After the traumatic stressor has abated, the hurricane is over, the battle has ceased, or the fire has been put out by heroic firefighters, what does a person in the midst of a developing PTSD episode experience? Understanding the course of an illness is a vital aspect of medical science and clinical work. By course, we mean how a disorder behaves or looks over time. How do the symptoms emerge? What pattern do they take? Do some go away and then come back again? And so on.
The first phase of PTSD is referred to as the acute phase. This is different than Acute Stress Disorder as identified in the DSM-IV-TR. The acute phase of PTSD refers to the acuteness of the symptoms within a 3-month period posttrauma. If those symptoms continue longer than 3 months, the disorder is considered chronic. If the onset of symptoms occurs at least 6 months after the stressor, the disorder is considered delayed. Delayed onset PTSD is considered relatively uncommon.
Blank (1993) identifies six patterns of PTSD. Acute, chronic, and delayed have already been discussed. He identifies three more: intermittent, residual, and reactivated. Intermittent PTSD refers to an "on-again-off-again" type of PTSD, with symptoms being present at one point but not at another. Residual PTSD refers to subthreshold PTSD symptoms that may be triggered by subsequent stress in a diathesis-stress model. That is, the PTSD was not delayed per se, but rather not severe enough until subsequent stressors or other problems experienced by an individual allowed for these symptoms to blossom into a full-blown PTSD episode or syndrome. Finally, reactivated PTSD refers to a situation in which an original episode of PTSD that has either resolved itself or has been successfully treated becomes reactivated by some new stressor or trigger.
Posttraumatic Stress Disorder symptoms will typically begin to emerge in the immediate aftermath of the stressor or event. However, the exact pattern of symptom emergence in PTSD is considered independent of the acute pattern of response (McFarlane & Yehuda, 1996). That is, an individual may show one symptom pattern during an event and yet another in the more chronic phase of the disorder. The exception to this is the relationship that some researchers have shown between dissociative symptoms and later pathology and severity. (For more on dissociative symptoms, see the previous section on dissociative symptoms.)
The symptom picture or presentation can fluctuate over time. However, disordered arousal is considered a relatively prominent symptom that pervades the course of the disorder. Blank (1993) reports that the prominence of intrusive symptoms gradually decreases over a 2-year period poststressor, while avoidance symptoms increase over that same period. Still other researchers state that with severe PTSD, symptoms may be stable but exist in less intense forms over time, the intrusive and avoidance symptoms decreasing, and affective and arousal symptoms remaining relatively stable. Still other researchers have found that those individuals that begin to show severe distress very early in the acute phase of the disorder show a more stable and enduring symptom pattern over time. Ultimately, the variability of the course is shaped by features of the precipitating event (e.g., Judith Herman  has argued that the consequences of child abuse are different than those following natural disaster), characteristics of the victim, and the nature of the recovery environment. In short, it is a complex diathesis-stress relationship.
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