Posttraumatic Stress Disorder Clinical Presentation
- Author: T Allen Gore, MD, MBA, CMCM, DFAPA; Chief Editor: Iqbal Ahmed, MBBS, FRCPsych(UK) more...
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).
DSM-5 diagnostic criteria
Currently, diagnosis of PTSD is based on 8 criteria from the DSM-5.
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
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
Exaggerated startle response
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.
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.
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.
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.)
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]
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.
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.
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.
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