verbal abilities, especially when they are very young,
and may have little insight about their thoughts and
feelings to offer the clinician. Children may also have
a different symptom pattern that is not well repre-
sented by the adult criteria for PTSD. For example, it
has been suggested that children may have longer
durations of avoidance and fewer symptoms of reex-
periencing (e.g., visual flashbacks) than adults have.
Children may also be more likely than adults to mask
their feelings of fear, helplessness, or horror with
rage, hostility, refusal to go to school, and behavioral
outbursts that may be more suggestive of conduct
disorder than PTSD. Children may also report more
concentration difficulties and cognitive changes post-
trauma than adults do. Finally, some studies have
shown that there are large numbers of children who
have been exposed to a severe discrete trauma who
fail to meet the full criteria for PTSD as specified for
adults; yet these reactions were of sufficient severity
to create a functional impairment for the child. Taken
as a whole, these findings have led researchers, such
as Michael Scheeringa and colleagues, to delineate an
alternative set of criteria for PTSD that can be used
with infants and very young children. The efficacy of
these criteria is currently being considered.
Diagnosing PTSD in individuals who have suffered
a traumatic brain injury is also controversial. Specifi-
cally, it has been questioned whether a person who has
posttrauma amnesia for the traumatic event can
receive a diagnosis of PTSD since these individuals
also have no recollection of feeling helpless, fearful,
or horrified in response to the trauma.
The symptom pattern of PTSD may also be differ-
ent and more complex in individuals who have expe-
rienced a chronic stressor (such as childhood physical
or sexual abuse or kidnapping and torture) as opposed
to those who have experienced a discrete stressor.
Some have argued that complex PTSD is better
described by the International Classification of
Diseases, 10th revision (ICD–10) diagnosis of endur-
ing personality change after catastrophic experience
than by the symptom pattern detailed for PTSD.PTSD: Current Controversies
Many controversies currently surround the diagnosis
of PTSD. As stated previously, there are differences of
opinion about which types of trauma should be consid-
ered as significant enough to generate symptoms
of PTSD. There is also debate about the number of
symptoms needed for the diagnosis, with some expertsarguing that significant impairment can still occur in
individuals who fail to qualify fully for the diagnosis.
Moreover, PTSD has been shown to have high rates of
comorbidity with other diagnoses such as major
depressive disorder, alcohol dependence, and other
anxiety disorders. These may be due to the high degree
of symptom overlap between PTSD and other disor-
ders. For example, PTSD and depression share symp-
toms of insomnia, impaired concentration, social
withdrawal, and diminished interest in or satisfaction
from previously pleasurable activities. Similarly,
PTSD and generalized anxiety disorder share symp-
toms of irritability, hypervigilance, exaggerated startle
response, impaired concentration, insomnia, and auto-
nomic hyperarousal. Thus, the degree to which there is
an identifiable stress reaction has been questioned, and
debate continues about how to differentiate a normal
reaction to a horrific event from an abnormal reaction
to a horrific event, such that it would constitute a psy-
chological disorder. Additionally, PTSD is theorized to
have a dose-response relationship with experienced
trauma, such that more severe stressors are thought to
be associated with worse symptoms and a greater like-
lihood of receiving the diagnosis of PTSD. While
some researchers have found evidence in support of
this relationship, data from other studies have failed to
establish a linear relationship between the severity of
the trauma experienced and the likelihood of experi-
encing PTSD symptoms.
The development of a theoretical model for what
causes PTSD to occur in some but not all individuals
has also engendered debate, as the prevalence of PTSD
is rather rare (between 1% and 8% of the general pop-
ulation) relative to the number of Americans known to
have been exposed to a sufficiently severe and poten-
tially traumatizing stressor (estimates suggest 66% or
more of the general population). These findings have
led researchers to conclude that trauma is necessary
but not sufficient to cause PTSD and that the person’s
subjective experience of and attributions about the
trauma may be as important as the event itself.
Another controversy that surrounds the diagnosis
of PTSD has focused on the validity of recovered
memories of trauma. For example, if recovered mem-
ories of childhood sexual abuse are not accurate, then
can they cause PTSD? Additionally, studies have
shown that trauma memories change across time, are
dynamic rather than static, and are related to a per-
son’s current clinical state.
Last, further concern has been generated with
regard to the efficacy of using early psychological612 ———Posttraumatic Stress Disorder (PTSD)P-Cutler (Encyc)-45463.qxd 11/18/2007 12:43 PM Page 612