Dr Robert London

PTSD: Another Great Masquerader

Clinical Psychiatry News - May 1, 2009

Over the years, physicians have been familiar with certain diseases they refer to as the Great Masqueraders. These illnesses have the capacity to appear in different forms from the usual presentations, and medical students are taught, oftentimes, to view them as illnesses that may masquerade with unusual symptoms.

In the past, tuberculosis and syphillis were considered masqueraders, and today connective tissue diseases such as systemic lupus erythematosus are examples of illness masqueraders, Dr. Lavonna J. Branker, an internist in New York City, said in an interview. Sometimes, illnesses present differently depending on the patient's gender, Dr. Branker pointed out. For example, cardiovascular disease in women can present or masquerade as jaw pain–not the typical chest pain.

Another masquerader is posttraumatic stress disorder (PTSD). This illness can masquerade as depression or various spins on anxiety disorders or “neurotic” behaviors that I discussed in my recent column on anxiety (“Anxiety Disorders: A Proposal,” March 2009, p. 37).

PTSD is defined clearly in the DSM-IV as the development of “characteristic symptoms following exposure to an extreme traumatic stressor.” Examples can be found in patients who have experienced military combat, violent personal assault, kidnapping, torture, incarceration, and/or man-made or natural disasters. The list of extreme traumatic stressors can be quite long. However, I believe that many depressed or anxiety-ridden people whose experiences were less severe than those described in the DSM-IV suffer from PTSD of the subthreshold or subclinical variety.

Over the last century, PTSD has been developed as an illness or disorder with a variety of names based on severe emotional trauma and symptomatology. Examples of such traumas and complexes are shell shock, soldier's heart, combat neurosis, combat fatigue, or De Costa syndrome, known for more than a century as neurocirculatory asthenia. And as descriptions and names have changed over the years, no common-sense continuum of this disorder, called PTSD since only 1980, has emerged.

In clinical medicine, for example, we establish many illnesses and disorders based on a continuum such as grades of headache and use of the terms mild or moderate. But PTSD is graded in narrower terms focusing on the severity of the original trauma or the patient's symptoms–not on a broader continuum as is often seen in practice.

In clinical practice many times we treat anxiety and depressive disorders, using various models of understanding and interpretation as to origins of the problem, i.e., psychodynamic, learning theory, and other models. But a fair number of these anxiety and depressive disorders, when explored by historical events in a person's life, are likely to be subthreshold or subclinical PTSD. Furthermore, these subthreshold or subclinical forms of PTSD are not necessarily less symptomatic than those that originate from extreme traumatic events. In my experience, a milder traumatic experience does not necessarily lead to a milder set of symptoms. It appears each case must be assessed individually.

I recall two distinct examples of problems that I treated as PTSD. Two men who experienced life events that were emotionally traumatic but not the kind of extreme trauma suggested by the DSM-IV. Each had suffered a major loss and disruption of lifestyle. The first person was affected profoundly by a job loss involving a substantial reduction in income and a subsequent change of lifestyle. The second was affected profoundly by divorce. Neither of these two events is usually considered a potential source of PTSD. Both were symptomatic for depression and anxiety. However, besides anxiety and depression, the patients experienced flashbacks and nightmares, which forced them to relive the traumatic experiences long after the events, as well as other symptoms usually present in PTSD.

The main difference between the men was that one had an intense reaction; the other suffered moderate PTSD symptoms. Many individuals would not be traumatized by these kinds of events, and would pick up the pieces and move along in life. And this leads us to consider various ideas that offer insights on predicting predispositions of certain mental disorders.

When treating PTSD, whether the traditional DSM type or the subthreshold or subclinical variants, numerous techniques have been and continue to be used. These techniques range from traditional explorative therapy (which is mainly outdated and ineffective in treating PTSD) to medication management, to behavior modification. The latter includes systematic desensitization, reciprocal inhibition, guided imagery, and variations of my own learning, philosophy, and action (LPA) technique.

Some of the latest techniques include virtual reality, in which, using a head-mounted device, an interactive program can be created to replay traumatic events in an ascending hierarchical manner to expose and desensitize the patient. Virtual reality employs techniques developed in video games, where people and places can be replicated to show and play back events of the trauma experienced by the patient. This is a high-tech version of in vitro desensitization, which many therapists using behavioral techniques have used successfully with guided imagery.

However, virtual reality goes a step further, as I see it, in bringing an in vitro technique closer to an in vivo situation that is more effective for many people but traditionally has not been used because of the logistics of doing in vivo desensitization. I certainly believe that virtual reality holds great promise, both in medical centers and outpatient settings, not only for PTSD but numerous medical/psychiatric disorders.

But it seems that visual techniques, whether guided imagery or in vitro virtual reality, produce the best outcomes when treating PTSD. Subthreshold and subclinical PTSD appear to be great masqueraders with origins and symptoms that lie along a broader continuum than suggested by the DSM-IV. It's important to recognize this continuum and offer our patients the best treatments.

Let me know your thoughts on subthreshold and subclinical PTSD, and I'll try to pass this along to my readers.