What we call a beginning is often the end and to make an end is to make a beginning. The end is where we start from.. .. We shall not cease from exploration And the end of all our exploring Will be to arrive where we started And know the place for the first time.-T. S. Eliot (1942) Though no man can draw a stroke between the confines of day and night, yet light and darkness are upon the whole tolerably distinguishable.

The DSM-IV-TR PTSD category demonstrates various types of validity. Criteria modification and textual clarifications are suggested to further improve its cross-cultural applicability.

ObjectiveWe conducted a systematic review of the literature to explore the longitudinal course of PTSD in DSM-5-defined trauma exposed populations to identify the course of illness and recovery for individuals and populations experiencing PTSD.MethodsWe reviewed the published literature from January 1, 1998 to December 31, 2010 for longitudinal studies of directly exposed trauma populations in order to: (1) review rates of PTSD in the first year after a traumatic event; (2) examine potential types of proposed DSM-5 direct trauma exposure (intentional and non-intentional); and (3) identify the clinical course of PTSD (early onset, later onset, chronicity, remission, and resilience). Of the 2537 identified articles, 58 articles representing 35 unique subject populations met the proposed DSM-5 criteria for experiencing a traumatic event, and assessed PTSD at two or more time points within 12 months of the traumatic event.ResultsThe mean prevalence of PTSD across all studies decreases from 28.8% (range  = 3.1–87.5%) at 1 month to 17.0% (range  = 0.6–43.8%) at 12 months. However, when traumatic events are classified into intentional and non-intentional, the median prevalences trend down for the non-intentional trauma exposed populations, while the median prevalences in the intentional trauma category steadily increase from 11.8% to 23.3%. Across five studies with sufficient data, 37.1% of those exposed to intentional trauma develop PTSD. Among those with PTSD, about one third (34.8%) remit after 3 months. Nearly 40% of those with PTSD (39.1%) have a chronic course, and only a very small fraction (3.5%) of new PTSD cases appears after three months.ConclusionsUnderstanding the trajectories of PTSD over time, and how it may vary by type of traumatic event (intentional vs. non-intentional) will assist public health planning and treatment.

There is a growing body of evidence linking the dissociative disorders to a trauma history, and to specific neural mechanisms.

US Hispanics, currently the largest minority group in the country, face disparities in the recognition and treatment of major depression. This article provides an evidence-based review of the prevalence, presentation, and management of major depression in primary care in this heterogeneous ethnic group. Under-recognition of depression in adult Hispanic Americans may be related to language differences, health literacy barriers, somatic presentations, and use of cultural idioms of distress. Hispanic patients are often agreeable to treatment but as a group may tend to prefer psychotherapy or combined counseling and medication to pharmacotherapy alone. Recent studies have found both psychological and pharmacologic treatment options are efficacious in this minority group. Treatment adherence should be actively monitored to help ensure its effectiveness. To help reduce the number of depressed Hispanic patients who pass through primary care undetected or inadequately treated, family physicians should make a concerted effort to increase their awareness of the presentation of major depression in this population and actively promote adherence to effective treatments.

In this introduction to the Special Issue on Trauma and Idioms of Distress, we provide an overview of the concept and typology of ''idioms of distress,'' focusing particularly on their clinical utility. This includes the role of idioms as indicators of trauma exposure, of various types of psychopathology and of levels of distress, risk and functioning. It likewise includes the fact that idioms of distress may profoundly influence the personal meaning of having a trauma-related disorder, may shape the interpersonal course of the disorder and may pattern help-seeking and self-treatment. Finally, it illustrates the fact that idioms may also help clinicians understand sufferers' views of the causes of their distress, constitute key therapeutic targets and help increase therapeutic empathy and treatment adherence. This special issue focuses on the role played by idioms of distress in the local trauma ontology, the associations between the idioms and psychiatric disorders occurring in the context of trauma and the mechanisms by which the idioms profoundly influence the personal and interpersonal course of trauma-related disorders.

The Outline for Cultural Formulation (OCF) introduced with DSM-IV provided a framework for clinicians to organize cultural information relevant to diagnostic assessment and treatment planning. However, use of the OCF has been inconsistent, raising questions about the need for guidance on implementation, training, and application in diverse settings. To address this need, DSM-5 introduced a cultural formulation interview (CFI) that operationalizes the process of data collection for the OCF. The CFI includes patient and informant versions and 12 supplementary modules addressing specific domains of the OCF. This article summarizes the literature reviews and analyses of experience with the OCF conducted by the DSM-5 Cross-Cultural Issues Subgroup (DCCIS) that informed the development of the CFI. We review the history and contents of the DSM-IV OCF, its use in training programs, and previous attempts to render it operational through questionnaires, protocols, and semi-structured interview formats. Results of research based on the OCF are discussed. For each domain of the OCF, we summarize findings from the DCCIS that led to content revision and operationalization in the CFI. The conclusion discusses training and implementation issues essential to service delivery.

The rationale, research literature, and proposed changes to the dissociative disorders and conversion disorder in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) are presented. Dissociative identity disorder will include reference to possession as well as identity fragmentation, to make the disorder more applicable to culturally diverse situations. Dissociative amnesia will include dissociative fugue as a subtype, since fugue is a rare disorder that always involves amnesia but does not always include confused wandering or loss of personality identity. Depersonalization disorder will include derealization as well, since the two often co-occur. A dissociative subtype of posttraumatic stress disorder (PTSD), defined by the presence of depersonalization or derealization in addition to other PTSD symptoms, is being recommended, based upon new epidemiological and neuroimaging evidence linking it to an early life history of adversity and a combination of frontal activation and limbic inhibition. Conversion disorder (functional neurological symptom disorder) will likely remain with the somatic symptom disorders, despite considerable dissociative comorbidity.