Post-traumatic stress disorder, resilience and vulnerability

Post-traumatic stress disorder (PTSD), recognised as a diagnostic entity in 1980, was originally associated with combat or war experiences. It has since been recognised that it is prevalent in any population exposed to traumatic events. Although much has been written about the management of PTSD, the concepts of resilience and vulnerability have not received the same attention. This article reviews the conceptualisation, epidemiology and comorbidities of PTSD and highlights the factors underlying vulnerability and conveying resilience.

In the current geopolitical climate, political and social instabilities as well as natural and man-made calamities have been on the increase. Civil wars often result in atrocities, violence, forced migration and mass fatalities. Exposure to such events can lead to psychological strain and pathology. This pathology includes acute stress reaction, adjustment disorder and post-traumatic stress disorder (PTSD). Of these, PTSD is associated with the highest morbidity and is often underdiagnosed. This prompted my review of the literature on the different aspects of PTSD, with special emphasis on vulnerability and resilience.

The ICD–10 (World Health Organization, 1992) considers an event or situation of exceptionally threatening or catastrophic nature, which would be likely to cause pervasive distress in anyone, as the main aetiological agent for PTSD. For an ICD–10 diagnosis, the symptoms need to have lasted for at least a month and to have occurred within 6 months of the traumatic event.

Post-traumatic stress disorder was introduced as a diagnostic entity in the DSM classification in DSM–III (American Psychiatric Association, 1980). In the first and second versions of the DSM (American Psychiatric Association, 1952, 1968), stress response syndromes were described as transient reactive processes. If the psychological disturbances were chronic, another diagnosis had to be used. DSM–IV has gone further and incorporates the individual’s reaction or emotional response to the traumatic event within the diagnostic criteria, requiring that ‘the person’s response involved intense fear, helplessness, or horror’ (American Psychiatric Association, 1994: p. 428).

Resilience and vulnerability

Given that the majority of people exposed to traumatic events do not experience PTSD, what is it that protects them? In considering this question, Bonanno (2004) has defined resilience as the ability to maintain a state of normal equilibrium in the face of extremely unfavourable circumstances. To enhance resilience, it is necessary to have an understanding of its determinants. Various factors such as beliefs, attitudes, coping strategies, behaviours and psychosocial cohesion have been suggested as conveying protection or endorsing resilience in the face of trauma. Resilient individuals may show insight, initiative, humour, creativity and independence. It is a dynamic quality. There may be discontinuities in resilience as people, situations, opportunities and environment change.