Clinical Definition

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM IV)⁶, a client must meet the following criteria to be classified as having PTSD:

Criterion A: Has been exposed to a traumatic event involving actual or threatened death or injury, during which the individual responded with panic, horror, and feelings of helplessness.

Criterion B: Reexperiences the trauma in the form of dreams, flashbacks, intrusive memories, or unrest at being in situations that remind the individual of the original trauma.

Criterion C: Shows evidence of avoidance behavior-numbing of emotions and reduced interest in other persons and the outside world.

Criterion D: Experiences physiological hyperarousal, as evidenced by insomnia, agitation, irritability, or outbursts of rage.

Criterion E: The symptoms in Criteria B, C, and D persist for at least one month.

Criterion F: The symptoms have significantly affected the personŐs social or vocational abilities or other important areas of life.

PTSD may be either acute or delayed in onset. Acute PTSD occurs within 6 months of a traumatic event. Delayed onset may occur any time later than 6 months after the traumatic event. This may be a year, 20 years, or even 40 years after the event.

Signs and Symptoms

In addition to a history of trauma, there are certain signs and symptoms to watch for when assessing a client for PTSD. Singly, the symptoms are not diagnostic; however, when observed as a cluster of signs and symptoms, the therapist should consider the possibility of PTSD.7

1. Hypervigilance (wariness of others) and hyperarousal (fight or flight response).
2. Emotional absence and/or unresponsiveness.
3. Avoidance of triggers that spring up memories of the trauma.
4. Dreams, nightmares, insomnia.
5. Difficulty in concentration.
6. Irritability or outbursts of anger.
7. Depression.
8. Suicidal thoughts or gestures of self-destructive behavior.
9. Exaggerated startle response or extreme ticklishness.
10. Numbness or hypersensitivity to touch over parts or all of the body.
11. Overwhelming feelings of anger, sadness, fear, despair, shame, guilt, or self-hatred.
12. Migrating symptoms of physical pain.
13. Migraines, fibromyalgia, extreme myofascial tension.
14. Disassociation from self, actions, or parts of the body.
15. Loss of connection with spiritual aspects of life or the ability to imagine a positive future.
16. Distorted relations with the perpetrator or others who remind the client of the perpetrator.

Massage therapists should be aware that there are many clients who may have experienced significant trauma, but their symptoms will appear more consistent with depression. For a concise description and delineation of responses other than PTSD to trauma, refer to Trauma and Recovery by Judith Herman.8 As with all medical and psychiatric conditions, it is extremely important that the client be diagnosed by an appropriate healthcare practitioner. Massage therapists are advised to develop a reliable list of practitioners to whom they can refer clients for diagnosis and with whom they can work to coordinate an effective multidisciplinary, client-centered treatment plan.

Neurobiology

Individuals experience traumatic events differently. For example, one individual who experiences being mugged at knife point may respond in the moment by complying with the mugger, handing over her wallet while memorizing the mugger's face. She thinks that when she gets out of this situation she will go to the police station, identify the perpetrator, and have him charged. Another individual may become frozen with fear and go to a place inside herself that is often described as a place of "speechless terror." She cannot communicate rationally with herself, or reassure herself about a course of action she will take in the future. At the time of the traumatic event she is convinced that she will die.

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