Consider PTSD Subtypes in Patient Workup

Posttraumatic stress disorder (PTSD) is a confusing diagnostic category because it includes victims of trauma as well as individuals exposed to trauma. Also, PTSD encompasses exposure to different types of trauma, which can have significant implications for symptom development and treatment. Consider the treatment history of a male combat veteran who exhibits multiple PTSD symptoms, including nightmares, flashbacks, social isolation, anger, and guilt related to his war experiences. Several psychiatrists saw the patient, which resulted in multiple medication changes but little benefit. On further assessment, the practitioners noted that the veteran's war experiences were minimally problematic; the prominent nightmares, ruminations, flashbacks, and guilt were related to his witnessing a civilian female being sexually assaulted. The veteran's guilt about not intervening was the basis of his PTSD. This led to a change in treatment from pharmacotherapy to a focus on supportive therapy. Conceptualizing subtypes of PTSD--similar to many DSM-IV-TR diagnoses such as phobias or delusional disorders--might help better define the diagnosis. Each subtype, as conceptualized below, might have its own prognosis and treatment. Our hope is that this strategy will benefit the patient by improving research and evidence-based practice. PTSD subtypes Victim-related trauma. Related to witnessing a criminal act or being a victim of a criminal act such as rape or assault. The patient is in a passive role. Natural disasters, such as a tornado, earthquake, or hurricane. Survivor guilt. The patient is not a perpetrator and might have been exposed to trauma, but symptoms are related to surviving while others close to the patient did not. Perpetrator guilt. It is debatable whether this should be a PTSD subtype but our experience suggests that this pattern severely complicates PTSD diagnosis and treatment. It often is not initially disclosed by patients but surfaces when treatment is not working despite a strong therapeutic alliance. PTSD not otherwise specified. This subtype is typical in patients who were not directly involved in a traumatic event but experienced symptoms related to it. Examples include picking up dead bodies, cleaning up a tornado site, or observing siblings being beaten. This category also may reflect an unclear picture if no primary subtype accounts for the majority of symptoms. Qualifiers Individuals who previously have been exposed to trauma are more vulnerable to subsequent trauma. Experiencing ongoing multiple traumatic events--such as in military combat--can have a cumulative effect. Thus, identifying episodes of trauma also should be part of the PTSD assessment. Single event. The patient is exposed to a single traumatic episode, such as being the victim of a crime. …