Posttraumatic Stress Disorder

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

Practice Essentials

Posttraumatic stress disorder (PTSD) is defined as a pathological anxiety that usually occurs after an individual experiences or witnesses severe trauma that constitutes a threat to the physical integrity or life of the individual or of another person.

Brain structures associated with the body’s reaction to fear and stress can be seen in the image below.

Brain structures involved in dealing with fear and Brain structures involved in dealing with fear and stress.

See Posttraumatic Stress Disorder (PTSD), a Critical Images slideshow, to help recognize the symptoms of PTSD and to determine effective treatment options.

Signs and symptoms

Symptoms of posttraumatic stress disorder (PTSD) include the following:

  • Persistent reexperiencing of a traumatic event
  • Resultant numbness, avoidance, and hyperarousal [1]
  • Avoidance
  • Negative thoughts and mood or feelings

Symptoms should be present for a minimum of 1 month following the initial traumatic event.

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

See Clinical Presentation for more detail.

Diagnosis

Currently, diagnosis of PTSD is based on 8 criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (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 condition

See Workup for more detail.

Management

Treatment includes the following:

  • Prevention, by initiating assessment and treatment quickly after the traumatic event, well before a diagnosis of PTSD can be made
  • A combination of pharmacologic and nonpharmacologic therapies for adults
  • Primarily psychotherapeutic intervention in adolescents and children

Nonpharmacologic therapies include the following:

  • Group therapy
  • Individual and family therapy
  • Cognitive behavioral therapy (CBT)
  • Play therapy
  • Art therapy
  • Anxiety management
  • Eye movement desensitization and reprocessing (EMDR)
  • Hypnosis
  • Relaxation techniques

Medications may be required to control the physiologic symptoms, which can enable the patient to tolerate and work through the highly emotional material in psychotherapy. The principal agents used include the following:

  • Selective serotonin reuptake inhibitors (SSRIs; eg, sertraline, paroxetine, fluoxetine): May relieve all 3 symptom clusters
  • Benzodiazepines (eg, lorazepam, diazepam): For anxiety and other symptomatic relief
  • Beta-blockers (eg, propranolol): For hyperarousal-related symptoms
  • Anticonvulsants (eg, carbamazepine, lamotrigine; off-label use): For impulsivity and emotional lability
  • Atypical antipsychotics (eg, risperidone, olanzapine; off-label use): For patients who do not respond to antidepressants
  • Alpha1 blockers (eg, prazosin; off-label use): For nightmares and sleep disturbances
  • Alpha2 agonists (eg, clonidine; off-label use): For hyperarousal, and possibly nightmares

The following medications have also been used in PTSD:

  • Monoamine oxidase inhibitors
  • Tricyclic antidepressants
  • Eszopiclone: To improve overall PTSD severity and sleep [3]
  • Low-dose glucocorticoids: For decreasing recall of traumatic memories [4]
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Background

Formerly in the "Anxiety Disorders" chapter, PTSD is now included in a new chapter of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) titled "Trauma- and Stressor-Related Disorders." Furthermore, a fourth diagnostic cluster (in addition to Criteria B, C, and D) capturing behavioral symptoms has been added. The 6 diagnostic criteria included in DSM-IV-TR were maintained, with minor revisions, and 2 additional criteria have been added: (1) negative alterations in cognition and mood associated with the traumatic event, beginning or worsening after the event, and (2) the disturbance is not attributed to the direct physiologic effects of a substance or another medical condition. [2]

The individual initially responds with intense fear, helplessness, or horror. The person later develops a response to the event that is characterized by persistently reexperiencing the event, with resultant symptoms of numbness, avoidance, and hyperarousal. [1] These symptoms result in clinically significant distress or functional impairment. To meet the full criteria for PTSD, these symptoms should be present for a minimum of 1 month following the initial traumatic event.

The events experienced may be natural disasters, violent personal assaults, war, severe automobile accidents, or the diagnosis of a life-threatening condition. For children, a developmentally inappropriate sexual experience may be considered a traumatic event, even though it may not have actually involved violence or physical injury.

Brain structures associated with the body’s reaction to fear and stress can be seen in the image below.

Brain structures involved in dealing with fear and Brain structures involved in dealing with fear and stress.

PTSD can be acute (symptoms lasting < 3 mo), chronic (symptoms lasting ≥3 mo), or of delayed onset (6 mo elapses from event to symptom onset).

Studies have pointed to a new, dissociative subtype of PTSD, with clinical and neurobiologic features that distinguish it from the nondissociative form. This dissociative subtype is described as an overmodulation of affect, or a form of emotion dysregulation, and is mediated by midline prefrontal inhibition of limbic regions. These findings are important in the treatment of PTSD, because patients can now be assessed for dissociative symptoms and treated accordingly. [5]

A second subtype is now also recognized. The PTSD preschool subtype is used to diagnose PTSD in children younger than 6 years. PTSD is also now developmentally sensitive, meaning that diagnostic thresholds have been lowered for children and adolescents. [2]

Complications of PTSD

Individuals with PTSD may have an increased risk of impulsive behavior, suicide, and homicide. Victims of sexual assault are at especially high risk for developing mental health problems and committing suicide.

Persons with PTSD may also be at increased risk for panic disorder, agoraphobia, obsessive-compulsive disorder, social phobia, specific phobia, major depressive disorder, and somatization disorder.

One study associated PTSD with a risk of developing dementia among older US male veterans. In a group of male veteran participants, those diagnosed with PTSD were twice as likely to develop dementia as were those without PTSD. Discovering the biological link between these disorders would be a monumental accomplishment in the fight to reduce the occurrence of dementia in PTSD victims. [6]

A retrospective study of 183,341 veterans aged 55 years or older who were diagnosed with PTSD found that in models adjusted for demographics and comorbidities, veterans with PTSD at an older age had significantly increased risks at 8-year follow-up for cerebrovascular disease (24%), congestive heart failure (CHF) (26%), peripheral vascular disease (PVD) (34%), and myocardial infarction (MI) (44%) compared with those without late-life PTSD. [7, 8]

In a study of 97 mothers of children aged 3 to 5 years, those with both PTSD and depression reported more aggression and physical assault toward their children as well as greater parenting stress than those with neither disorder. Additionally, more traumatic events were experienced by the children of mothers who had PTSD with or without depression than by those of mothers who had neither disorder or who had depression only. Compared with mothers without either disorder, those with PTSD only (P=.001) and those with both PTSD and depression (P=.04) reported significantly higher levels of child-directed psychological aggression. Those with both disorders also reported significantly higher levels of child-directed physical assault (P=.03) and parenting-related stress (P< .001). [9, 10] Regardless of depression severity, the risk for child-directed psychological aggression was significantly and consistently high (P=.03) when maternal PTSD symptom severity scores were high. [9, 10]

The legal system and PTSD

One major reason for litigation in the event of trauma and criminal offenses is to punish persons involved in violence and criminal activity. As a witness to an act of violence, the victim has an obligation to report the crime and to cooperate with law enforcement officials.

This may involve testifying before a grand jury, which occurs before the case formally begins.

The victim acts as a witness to the case and, therefore, is not a party to the criminal proceedings and is not represented. This can be difficult after experiencing the event itself, which characterizes loss of power, control, and dignity.

Victims often require the support and advocacy of legal representation, but the system does not provide it. The prosecuting attorney is the supposed advocate for the victim, but the attorney's job of defending the interests of justice may conflict with the interests of the victim.

The process of a trial can be very traumatic for the victim, particularly in cases of sexual trauma. Defense tactics sometimes involve blaming the victim for the crime by tainting his or her character; this may add more pain to an already painful process.

Go to Anxiety Disorders for more complete information on this topic.

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Etiology

When PTSD occurs, symptoms of PTSD usually begin within 3 months of the traumatic event. However, a delay of months or years may occur before symptoms appear.

Physiologic factors

The amygdala is a key brain structure implicated in PTSD. Research has shown that exposure to traumatic stimuli can lead to fear conditioning, with resultant activation of the amygdala and associated structures, such as the hypothalamus, locus ceruleus, periaqueductal gray, and parabrachial nucleus. This activation and the accompanying autonomic neurotransmitter and endocrine activity produce many of the symptoms of PTSD.

The orbitoprefrontal cortex exerts an inhibiting effect on this activation. The hippocampus also may have a modulating effect on the amygdala. However, in people who develop PTSD, the orbitoprefrontal cortex appears to be less capable of inhibiting this activation, possibly due to stress-induced atrophy of specific nuclei in this region. [11, 12]

Risk factors

As mentioned, PTSD is caused by experiencing, witnessing, or being confronted with an event involving serious injury, death, or threat to the physical integrity of an individual, along with a response involving helplessness and/or intense fear or horror. In various studies, a direct relationship has been observed between the severity of the trauma and the risk of developing PTSD. [4]

When these events involve an individual with a physiologic vulnerability based on genetic (inherited) contributions and other personal characteristics, PTSD results. These personal characteristics include prior exposure to trauma, childhood adversity (eg, separation from parents), and preexisting anxiety or depression.

One of the most pivotal observations in relation to the development of PTSD in adults who were traumatized as children is the association between early trauma exposure and subsequent retraumatization. [13]

Researchers have identified factors that interact to influence vulnerability to developing PTSD. [14, 15] These factors include the following:

  • Characteristics of the trauma exposure itself
  • Characteristics of the individual
  • Posttrauma factors

Regarding characteristics of the trauma exposure itself, factors that influence the development of PTSD include the trauma’s proximity and severity, as well as the duration of an individual’s exposure to the trauma

Characteristics of the individual that increase vulnerability to PTSD include prior trauma exposures, family history or prior psychiatric illness, and sex (women are at greatest risk for many of the most common assertive traumas).

Posttrauma factors that influence whether PTSD develops include availability of social support, emergence of avoidance or numbing, hyperarousal, and reexperiencing symptoms.

With regard to reexperiencing symptoms, a pilot monozygotic twin study showed that patients with PTSD have impaired extinction of novel conditioned fear stimuli. [16]

Combat and PTSD

Approximately 30% of men and women who have spent time in a war zone experience PTSD. [17]

Studies conducted with veteran participants from Operation Iraqi Freedom and Operation Enduring Freedom (Afghanistan) determined a strong correlation between duration of combat exposure and PTSD. Service members from Operation Enduring Freedom (Afghanistan) reported less combat experience and, consequently, a lower incidence of mental health disorder compared with veterans of Operation Iraqi Freedom, who reported greater combat exposure. [18, 19] A study by Polusney et al suggests that combat-related PTSD is strongly associated with postconcussive symptoms and psychosocial outcomes one year after return from Iraq; however, little evidence of a long-term negative impact due to concussion and mild traumatic brain injury after accounting for PTSD. [20]

Research shows that women who served in the Vietnam War are at greater risk for both lifetime and current posttraumatic stress disorder (PTSD) compared with either their counterparts stationed in a nearby base during the same era or with those who served in the United States.The Health of Vietnam-Era Women's Study (HealthVIEWS) found that the lifetime prevalence of PTSD for women in the Vietnam cohort was 20.1% compared with a lifetime prevalence of PTSD of 11.5% in the near-Vietnam cohort and a 14.1% prevalence in the US-based cohort. [21]

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Epidemiology

Incidence of PTSD in the United States

PTSD has a lifetime prevalence of 8-10% and accounts for considerable disability and morbidity. One study found the prevalence of PTSD in a sample of adolescent boys to be 3.7% and the prevalence in adolescent girls to be 6.3%. [22]

Sex preference in PTSD

Females may be at higher risk for PTSD than are males. An epidemiologic survey of adult women indicated alarmingly high rates of traumatic events, particularly events associated with being crime victims. Sexual assault probably has the most impact on women, and trauma from combat probably has the most impact on men.

Although earlier veteran studies were somewhat inconsistent, subsequent studies have suggested that service in Operation Iraqi Freedom presented equal PTSD risk to both sexes, with the duration and severity of combat experience having a greater influence than sex on the likelihood of a veteran having PTSD. [23, 24]

Age preference in PTSD

PTSD can occur in persons of any age, including children.

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Prognosis

Prognosis in cases of PTSD is difficult to determine, because it varies significantly from patient to patient. Some individuals who do not receive care gradually recover over a period of years. Many individuals who receive appropriate medical and psychiatric care recover completely (or nearly completely). Rarely, even with intensive intervention, individuals experience worsening symptoms and commit suicide.

In patients with PTSD who are receiving treatment, the average duration of symptoms is 36 months, compared with 64 months for those patients who do not receive treatment. However, more than one third of patients who have PTSD never fully recover.

Factors associated with a good prognosis include rapid engagement of treatment, early and ongoing social support, avoidance of retraumatization, positive premorbid function, and an absence of other psychiatric disorders or substance abuse.

Results from a pilot study in civilians suggested that patients with PTSD who experienced peritraumatic tonic immobility during the traumatic event have a poor response to pharmacologic treatment. [25]

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Patient Education

When a family member is diagnosed with PTSD, the entire family may be affected. Members may experience shock, fear, anger, and pain because of their concern for the victim. Living with family members who have PTSD does not cause PTSD. Yet, it can cause some similar symptoms, such as feelings of alienation from and anger toward the victim. Other family members may find it difficult to communicate with a person with PTSD. Sleep disturbance and abuse (physical and substance) may occur among family members.

Families should engage in counseling if anger, addiction, or problems in school or work become issues. Stress and anger management and couples' therapy are possibilities. Families should try to maintain their outside relationships and should continue to be involved in pleasurable activities.

For patient education information, see the Mental Health Center, as well as Post-traumatic Stress Disorder (PTSD) and Stress.

The following Web sites also provide valuable information for patients and their families: US Department of Veteran Affairs National Center for PTSD, US Army Office of Behavioral Health, Afterdeployment.org, National Institute of Mental Health, American Academy of Child and Adolescent Psychiatry, and Mayo Clinic.

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