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Posttraumatic Stress Disorder Clinical Presentation

  • Author: T Allen Gore, MD, MBA, CMCM, DFAPA; Chief Editor: Iqbal Ahmed, MBBS, FRCPsych(UK)  more...
Updated: Nov 06, 2015


The information elicited from the interview with the patient must satisfy certain diagnostic criteria to make the formal diagnosis. As with many diagnoses, PTSD can be subclinical, in which the criteria are almost, but not fully, met. Diagnosis is based on criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).[2]

DSM-5 diagnostic criteria

Currently, diagnosis of PTSD is based on 8 criteria from the DSM-5.[2]

The first DSM criterion has 4 components, as follows:

  • Directly experiencing the traumatic event(s)
  • Witnessing, in person, the event(s) as it occurred to others
  • Learning that the traumatic event(s) occurred to a close family member or friend
  • Experiencing repeated or extreme exposure to aversive details of the traumatic event(s); this does not apply to exposure through media such as television, movies, or pictures

The second criterion involves the persistent reexperiencing of the event in 1 of several ways:

  • Thoughts or perception
  • Images
  • Dreams
  • Illusions or hallucinations
  • Dissociative flashback episodes
  • Intense psychological distress or reactivity to cues that symbolize some aspect of the event

Unlike adults, children reexperience the event through repetitive play rather than through perception.

The third criterion involves avoidance of stimuli that are associated with the trauma and numbing of general responsiveness, as determined by the presence of 1 or both of the following:

  • Avoidance of thoughts, feelings, or conversations associated with the event
  • Avoidance of people, places, or activities that may trigger recollections of the event

The fourth criterion is 2 or more of the following symptoms of negative alterations in cognitions and mood associated with the traumatic event(s):

  • Inability to remember an important aspect of the event(s)
  • Persistent and exaggerated negative beliefs about oneself, others, or the world
  • Persistent, distorted cognitions about the cause or consequences of the event(s)
  • Persistent negative emotional state
  • Markedly diminished interest or participation in significant activities
  • Feelings of detachment or estrangement from others
  • Persistent inability to experience positive emotions

The fifth criterion is marked alterations in arousal and reactivity, as evidenced by 2 or more of the following:

  • Irritable behavior and angry outbursts
  • Reckless or self-destructive behavior
  • Hypervigilance
  • Exaggerated startle response
  • Concentration problems
  • Sleep disturbance

The remaining 3 criteria are as follows:

  • The duration of symptoms is more than 1 month
  • The disturbance causes clinically significant distress or impairment in functioning
  • The disturbance is not attributable to the physiological effects of a substance or other medical conditionFirst DSM diagnostic criterion

Children and PTSD

Children may have different reactions to trauma than do adults. For children aged 5 years or younger, typical reactions can include a fear of being separated from a parent, crying, whimpering, screaming, immobility and/or aimless motion, trembling, frightened facial expressions, and excessive clinging. Parents may also notice regressive behaviors. Children of this age tend to be strongly affected by their parents' reactions to the traumatic event.[26]

Children aged 6-11 years may show extreme withdrawal, disruptive behavior, and/or an inability to pay attention. Regressive behaviors, nightmares, sleep problems, irrational fears, irritability, refusal to attend school, outbursts of anger, and fighting are also common. The child may have somatic complaints with no medical basis. Schoolwork often suffers. Also, depression, anxiety, feelings of guilt, and emotional numbing are often present. Adolescents aged 12-17 years may have responses similar to those of adults.[26]

Substance abuse in PTSD

Over time, untreated and undertreated individuals with PTSD are especially susceptible to a deterioration of personal and work relationships and to the development of substance abuse or dependence.

In one study, men with PTSD reported an earlier age of onset of alcohol dependence, greater alcohol use intensity and craving, and more severe legal problems due to alcohol use.

In the same study, women had higher rates of positive test results for cocaine use at treatment entry than did men. Moreover, PTSD more often preceded alcohol dependence in women than men. These findings illustrate the possibility of sex differences in the pathology of PTSD.[27]

Another study found that 51.9% of men with PTSD concomitantly abused or were dependent on alcohol.

In a study of 173 African American mental health outpatients, investigators noticed an increased use of analgesic medications (opiate and nonopiate) among members of this cohort who had been diagnosed with PTSD than in those patients in the study without PTSD. (However, the study had a number of limitations.)[28]

Myocardial ischemia and PTSD

In a prospective study, myocardial ischemia, detected by exercise treadmill testing, was observed in 43 (10%) of the 433 outpatients without PTSD and 40 (17%) of the 233 outpatients with PTSD (P = .006).[29, 30, 31] The relationship between PTSD and myocardial ischemia remained significant after adjustment for potential confounders, including age, sex, and prior cardiovascular disease. Additionally, the researchers found that patients with more severe symptoms were also significantly more likely to have myocardial ischemia.[29, 30, 31]


Physical Examination

Patients with PTSD may present with physical injuries from the traumatic event (eg, bruises in victims of domestic abuse). Individuals with chronic PTSD may present with somatic complaints and, possibly, general medical conditions. Special attention should be paid to the patient's sleep hygiene.

In addition, the patient’s general appearance may be affected by PTSD. Individuals may appear disheveled and have poor personal hygiene.

In children, the combination of an elevated heart rate 24 hours posttrauma and a novel survey, the Child Trauma Screening Questionnaire, identified children likely to develop PTSD with adequate sensitivity, and with high specificity and negative predictive values at 1 and 6 months post trauma.[32]


Mental Status Examination

Patients with PTSD may display altered behavior. They may appear agitated, and their startle reaction may be extreme.

Orientation is sometimes affected in patients with PTSD. The patient may report episodes of not knowing the current place or time, even though this may not have been evident during the interview.

Memory is likely to be affected in PTSD. Patients may report forgetfulness, especially concerning the specific details of the traumatic event. A pilot study suggested that memory abnormalities may not be limited to the traumatic event itself.[33]

Patients can also have poor concentration, poor impulse control, and an altered speech rate and flow.

Mood and affect may be changed. Patients may have feelings of depression, anxiety, guilt, and/or fear.

Thoughts and perception may be affected. Patients may be more concerned with the content of hallucinations, delusions, suicidal ideation, phobias, and reliving the experience; certain patients may become homicidal. Potential for suicide and homicide must be noted as part of the mental status.

One study found that 48.5% of women with PTSD had major depressive disorder.

Contributor Information and Disclosures

T Allen Gore, MD, MBA, CMCM, DFAPA Volunteer Associate Professor, Department of Psychiatry, Howard University School of Medicine; Senior Psychiatrist and Director, Medical Education, Comprehensive Psychiatric Emergency Program, District of Columbia Department of Mental Health

T Allen Gore, MD, MBA, CMCM, DFAPA is a member of the following medical societies: American Psychiatric Association, National Association of Managed Care Physicians, National Medical Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Alkermes, Inc.: Otsuka America Pharmaceutical, Inc. and Lundbeck.


Joel Z Lucas, MD Senior Medical Writer, Reckitt Benckiser Pharmaceuticals, Inc

Joel Z Lucas, MD is a member of the following medical societies: American College of Physicians, American Medical Student Association/Foundation, Student National Medical Association

Disclosure: Received salary from Johnson & Johnson for employment.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Iqbal Ahmed, MBBS, FRCPsych(UK) Faculty, Department of Psychiatry, Tripler Army Medical Center; Clinical Professor of Psychiatry, Uniformed Services University of the Health Sciences; Clinical Professor of Psychiatry, Clinical Professor of Geriatric Medicine, University of Hawaii, John A Burns School of Medicine

Iqbal Ahmed, MBBS, FRCPsych(UK) is a member of the following medical societies: Academy of Psychosomatic Medicine, American Neuropsychiatric Association, American Society of Clinical Psychopharmacology, Royal College of Psychiatrists, American Association for Geriatric Psychiatry, American Psychiatric Association

Disclosure: Nothing to disclose.


The authors would like to thank all colleagues and students who contributed to this article. We are especially grateful to the following individuals:

Georgianna M Richards-Reid, MD, Staff Physician, Department of Neurology, Howard University Hospital, Howard University College of Medicine

Zachary Osborne, MD; Ross University School of Medicine

Bobbi Adams, BS; University of Alabama

  1. Risser HJ, Hetzel-Riggin MD, Thomsen CJ, McCanne TR. PTSD as a mediator of sexual revictimization: the role of reexperiencing, avoidance, and arousal symptoms. J Trauma Stress. 2006 Oct. 19(5):687-98. [Medline].

  2. American Psychiatric Association. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: 2013.

  3. Pollack MH, Hoge EA, Worthington JJ, et al. Eszopiclone for the treatment of posttraumatic stress disorder and associated insomnia: a randomized, double-blind, placebo-controlled trial. J Clin Psychiatry. 2011 Jul. 72(7):892-7. [Medline].

  4. de Quervain DJ, Margraf J. Glucocorticoids for the treatment of post-traumatic stress disorder and phobias: a novel therapeutic approach. Eur J Pharmacol. 2008 Apr 7. 583(2-3):365-71. [Medline].

  5. Yaffe K, Vittinghoff E, Lindquist K, Barnes D, Covinsky KE, Neylan T, et al. Posttraumatic stress disorder and risk of dementia among US veterans. Arch Gen Psychiatry. 2010 Jun. 67(6):608-13. [Medline]. [Full Text].

  6. Lanius RA, Vermetten E, Loewenstein RJ, Brand B, Schmahl C, Bremner JD, et al. Emotion modulation in PTSD: Clinical and neurobiological evidence for a dissociative subtype. Am J Psychiatry. 2010 Jun. 167(6):640-7. [Medline].

  7. Beristianos M, Yaffe K, Cohen B, Byers AL. The impact of late-life PTSD on vascular-related disorders [abstract EI-01]. Presented at: American Association for Geriatric Psychiatry (AAGP) 2014 Annual Meeting; March 16, 2014; Orlando, Fla. Am J Geriatr Psychiatry. March 2014. 22 (3 suppl):S55. [Full Text].

  8. Brauser D. Late-life PTSD linked to specific types of vascular disease. Medscape Medical News. March 24, 2014. [Full Text].

  9. Chemtob CM, Gudino OG, Laraque D. Maternal Posttraumatic Stress Disorder and Depression in Pediatric Primary Care: Association With Child Maltreatment and Frequency of Child Exposure to Traumatic Events. JAMA Pediatr. 2013 Sep 2. [Medline].

  10. Brauser D. Maternal PTSD Linked to Risk for Child Maltreatment. Medscape [serial online]. Available at Accessed: September 14, 2013.

  11. Medina J. Stress, PTSD and the Hippocampus. Presented at: 16th Annual US Psychiatric and Mental Health Congress. Orlando, FL: November 6-9, 2003.

  12. Smith ME. Bilateral hippocampal volume reduction in adults with post-traumatic stress disorder: a meta-analysis of structural MRI studies. Hippocampus. 2005. 15(6):798-807. [Medline].

  13. Krahe B, Scheinberger-Olwig R, Waizenhofer E, Kolpin S. Childhood sexual abuse and revictimization in adolescence. Child Abuse Negl. 1999 Apr. 23(4):383-94. [Medline].

  14. Deykin EY. Posttraumatic Stress Disorder in Childhood and Adolescence: A Review. 1999. Medscape Mental Health [online]. Available at

  15. Marshall RD, Pierce D. Implications of recent findings in posttraumatic stress disorder and the role of pharmacotherapy. Harv Rev Psychiatry. 2000 Jan-Feb. 7(5):247-56. [Medline].

  16. Milad MR, Orr SP, Lasko NB, Chang Y, Rauch SL, Pitman RK. Presence and acquired origin of reduced recall for fear extinction in PTSD: results of a twin study. J Psychiatr Res. 2008 Jun. 42(7):515-20. [Medline]. [Full Text].

  17. Johnson H, Thompson A. The development and maintenance of post-traumatic stress disorder (PTSD) in civilian adult survivors of war trauma and torture: a review. Clin Psychol Rev. 2008 Jan. 28(1):36-47. [Medline].

  18. Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA. 2006 Mar 1. 295(9):1023-32. [Medline].

  19. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med. 2004 Jul 1. 351(1):13-22. [Medline].

  20. Polusny MA, Kehle SM, Nelson NW, Erbes CR, Arbisi PA, Thuras P. Longitudinal effects of mild traumatic brain injury and posttraumatic stress disorder comorbidity on postdeployment outcomes in national guard soldiers deployed to Iraq. Arch Gen Psychiatry. 2011 Jan. 68(1):79-89. [Medline].

  21. Harrison, P. Female Vietnam Vets at Higher Risk for Lifetime/Current PTSD. Medscape Medical News. Available at October 7, 2015; Accessed: November 6, 2015.

  22. American Psychiatric Association. High Percentage of Youth in the U.S. Report Symptoms of Posttraumatic Stress and Other Disorders [press release]. Washington, DC: American Psychiatric Association; Aug 3 2003.

  23. Hoge CW, Clark JC, Castro CA. Commentary: women in combat and the risk of post-traumatic stress disorder and depression. Int J Epidemiol. 2007 Apr. 36(2):327-9. [Medline].

  24. Rona RJ, Fear NT, Hull L, Wessely S. Women in novel occupational roles: mental health trends in the UK Armed Forces. Int J Epidemiol. 2007 Apr. 36(2):319-26. [Medline].

  25. Fiszman A, Mendlowicz MV, Marques-Portella C, Volchan E, Coutinho ES, Souza WF, et al. Peritraumatic tonic immobility predicts a poor response to pharmacological treatment in victims of urban violence with PTSD. J Affect Disord. 2008 Apr. 107(1-3):193-7. [Medline].

  26. National Institute of Mental Health. Helping Children and Adolescents Cope with Violence and Disasters. NIH Publication No. 01-3518. Bethesda, Md:. National Institute of Mental Health; 2001. [Full Text].

  27. Sonne SC, Back SE, Diaz Zuniga C, Randall CL, Brady KT. Gender differences in individuals with comorbid alcohol dependence and post-traumatic stress disorder. Am J Addict. 2003 Oct-Dec. 12(5):412-23. [Medline].

  28. Schwartz AC, Bradley R, Penza KM, Sexton M, Jay D, Haggard PJ, et al. Pain medication use among patients with posttraumatic stress disorder. Psychosomatics. 2006 Mar-Apr. 47(2):136-42. [Medline]. [Full Text].

  29. Turner JH, Neylan TC, Schiller NB, Li Y, Cohen BE. Objective evidence of myocardial ischemia in patients with posttraumatic stress disorder. Biol Psychiatry. 2013 Dec 1. 74(11):861-6. [Medline].

  30. Vaccarino V, Bremner JD. Traumatic stress is heartbreaking. Biol Psychiatry. 2013 Dec 1. 74(11):790-2. [Medline].

  31. Cassels C. PTSD Independently Linked to Ischemic Heart Disease. Medscape [serial online]. Available at Accessed: December 2, 2013.

  32. Olsson KA, Kenardy JA, De Young AC, Spence SH. Predicting children's post-traumatic stress symptoms following hospitalization for accidental injury: combining the Child Trauma Screening Questionnaire and heart rate. J Anxiety Disord. 2008 Dec. 22(8):1447-53. [Medline].

  33. Dickie EW, Brunet A, Akerib V, Armony JL. An fMRI investigation of memory encoding in PTSD: influence of symptom severity. Neuropsychologia. 2008 Apr. 46(5):1522-31. [Medline].

  34. Rodriguez BF, Weisberg RB, Pagano ME, Machan JT, Culpepper L, Keller MB. Mental health treatment received by primary care patients with posttraumatic stress disorder. J Clin Psychiatry. 2003 Oct. 64(10):1230-6. [Medline].

  35. Kasai K, Yamasue H, Gilbertson MW, Shenton ME, Rauch SL, Pitman RK. Evidence for acquired pregenual anterior cingulate gray matter loss from a twin study of combat-related posttraumatic stress disorder. Biol Psychiatry. 2008 Mar 15. 63(6):550-6. [Medline]. [Full Text].

  36. Hogberg G, Pagani M, Sundin O, Soares J, Aberg-Wistedt A, Tarnell B, et al. Treatment of post-traumatic stress disorder with eye movement desensitization and reprocessing: outcome is stable in 35-month follow-up. Psychiatry Res. 2008 May 30. 159(1-2):101-8. [Medline].

  37. Ponniah K, Hollon SD. Empirically supported psychological treatments for adult acute stress disorder and posttraumatic stress disorder: a review. Depress Anxiety. 2009. 26(12):1086-109. [Medline].

  38. Bronson D, Franco K, Budur K. Posttraumatic stress disorder in primary care patients. Compr Ther. 2007 Winter. 33(4):208-15. [Medline].

  39. Nijdam MJ, Gersons BP, Reitsma JB, de Jongh A, Olff M. Brief eclectic psychotherapy v. eye movement desensitisation and reprocessing therapy for post-traumatic stress disorder: randomised controlled trial. Br J Psychiatry. 2012 Mar. 200(3):224-31. [Medline].

  40. Litz BT, Engel CC, Bryant RA, Papa A. A randomized, controlled proof-of-concept trial of an Internet-based, therapist-assisted self-management treatment for posttraumatic stress disorder. Am J Psychiatry. 2007 Nov. 164(11):1676-83. [Medline].

  41. Germain A, Shear MK, Hall M, Buysse DJ. Effects of a brief behavioral treatment for PTSD-related sleep disturbances: a pilot study. Behav Res Ther. 2007 Mar. 45(3):627-32. [Medline].

  42. Raskind MA, Peskind ER, Hoff DJ, Hart KL, Holmes HA, Warren D, et al. A parallel group placebo controlled study of prazosin for trauma nightmares and sleep disturbance in combat veterans with post-traumatic stress disorder. Biol Psychiatry. 2007 Apr 15. 61(8):928-34. [Medline].

  43. Brooks M. New WHO Guideline on Mental Health Care After Trauma. Medscape Medical News. Available at Accessed: August 14, 2013.

  44. Tol WA, Barbui C, van Ommeren M. Management of acute stress, PTSD, and bereavement: WHO recommendations. JAMA. 2013 Aug 7. 310(5):477-8. [Medline].

  45. Lambert MT. Aripiprazole in the management of post-traumatic stress disorder symptoms in returning Global War on Terrorism veterans. Int Clin Psychopharmacol. 2006 May. 21(3):185-7. [Medline].

  46. Harrison P. Evidence Supports Psychological Therapies for PTSD Kids. Medscape Medical News. December 11, 2012. [Full Text].

  47. Gillies D, Taylor F, Gray C, O'Brien L, D'Abrew N. Psychological therapies for the treatment of post-traumatic stress disorder in children and adolescents. Cochrane Database Syst Rev. 2012 Dec 12. 12:CD006726. [Medline].

  48. Connor KM, Sutherland SM, Tupler LA, Malik ML, Davidson JR. Fluoxetine in post-traumatic stress disorder. Randomised, double-blind study. Br J Psychiatry. 1999 Jul. 175:17-22. [Medline].

  49. Davis LL, Frazier EC, Williford RB, Newell JM. Long-term pharmacotherapy for post-traumatic stress disorder. CNS Drugs. 2006. 20(6):465-76. [Medline].

  50. Brunet A, Orr SP, Tremblay J, Robertson K, Nader K, Pitman RK. Effect of post-retrieval propranolol on psychophysiologic responding during subsequent script-driven traumatic imagery in post-traumatic stress disorder. J Psychiatr Res. 2008 May. 42(6):503-6. [Medline].

  51. Krystal JH, Rosenheck RA, Cramer JA, Vessicchio JC, Johnes, KM, et al. Adjunctive risperidone treatment for antidepressant-resistant symptoms of chronic military service-related PTSD. JAMA. Aug 2011. 306(5):461-568.

  52. A Message From APA President Dilip Jeste, M.D., on DSM-5. Available at Accessed: December 1, 2012.

  53. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, DSM-VI-TR. Anxiety Disorders. Washington, DC: American Psychiatric Association; 2000. 463-8.

  54. APA. Posttraumatic Stress Disorder. Available at Accessed: July 1, 2013.

  55. Bandelow B. Defining response and remission in anxiety disorders: toward an integrated approach. CNS Spectr. 2006 Oct. 11(10 Suppl 12):21-8. [Medline].

  56. Bisson JI, Ehlers A, Matthews R, Pilling S, Richards D, Turner S. Psychological treatments for chronic post-traumatic stress disorder. Systematic review and meta-analysis. Br J Psychiatry. 2007 Feb. 190:97-104. [Medline].

  57. Bremner JD. Neuroimaging in posttraumatic stress disorder and other stress-related disorders. Neuroimaging Clin N Am. 2007 Nov. 17(4):523-38, ix. [Medline]. [Full Text].

  58. Brooks M. Heavy drinking, PTSD in college students linked. Medscape Medical News. January 23, 2014. [Full Text].

  59. Connor KM, Davidson JR. Further psychometric assessment of the TOP-8: a brief interview-based measure of PTSD. Depress Anxiety. 1999. 9(3):135-7. [Medline].

  60. Hamilton A. Diagnosis and rating of anxiety. Special Publication: Br J Psychiatry; 1969. 3:76-79.

  61. Hamilton M. Development of a rating scale for primary depressive illness. Br J Soc Clin Psychol. 1967 Dec. 6(4):278-96. [Medline].

  62. Read JP, Wardell JD, Colder CR. Reciprocal associations between PTSD symptoms and alcohol involvement in college: a three-year trait-state-error analysis. J Abnorm Psychol. 2013 Nov. 122(4):984-97. [Medline].

  63. Sheehan DV, Harnett-Sheehan K, Raj BA. The measurement of disability. Int Clin Psychopharmacol. 1996 Jun. 11 Suppl 3:89-95. [Medline].

  64. Stetka B, Correll, C. A Guide to DSM-5: Posttraumatic Stress Disorder. Medscape Medical News. Available at Accessed: July 1, 2013.

  65. Zatzick D, Jurkovich G, Rivara FP, Russo J, Wagner A, Wang J, et al. A randomized stepped care intervention trial targeting posttraumatic stress disorder for surgically hospitalized injury survivors. Ann Surg. 2013 Mar. 257(3):390-9. [Medline]. [Full Text].

Brain structures involved in dealing with fear and stress.
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