Post-traumatic stress disorder (PTSD) is characterised by intrusive, anxious, and avoidant symptoms that are triggered after a stressful experience and affect the mood. The definition of a stressor that generates PTSD has been debated in recent years, as a clinical picture compatible with the disorder can occur after exposure to stressors that do not meet the criteria A1 of the DSM V; these stressors have been defined in the literature as "of low magnitude, uncommon, unusual or atypical".
Clinical caseWe present the clinical case of a paediatric patient who developed PTSD after being exposed to an atypical stressor.
ConclusionsThe literature shows these stressors to be more frequently documented in the paediatric population. We therefore suggest that cases should be analysed as a complex interweaving of variables, where one of the most important is each patient's interpretation of the event according to their life history and social context, and not because of an inherent characteristic of the stressor itself.
El trastorno de estrés postraumático (TEPT) se caracteriza por síntomas intrusivos, ansiosos y evitativos que se desencadenan luego de una experiencia estresante y afectan a la esfera del ánimo. La definición de un estresor que genera un TEPT ha estado en controversia en los últimos años, ya que se puede presentar un cuadro clínico compatible con el trastorno tras la exposición a estresores que no cumplen el criterio A1 del DSM-V. Estos estresores se han definido en la literatura como «de baja magnitud, poco comunes, inusuales o atípicos».
Caso clínicoSe presenta el caso clínico de un paciente en edad pediátrica en el que se desarrolló un TEPT luego de exponerse a un estresor atípico.
ConclusionesSe evidencia en la literatura que estos estresores se han documentado más a menudo en la población pediátrica, por lo cual se propone analizar los casos como un complejo entrecruzamiento de variables, de las que una de las más importantes es la interpretación que cada paciente hace del evento según su historia de vida y su contexto social, y no por una característica inherente al estresor en sí.
Post-traumatic stress disorder (PTSD) has a prevalence of approximately 3.5% in the United States, with lower rates in the rest of the world of approximately 0.5–1%.1 Among the paediatric population, the prevalences of PTSD are more inconsistent due to geographical area, resilience, age and sex, but there are reports in Colombia of a prevalence of approximately 4.7%.2 PTSD is characterised by symptoms of intrusion, anxiety and avoidance, which are triggered after a stressful experience and affect the mood. In DSM-5,1 a stressor is defined as a situation perceived as threatening, with a risk of death, sexual violence or serious injury.3 Some examples include kidnapping, torture, social adversity, natural disasters and road traffic accidents.4 In Colombia, the internal armed conflict is an important factor.2,5–7
The definition of a stressor that generates PTSD has been debated in recent years, as a clinical picture compatible with the disorder can occur after exposure to stressors that do not meet criterion A1 of the DSM-5.3,4,8–12 These stressors have been defined in the literature as “of low magnitude, uncommon, unusual or atypical”. Some examples include movies, animated series, eating spoiled foods and other everyday experiences. There is evidence that atypical stressors can generate symptoms consistent with PTSD. To demonstrate this, we present the case report of a paediatric patient who developed PTSD after being exposed to an atypical stressor.
Case reportA 13-year-old male patient, who was in year six of basic education, was brought in for an appointment 1 year after watching a video at night-time in the company of his mother. The video was about the history of the animated series Kick Buttowski. During the video, the protagonist enters into a Faustian pact with Lucifer and sells his soul for some of Lucifer's clothing. The patient's symptoms began with recurrent episodes of anxiety, feelings of impending doom, depersonalisation, derealisation, shaking, palpitations, dyspnoea, tachycardia and crying, which lasted for approximately 15 min and occurred 3–4 times a day. In addition to dysautonomia symptoms, this caused the patient to feel terror and anguish between crises and he was unable to stay at home on his own, to sleep alone or to turn off the lights. This was associated with insomnia, nightmares, flashbacks and avoidance related to the content of the video, evidenced in acts such as no longer watching television, getting rid of video games, and avoiding any conversation regarding the situation or related content, to the point of not being able to say the title of this video. He stated: "That video is demonic; I should never have watched it".
The patient is an only child and was the result of a preterm pregnancy during which the mother suffered from depression, with no other complications. He was born by caesarean section due to the cord being wrapped around his neck and non-reassuring foetal status, with a normal Apgar score. He had normal psychomotor development with normal performance at school. His interpersonal relationships were described as good. The patient lived with his parents and the family dynamic was adequate. The father has obsessive personality traits. There is a history of type I bipolar affective disorder, alcoholism and dementia in the uncles and grandparents.
The patient's physical examination, lab tests, cognitive assessment and brain CT scan were normal. A mental examination showed a non-cooperative attitude during the interview, that he was fearful, with phobias and flashbacks of the video. There were no hallucinations or hallucinatory behaviours. Consequently, the patient's condition was diagnosed as a specific phobia and treatment with fluvoxamine 100 mg/day was prescribed for 3 months.
After 6 months of treatment, when the authors became aware of the case, the patient showed a partial improvement with greater tolerance for being alone, resolution of the fear of the dark and a better capacity to cope with the event. The same treatment was continued and psychotherapy was added but the patient did not continue to attend check-ups.
Due to the presence of symptoms triggered by exposure to a specific event that was perceived in an aberrant way and the associated symptoms of anxiety and dissociation, intrusive ideas and avoidant behaviours, together with deterioration of the patient's social and family circles, the diagnosis was changed to PTSD.
DiscussionWe have presented the case of a patient diagnosed with PTSD secondary to an atypical stressor. Initially, the patient was diagnosed with phobic anxiety disorder with agoraphobia, generalised anxiety disorder and panic disorder, but his clinical symptoms indicated the possibility of PTSD.
There is currently controversy surrounding the definition of a stressful event in PTSD. In DSM-4 and DSM-5, substantial changes were made to the definition of Criterion A, which is less specific in the latest version, but the stressor concept did not change.13–16 Today, it excludes the possibility that there is a group of stressors that do not comply with the historical definition, omitting to take into account reports of cases of PTSD secondary to so-called "low magnitude, unusual, uncommon or atypical" stressors, little studied in the paediatric population,17,18 thus revealing the need for a discussion, at least with respect to this group of patients.
Various studies link PTSD to events such as kidnapping, rape, terrorist attacks, wars and catastrophic events in both the adult and paediatric population.19–23 Regarding atypical stressors in the adult population, there are case reports of a neurosis associated with watching the movie The Exorcist in 197524 and the case of a 47-year-old man who was diagnosed with this disorder with the stressor of having eaten a bar of chocolate infested with worms.4
Reports of atypical stressors among the paediatric population are less common. Two articles were found regarding atypical stressors that caused this disorder in children. One study, conducted in Iran in 2013, studied 84 patients aged 6−11 years. The study found that 33% of the patients had symptoms consistent with PTSD related to watching violent or catastrophic events on television, including movies, news programmes and cartoons.17 In a 2010 study involving a sample of 1420 children aged 9–13 years, the Adolescent Psychiatric Assessment (CAPA) was applied to screen and classify exposure to high and low-magnitude stressors. Fifteen items were used to assess low-magnitude stressors, including the loss of a loved one, parental separation, moving house, moving to a new school, and breaking up with a friend or a boyfriend or girlfriend. Children were then assessed for symptoms such as painful recall or avoidance and for autonomic symptoms related to the exposure. It was found that "low-magnitude" stressors were more prevalent, even though the proportion of symptoms in both groups was similar.18
In addition, a 2013 study found that the DSM-4 Criterion A2 had greater sensitivity, with a high negative predictive value, for the onset of post-traumatic stress in children, and assigns importance to the emotional perspective of each stressor in the paediatric population.25 On considering this case, the authors believe that a stressor should not be classified only from a historical perspective, since one can fall into a reductionist perspective,26 but should also take into account other variables, such as social context, age, sex, resilience, one's own perspective, and even nationality.27–32 We therefore suggest that paediatric cases should be analysed as a complex interweaving of variables, where one of the most important is each patient's interpretation of the event according to their life history and social context, and not because of a characteristic inherent to the stressor itself.33
Conflicts of interestThe authors have no conflicts of interest to declare.
