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April 1998

Some Biological Factors in the Development of Post-Traumatic Stress Disorder

by Michal Kunz, M.D.

<Read this article on The New York State Psychiatric Association (NYSPA)>

PTSD is a syndrome that develops following an exposure to a severely traumatic event. It is characterized by a persistent reexperiencing of the traumatic event either in intrusive painful recollections (flashbacks) or in dreams, avoidance of situations that trigger the recollection of trauma, numbing of general responsiveness and signs of hyperarousal.

Exposure to trauma produces PTSD. Most common PTSD-producing trauma in males is combat experience, while in females it is rape. Most data on PTSD was derived from war veterans, however the findings can be generalized to non-combat-related PTSD. The National Vietnam Veteran Readjustment Study retrospectively examined symptoms and found a 30% prevalence of PTSD in the year after the war and a 15% prevalence of PTSD twenty years later in Vietnam combat veterans (2). An additional 22% of veterans had experienced partial or subclinical forms of PTSD. 38.8% of males exposed to direct combat experience later developed PTSD as reported in National Comorbidity Survey (3). That indicates that although exposure to trauma is a necessary condition for the development of PTSD, other factors are involved.

Both biological and psychological factors may contribute to the development of a PTSD. Early childhood trauma is associated with the development of combat-induced PTSD. Gurvits et al. (4) found a high prevalence of developmental problems, including delayed onset of walking and speech and learning disabilities in a group of Vietnam War veterans with PTSD. 43.3% of men and 15.4% of women with PTSD had a history of comorbid Conduct Disorder (3).

A group of researchers at the Veterans Hospital in Manhattan (1) investigated the comorbidity of Attention-Deficit Disorder (ADD) and PTSD hypothesizing that ADD, a familial neuropsychiatric disorder, may contribute to the development of PTSD as a vulnerability factor.

PTSD and ADD share numerous common symptoms, including hyperfocus, easy startle response, inattentiveness, feelings of detachment, irritability and angry outbursts. ADD increases the risk for anxiety disorders, mood disorders, substance abuse (7,8) including cocaine abuse (9), Cluster B personality disorders (10) and criminal behavior (11).

In the pilot study (1), 25 male veterans with PTSD and 22 male veterans with Panic Disorder were evaluated for the presence of ADD 36% of subjects with PTSD and only 9% subjects with PD met the criteria for ADD.

There are important implications if ADD is indeed a vulnerability factor for the development of PTSD in terms of preventative treatment of ADD symptoms in at risk population (e.g. military inductees) or pharmacological treatment selection in patients with comorbid ADD and PTSD.

Defining vulnerabilities for trauma-related psychiatric disorders may have implications for forensic-psychiatric evaluations of psychologic damages in civil negligence litigations. Some individuals with significant vulnerabilities may develop PTSD after exposure to an event that does not fulfill the criteria of stressor as defined in the "Diagnostic and Statistical Manual of Mental Disorders, 4th edition" (DSM-IV). The resulting psychiatric damage may be compensable under the legal maxim, "The victim is taken as he is found."

References

1. Adler, L.A., Kunz, M., Resnik, S., Rotrosen, J., Comorbidity of Attention Deficit Disorder in adult patients screened for PTSD. Presented as a poster at 51st Annual Convention of The Society of Biological Psychiatry, 1996.
2. Kulka RA, Schlenger WF, Fairbank JA, Hough RL, Jordan BK, Marmar CR, Weiss DS: Trauma and the Vietnam War Generation: Report of Findings From the National Vietnam Veterans Readjustment Study. New York, Brunner/Mazel, 1990.
3. Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB: Posttraumatic stress disorder in the national comorbidity survey. Arch Gen Psychiatry 1995;52: 1048-1060.
4. Gurvits TV, Lasko NB, Schachter SC, Kuhne AA, Orr SP, Pitman RK: Neurological status of Vietnam veterans with posttraumatic stress disorder. J Neuropsychiatry Clin Neurosci 1993;5: 183-188.
5. Biederman J, Faraone SV, Spencer T, Wilens T, Norman D, Lapey KA, Mlck I Lehman BK, Doyle A: Patterns of psychiatric comorbidity, cognition and psychosocial functioning in adults with attention deficit disorder. Am J Psychiatry 1993;150: 1792-1798.
6. Biederman J, Newcorn J, Sprich S: Comorbidity of attention deficit hyperactivity disorder with conduct, depressive anxiety and other disorders. Am J Psychiatry 1991;148:564-577.
7. Biederman J, Wilens T, Mick E, Milberger S, Spencer TJ, Faraone SV: Psychoactive substance use disorders in adults with attention deficit hyperactivity disorder (ADHD): Effects of adW and psychiatric comorbidity. Am J Psychiatry 1995;152: 1652-1658.
8. Wilens TE, Biederman J, Spencer TJ, Frances RJ: Comorbidity of attention-deficit hyperactivity and psychoactive substance use disorders. Hosp Community Psychiatry 1994; 45:421-435.
9. Levin FR, Evans SM, Lugo L, Seham JC, Baird D, Kleber HD: ADHD in cocaine abusers: psychiatric comorbidity and pattern of drug use. Abstracts from 58th annual scientific meeting of CPDD 1996; San Juan, Puerto Rico.
10. Rey JM, Morris-Yates A, Singh M, Andrews G, Stewart GW: Continuities between psychiatric disorders in adolescents and personality disordered in young adults. Am J Psychiatry 1995;152:895-900.
11. Eystone LL, Howell RJ: An epidemiological study of attention deficit hyperactivity disorder and major depression in male prison population. Bull Am Acad Psychiatry Law 1994;22: 181-193 .

Dr. Kunz is a Fellow in the Program in Psychiatry and Law, Department of Psychiatry, New York University Medical Center in New York City.

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