Posttraumatic Stress Disorder Clinical Presentation

  • Author: T Allen Gore, MD, MBA, CMCM, DFAPA; Chief Editor: Iqbal Ahmed, MBBS, FRCPsych (UK)   more...
 
Updated: Apr 25, 2012
 

History

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, Fourth Edition, Text Revision (DSM).[1] The mental status examination should routinely consist of questions about exposure to trauma or abuse.

First DSM diagnostic criterion

The first criterion has 2 components, as follows:

  • Experiencing, witnessing, or being confronted with an event involving serious injury, death, or a threat to a person's physical integrity
  • A response involving helplessness, intense fear, or horror (sometimes expressed in children as agitation or disorganized behavior)

Second DSM diagnostic criterion

The second major criterion involves the persistent reexperiencing of the event in 1 of several ways. This may involve thoughts or perception, images, dreams, illusions, hallucinations, dissociative flashback episodes, or intense psychological distress or reactivity to cues that symbolize some aspect of the event. Unlike adults, however, children reexperience the event through repetitive play rather than through perception.

Third DSM diagnostic criterion

The third diagnostic criterion involves avoidance of stimuli that are associated with the trauma and numbing of general responsiveness; this is determined by the presence of 3 or more of the following:

  • Avoidance of thoughts, feelings, or conversations that are associated with the event
  • Avoidance of people, places, or activities that may trigger recollections of the event
  • Inability to recall important aspects of the event
  • Significantly diminished interest or participation in important activities
  • Feeling of detachment from others
  • Narrowed range of affect
  • Sense of having a foreshortened future

In a study, women reported greater exposure to sexually related traumas, greater frequency and intensity of avoidance of trauma-related thoughts and feelings, and greater social impairment due to PTSD. Women also had higher rates of other anxiety disorders and of positive test results for cocaine use at treatment entry than did men.

Fourth DSM diagnostic criterion

The fourth criterion is symptoms of hyperarousal, and 2 or more of the following symptoms are required to fulfill this criterion:

  • Difficulty sleeping or falling asleep
  • Decreased concentration
  • Hypervigilance
  • Outbursts of anger or irritable mood
  • Exaggerated startle response

Fifth DSM diagnostic criterion

Fifth, the duration of the relevant criteria symptoms should be more than 1 month, as opposed to acute stress disorder, for which the criterion is a duration of less than 1 month.

Sixth DSM diagnostic criterion

The sixth criterion is that the disturbance is a cause of clinically significant distress or impairment in functioning.

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.[20]

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.[20]

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.[21]

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.)[22]

History assessment in immigrants

Individuals who have emigrated from countries experiencing political unrest may be unwilling to discuss their traumatic experiences because of legal issues.

Next

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.[23]

Previous
Next

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.[24]

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.

Previous
Proceed to Differential Diagnoses
 
 
Contributor Information and Disclosures
Author

T Allen Gore, MD, MBA, CMCM, DFAPA  Assistant 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 College of Managed Care Medicine, American Psychiatric Association, and National Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

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, and Student National Medical Association

Disclosure: Johnson & Johnson Salary 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: Medscape Salary Employment

Chief Editor

Iqbal Ahmed, MBBS, FRCPsych (UK)  Faculty, Department of Psychiatry, Tripler Army Medical Center; Clinical Professor of Psychiatry, Uniformed Services University of 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 Association for Geriatric Psychiatry, American Neuropsychiatric Association, American Psychiatric Association, American Society of Clinical Psychopharmacology, and Royal College of Psychiatrists

Disclosure: Nothing to disclose.

Additional Contributors

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

References

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

  2. 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. Oct 2006;19(5):687-98. [Medline].

  3. 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. Jun 2010;67(6):608-13. [Medline]. [Full Text].

  4. 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. Jun 2010;167(6):640-7. [Medline].

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

  6. 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].

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

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

  9. Deykin EY. Posttraumatic Stress Disorder in Childhood and Adolescence: A Review. 1999. Medscape Mental Health [online]. Available at http://medscape.com.

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

  11. 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. Jun 2008;42(7):515-20. [Medline]. [Full Text].

  12. 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. Jan 2008;28(1):36-47. [Medline].

  13. 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. Mar 1 2006;295(9):1023-32. [Medline].

  14. 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. Jul 1 2004;351(1):13-22. [Medline].

  15. 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. Jan 2011;68(1):79-89. [Medline].

  16. 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.

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

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

  19. 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. Apr 2008;107(1-3):193-7. [Medline].

  20. 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].

  21. 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. Oct-Dec 2003;12(5):412-23. [Medline].

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

  23. 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. Dec 2008;22(8):1447-53. [Medline].

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

  25. 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. Oct 2003;64(10):1230-6. [Medline].

  26. 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. Mar 15 2008;63(6):550-6. [Medline]. [Full Text].

  27. Högberg G, Pagani M, Sundin O, Soares J, Aberg-Wistedt A, Tärnell 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. May 30 2008;159(1-2):101-8. [Medline].

  28. 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].

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

  30. 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. Mar 2012;200(3):224-31. [Medline].

  31. 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. Nov 2007;164(11):1676-83. [Medline].

  32. 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. Mar 2007;45(3):627-32. [Medline].

  33. 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. Apr 15 2007;61(8):928-34. [Medline].

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

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

  36. 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].

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

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

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

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

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

  42. 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. Jul 2011;72(7):892-7. [Medline].

  43. 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. May 2008;42(6):503-6. [Medline].

  44. 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.

  45. [Best Evidence] 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. Feb 2007;190:97-104. [Medline].

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

 
Previous
Next
 
Brain structures involved in dealing with fear and stress.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.