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The National Council of Psychotherapists

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Categories of PTSD Sufferers

Michael O'Sullivan FNCP


In addition to understanding the signs, symptoms and causes of PTSD it is also necessary to gain an understanding of the various subtypes and sub-classifications of PTSD and the probable course of the disorder. PTSD is a generic term, which means that it covers a lot of ground. In order to simplify matters for helper it is useful to chunk this so those clearly discernible patterns can be recognised for what they are. In our discussions of the various categories below remember to bear in mind that generally speaking at least, avoidance symptoms of one form or another can be expected to be present from the moment that the critical incident occurs.


There are considered to be five main 'subtypes' of PTSD sufferer to consider. These are listed in DSM-III-R as:

  1. Acute

  2. Chronic

  3. Delayed

  4. Delayed and chronic

  5. Conditioned Emotional Response


    To this list we also have added further sub-classifications which are:


  7. Simple

  8. Complicated.

Each of these groups is briefly explained:

  1. Acute


    In the acute sufferer symptoms appear within and do not last for longer than six months of the originating stressor. The most common manifestation of PTSD, the acute form is also the category that holds the promise of the most optimistic results for helpers and therapists. Where symptoms develop early we are presented with the best opportunities for early diagnosis, intervention and treatment where appropriate.


    The other forms of PTSD are a lot less common and present much more of a challenge. This is not to detract in any way the very real distress that can be experienced by the acute sufferer, it is merely stating a fact.


  3. Chronic


    The chronic sufferer is displaying symptoms beyond six months of the original stressor. At this point you may be asking why the six month cut off point in both cases. Initially this decision was arbitrary. To complicate things a little bit further an initial diagnosis of acute PTSD within the six-month limit must be re-diagnosed when symptoms persist beyond that time scale.


  5. Delayed


    One of the characteristics of PTSD is that the onset of the condition can be delayed for an unpredictable period of time. It can be a period of months, years or decades. Again the arbitrary six-month cut off is used. Where symptoms don't appear until after six-month of the original stressor then delayed PTSD is diagnosed.


  7. Delayed and chronic


    This is a logical next step in the diagnostic process. In cases where symptoms do not appear until after six months but last for greater than six-months then delayed and chronic PTSD is diagnosed.


  9. Conditioned Emotional Response


    This is a subclass of the delayed & chronic classification of PTSD mentioned above. This classification is not discussed in any detail here because in order to diagnose its presence full medical facilities are required as it involves the administration of sodium pentathol.


  11. Simple


    This refers to the individual sufferer. A 'simple' case of PTSD involves an individual with no previous history of mental health problems (this refers to the full spectrum from stress through neurosis to psychosis) who has experienced difficulties as a result of a single critical incident. In other words until they unexpectedly became involved in a traumatic incident they had never been exposed to any significant psychological distress.


  13. Complicated.

'Complicated' cases of PTSD involve sufferers with a previous history of psychological distress, exposure to multiple critical incidents, or previous long-term exposure to stress syndrome.


As a rule don't be too concerned with taking all of these different classifications, types and diagnostic criteria on board in order to work within a rigid framework. There is a danger of pigeon holing and labelling a client. At the end of the day, although an awareness of the different manifestations of PTSD is very important in the end it all boils down to being able to work with the individual that you find facing you. He is less interested in academic knowledge than you are. All he wants to know is can you help him? The textbook is useful in its place but can't replace empathy, understanding and a willingness to give it your best.

  • Low & High Symptom PTSD

It has become common in discussing PTSD to define the trauma experienced by the nature of the trauma that the person has been exposed to. Fortunately most people never have the need to educate themselves properly about the issues raised by trauma.


For this reason those same people expect an individual to be more traumatised by involvement in a headlining dramatic event and remain unaware that every day produces new trauma victims - Road Traffic Accidents (RTA's) are a common cause for example. Most RTA's do not make the headlines and often only merit a mention on local radio if there has been a fatality or if they are the cause of a road being blocked.


Hence in most peoples minds they become a five minute headline, forgotten almost as soon as heard, or an inconvenience making them detour or delaying them on the way home from work. What is forgotten in this scenario is that it is not possible to objectively analyse possible affects because these will be experienced subjectively by those both directly and indirectly involved in a trauma. To provide an example - it is very possible for a Mother to experience a much more severe traumatic response to an incident involving her child than might be experienced by the child himself.


Perception plays a key role in PTSD, thus we may like to consider that it may not be so much what happened that is causing the problems associated with it - but rather peoples perceptions of it. This may not make sense to some people but it is never the less it seems to be true!


Therapists of every discipline agree that in many cases helping a person to change the way that they perceive things plays an important part in helping them to come to terms with or overcome problems in their lives. PTSD is no exception.


Stressor events


Let's examine briefly four classifications of stressor events - Type I, II, III & IV.:

  • Type I stressors are unanticipated sudden single events leading to PTSD. An RTA can qualify as such an event.

  • Type II are enduring and repetitive in nature and are predictable after onset. Domestic violence, torture and sexual molestation are points in case.

  • The Type III paradigm was developed in order to provide a framework for working with institutionalised children from dysfunctional families. Berk listed eight common characteristics in the history of these children as a result of his studies:

  1. Lack of positive role modelling

  2. Failure to protect the child or engender a feeling of safety

  3. Lack of structure

  4. Lack of unconditional positive regard

  5. Lack of suitable problem solving strategies

  6. Lack of education in social norms

  7. Raised in 'Abnormal' environment which became their 'Normal' environment

  8. High levels of inconsistency and unpredictability

In this case it is the environment as a whole which is considered to be the stressor rather than a single incident. Berk proposed that eventually Type II environments lead to the development of PTSD symptoms. Type III PTSD is characterised by irritability, startle response, sleep problems, detachment, numbing and dissociative reactions. Personality disorders can be experienced as learned behaviour and an institutionalised child from such a family background may also consider conflict interpersonal relationships to be the norm. (The - If you are not hitting me you can't love me syndrome)


  • Type IV stressor - Chernobyl is a classic example of a Type IV stressor. The long term affects are very difficult to measure effectively - leaving aside for a moment those people who were directly involved in the incident. People on the other side of the Planet experienced great distress as a result of the incident and some had to be helped to overcome a fear of being poisoned by radioactivity.

Remaining with the theme of Nuclear release the 1970's saw hundreds of women camp outside American bases known to house nuclear weapons (Greenham Common) so indicating the very high levels of concern that can be raised. Almost certainly for every person willing to take such an action many more would have been seriously concerned.


Obviously not everyone is affected to exactly the same degree through involvement in a critical incident and it might be more useful to consider the affects that the whole situation is having on the client.


Trauma Resources


Traumatic Stress Clinic - 73 Charlotte Street, London W1P 1LB 020 7436 9000

Trauma Aftercare Trust - Buttfields, The farthings, Withington GL54 4DF - 24 hour Helpline: 01242 890306

Tavistock Centre (Trauma referrals via GP) - 120 Belsize lane, London NW3 5BA 020 7435 7111

Disaster Action - 49/ 50 Eagle Wharf Road, London N1 7ED - 020 7251 2427

Surviving Trauma - 27A Church Street, Rugby, Warwickshire CV21 3PU - 01788 560 800

The Stress Monitor Web Site -

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