Introduction

Several symposia at the 154th Annual Meeting of the American Psychiatric Association were focused on the psychological disorders that arise from traumatic life experience.^[1]

Statistics tell a surprising story but the incidence of comorbidity and the association of severe mental illness with posttraumatic stress disorder (PTSD) and extreme stress or trauma highlights a need for more research and greater clinical awareness.

The National Comorbidity Study found a lifetime prevalence rate of PTSD of 7.8%, with rates being twice as high in women (10.4%) as in men (5%).^[2] There were exceedingly high rates of psychiatric comorbidity in respondents with PTSD in this study -- 88.3% were found to have 1 or more comorbid Axis I diagnosis. Males with PTSD were especially likely to have a comorbid psychiatric diagnosis. These males were 14 times more likely to have a second lifetime diagnosis, whereas females with PTSD were 8 times more likely to have a second lifetime diagnosis. The most common diagnoses that were comorbid with PTSD were alcohol abuse and major depression, each occurring in approximately half of patients. Although males were found to be exposed to more trauma, women were found to be more likely to develop PTSD after trauma, with approximately 20% of women developing PTSD after trauma compared with 8.8% of men.

Researchers have used data from a large epidemiologic study in Australia, the National Mental Health and Well-Being Survey, to examine whether PTSD precedes other Axis I comorbid disorders chronologically.^[3] They found that after the development of PTSD, respondents were:

• 26 times more likely to develop affective illness  
• 37 times more likely to develop generalized anxiety disorder  
• 28.6 times more likely to develop panic disorder  
• 6.5 times more likely to develop alcohol abuse

In total, 89.5% of affective disorders in men and 65.5% of affective disorders in women occurred after development of PTSD. Also 62.5% of anxiety disorders in men and 50% of anxiety disorders in women occurred after the development of PTSD.

Suicide ideation and attempts also appear to be a major risk for patients with PTSD. Sixty-two percent of respondents in the Australian study with PTSD were found to have experienced suicidal ideation.

One of the common experiences clinicians have is that the severity of PTSD varies greatly among patients and is based on the developmental phase in which the trauma occurred and how repetitive the trauma was. PTSD researchers have developed several new diagnostic terms to describe patients with severe PTSD who often had early trauma exposure that was repetitive and severe. They have coined the diagnostic terms "complex posttraumatic stress disorder" and "disorders of extreme stress (DESNOS)" to describe these patients.^[4] The diagnostic criteria for these disorders involve impairment of affective regulation; chronic self-destructive behavior (eg, self-mutilation and drug abuse); amnestic and dissociative episodes; alterations in relationship to the self; distorted relationships to others; somatization and loss of sustaining beliefs. Data from the DSM-IV field trials showed that patients with PTSD who had sustained trauma before age 14 were more likely to meet these criteria for complex PTSD.^[5] Also when researchers have compared clinical populations of patients with PTSD to respondents of epidemiologic community surveys who have PTSD, the clinical populations have been found to have more suicidal ideation, affective dysregulation, and unprotected and promiscuous sexual behavior.^[6] In other words, clinical populations are more likely to include patients with complex PTSD. Patients with this complex form of PTSD have been found to have an average of 4 or more DSM-IV comorbid conditions and a high likelihood of meeting criteria for 1 or more personality disorders.

Also emphasized in this symposium was that fact that most trials of either medication or psychotherapy for PTSD have not enrolled representative populations because patients with complex PTSD have usually been excluded due to their comorbidities. It is essential in future trials to include these patients because they represent a large number of patients that clinicians are faced with in everyday practice, and yet there are no scientific studies to guide treatment choices. This point was emphasized by the data presented by Julian Ford, PhD,^[1] of the University of Connecticut, Farmington. He examined the experience of multiple traumas that patients with severe and persistent illness experienced over their lifetime and found that there was a 100% lifetime prevalence of at least 3 of 12 possible types of psychological trauma. There was also a 40% current and 75% lifetime prevalence of PTSD and complex PTSD as well as substantial Axis I and Axis II comorbidity. Complex PTSD was the disorder most associated with psychiatric illness, substance abuse severity, and healthcare utilization.^[7,8]

References

1. Ford J, Fournier D, Moffitt K. Trauma, PTSD, and disorders of extreme stress in women with severe mental illness. Program and abstracts of the 154th Annual Meeting of the American Psychiatric Association; May 5-10, 2001; New Orleans, Louisiana. Symposium 70D.
2. Kessler RC, Davis CG, Kendler KS. Childhood adversity and adult psychiatric disorder in the US national comorbidity survey. Psych Med. 1997;27:1101-1119.
3. Henderson S, Andrews G, Hall W. Australia's mental health: an overview of the general population survey. Aust N Z J Psychiatry. 2000;34:197-205.
4. Ford JD. Disorders of extreme stress following war-zone military trauma: associated features of posttraumatic stress disorder or comorbid but distinct syndromes? J Consult Clin Psychol. 1999;67:3-12.
5. Roth S, Newman E, Pelcovitz D, van der Kolk B, Mandel FS. Complex PTSD in victims exposed to sexual and physical abuse: results from the DSM-IV Field Trial for Posttraumatic Stress Disorder. J Trauma Stress. 1997;10:539-555.
6. Brom D, Kleber RJ, Witztum E. The prevalence of posttraumatic psychopathology in the general and the clinical population. Isr J Psychiatry Relat Sci. 1992;28:53-63.
7. Rosenberg HJ, Rosenberg SD, Wolford GL 2nd, Manganiello PD, Brunette MF, Boynton RA. The relationship between trauma, PTSD, and medical utilization in three high risk medical populations. Int J Psychiatry Med. 2000;30:247-259.
8. Hidalgo RB, Davidson JR. Posttraumatic stress disorder: epidemiology and health-related considerations. J Clin Psychiatry. 2000;61(suppl 7):S5-S13.