexuality, is markedly decreased.

4. Increased arousal

   At least one of the five of the following symptoms not present before the trauma is required:

   1. Difficulty falling or staying asleep (recurrent nightmares during which the traumatic event is relived are sometimes accompanied by middle or terminal sleep disturbance)
   2. Irritability or anger
   3. Poor concentration
   4. Hyper-vigilance
   5. Exaggerated startle response

Some persons complain of difficulty in concentrating or in completing tasks. Many report increased aggression. In mild cases, this may take the form of irritability with fear of losing control. In more severe forms, particularly in cases in which the survivor has actually committed acts of violence (as in war veterans), the fear is conscious and pervasive and the reduced capacity for expressing angry feelings may lead to unpredictable explosions of aggressive behaviour.

Avoidance of stimuli, numbing of general responsiveness, and hyperarousal symptoms must occur after the exposure to trauma if they are to be valid diagnostic symptoms. This can be a difficult judgment to make in cases in which PTSD has arisen from an ill-defined set of early childhood traumas or even a clearly defined event some 20 or 30 years earlier. A detailed summary of symptoms and manifestations of PTSD includes the following:

The long term course of PTSD is variable. Recovery varies from permanent recovery to no resolution of symptoms and deterioration with age. There may exist a relatively unchanging course with only mild fluctuations, or obvious fluctuations with intermittent periods of well-being and recurrences of major symptoms. The startle response, nightmares, irritability, and depression have been noted to increase with time in many persons. These symptoms often represent a poor prognostic sign.

It is important to remember that there are diseases other than PTSD which can result from trauma, e.g. mood disorders, other anxiety disorders, dissociative disorders, eating disorders, and substance abuse.

It should also be noted that PTSD is unlikely to occur alone. Psychiatric comorbidity is the rule rather than the exception, and a number of studies have demonstrated that in both clinical and epidemiological populations a wide range of disorders is likely to occur. These include some depression disorders, all of the anxiety disorders, alcohol and substance abuse disorders, somatization disorders, schizophrenia and schizophreniform disorder.

Schizophrenia and schizophreniform disorders are not commonly observed in the military, having been screened out early in an individual's military career. It should also be noted that PTSD may overlap with impulse control disorders in view of the anger, irritable outbursts and periodical recourse to violence that occur in PTSD.

Pension Considerations

1. Causes and / or aggravation
2. Medical conditions which are to be included in Entitlement / Assessment
3. Common medical conditions which may result in whole or in part from Post-Traumatic Stress Disorder and / or its treatment

1. Causes and/or Aggravation

   The timelines cited below are not binding. each case should be adjudicated on the evidence provided and its own merits.

   1. Exposure to a traumatic stressor prior to clinical onset or aggravation

      PTSD need not have its onset during combat. For example, vehicular or airplane crashes, large fires, floods, earthquakes, and other disasters could evoke significant distress in most involved persons.

      Trauma may be experienced alone (e.g. rape or assault), or in the company of groups of persons (e.g. military combat).

      A stressor should not be limited to one episode. A group of experiences may lead to PTSD. In some circumstances, for example, assignment to a grave registration unit/burn care unit, or liberation/internment camps could have the cumulative effect of powerful, distressing experiences essential to a diagnosis of PTSD.

      PTSD can be caused by events which occur before, during, or after service. The relationship between stressors during service and current problems/symptoms will govern the question of service- connection.

      PTSD can occur hours, months, or years after a service-related stressor. Despite this long latent period, service-connected PTSD may be recognizable by a relevant association between the stressor and the current presentation of symptoms.

   2. Inability to obtain appropriate clinical management
2. Medical Conditions Which are to be Included in Entitlement/Assessment
   • Anxiety disorders
   • Mood disorders
   • Schizophrenia and other psychotic disorders
   • Adjustment disorders
   • Personality disorders
   • Eating disorders
   • Substance-related disorders
   • Dissociative disorders
   • Pain disorders/chronic pain syndromes
   
   
3. Common Medical Conditions Which may Result in Whole or in Part From Post-Traumatic Stress Disorder and/or its Treatment
   • Sexual dysfunction (e.g. erectile dysfunction)
   • Irritable bowel syndrome

References for Post-traumatic Stress Disorder

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington: American Psychiatric Association, 1994.
2. Australia. Department of Veterans Affairs: medical research in relation to the Statement of Principles concerning Post-Traumatic Stress Disorder, which cites the following as references:
   1. American Psychiatric Association. 1980. Diagnostic and Statistical Manual of Mental Disorders (3rd ed.) Washington: American Psychiatric Association.
   2. American Psychiatric Association. 1987. Diagnostic and Statistical Manual of Mental Disorders (3rd ed. revised) Washington: American Psychiatric Association.
   3. Boyle C.A., Decoufle P, & O'Brien T.R. 1989. Long-term health Consequences of Military Service in Vietnam. Epidemiologic Reviews 11:1-27.
   4. Davidson J.R.T., Hughes D., Blazer D.G., and George L.K. (1991) Post-traumatic stress disorder in the community: an epidemiological study. Psychological Medicine, 21: 713-721.
   5. Eaton W.W. & Kessler L.G. 1985. The NIMH Epidemiological Catchment Area Program. In Epidemiological Field Methods in Psychiatry (ed. W.W. Eaton & L.G. Kessler) Academic Press: New York.
   6. Goldberg J, True W, Eisen S, Henderson W.G. 1990. A Twin study of the Effects of the Vietnam War on Post-Traumatic Stress Disorder. JAMA, 263:1227-1232.
   7. Helzer J.E., Robins L. & McEvoy L. 1987. Post-traumatic stress disorder in the general population. Findings from the Epidemiologic Catchment Area Survey. New Eng J Med 317: 1630-1634.
   8. The Centres for Disease Control Vietnam Experience Study, 1989. Health Status of Vietnam Veterans: Volume IV. Psychological and Neuropsychological Evaluation. US. Department of Health and Human Services, Atlanta, Georgia.
   9. The Centres for Disease Control Vietnam Experience Study. 1988. Health Status of Vietnam Veterans. 1. Psychosocial Characteristics. JAMA. 259: 2701-2707.
3. Friedman, Matthew J. Aug 1998. Current and Future Drug Treatment for Post-Traumatic Stress Disorder Patients. Psychiatric Annals. 28(8):461-468.
4. Kaplan, Harold I. and Benjamin J. Sadock, eds. Comprehensive Textbook of Psychiatry. 6th ed. Baltimore: William and Wilkins, 1995.
5. Marshall, Randall D. and D. Pierce. 2000. Implications of Recent Findings in Post Traumatic Stress Disorder and the Role of Pharmacotherapy. Harvard Review of Psychiatry. 7:247-256.
6. Pain, Clare. Feb 2000. Post-traumatic stress disorder: Understanding and Treatment. Patient Care Canada. 11(2).
7. Tasman, Allan and Jerald Kay, et al. Psychiatry. 1ST ed. Philadelphia: W.B. Saunders, 1997.
8. Ungar, Thomas E., et al. June 2000. Recognizing Post-Traumatic Stress. Patient Care Canada. 11(6).
9. Veterans Affairs Canada. Medical Guidelines on Stress, 2000.
10. Veterans Affairs Canada. Protocol for Disability Pensions and Health Care. Management and Adjudication of Cases. Feb 17, 2000.
11. Watson, Patricia, Miles McFall, Caroll McBrine, et al. Updated Practice Guideline for Post-Traumatic Stress Disorder. Compensation and Pension Examinations. National Center for PTSD. Received by VAC via e-mail, Aug 2000.
12. Weir, Erica. Oct. 31, 2000. Veterans and post-traumatic stress disorder. Canadian Medical Association Journal. 163(9):1187.

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