Introduction
Background
The formal diagnosis of posttraumatic stress disorder (PTSD) was not introduced into the Diagnostic and Statistical Manual of Mental Disorders until its third publication in 1980. In earlier DSM editions, this relatively new diagnosis was characterized as stress response syndrome, a type of gross stress reaction, or a situational disorder, and often incorrectly associated with personal weakness instead of situational trauma.
PTSD is now 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.
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. 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.
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).
Pathophysiology
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 less capable of inhibiting this activation, possibly due to stress-induced atrophy of specific nuclei in this region.
Frequency
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 adolescent girls to be 6.3%.1 Approximately 30% of men and women who have spent time in a war zone experience PTSD.2
Mortality/Morbidity
- In various studies, a direct relationship is observed between the severity of the trauma and the risk for PTSD.3
- Individuals with the disorder 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.
- 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.4
- 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.5,6
Sex
- Females may be at a higher risk than males. An epidemiologic survey of adult women indicates alarmingly high rates of traumatic events, particularly those events relating to being victims of crimes. Sexual assault probably has the most impact on women, and trauma from combat probably has the most impact on men.
- Although earlier veteran studies have been somewhat inconsistent, recent studies suggest that Operation Iraqi Freedom service confers equal PTSD risk to both genders, with the duration and severity of combat experience having a greater influence upon the likelihood of developing PTSD.7,8
Age
- PTSD can occur in persons of any age, including children. Symptoms usually begin within 3 months of the event, although a delay of months or years may occur before symptoms appear.
Clinical
History
One study found that nearly half (48%) of the patients in general medical practices with posttraumatic stress disorder (PTSD) were receiving no mental health treatment at the time of intake to the study. The most common reason patients gave for not receiving medication was the failure of physicians to recommend such treatment.9
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. The mental status examination should routinely consist of questions about exposure to trauma or abuse.
- 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)
- The second major criterion involves the persistent reexperiencing of the event in one 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. However, children reexperience the event through repetitive play, not through perception like adults.
- 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
- 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, 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.
- Finally, the disturbance is a cause of clinically significant distress or impairment in functioning.
- Children may have different reactions to trauma than 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.10
- 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 adults.10
Physical
Patients may present with physical injuries from the traumatic event (eg, bruises in victims of domestic abuse). Patients with chronic PTSD may present with somatic complaints and, possibly, general medical conditions. Special attention should be paid to the patient's sleep hygiene. Recent studies suggest that even a single cognitive behavior treatment (CBT) for sleep abnormalities can significantly improve daytime PTSD symptoms, as can pharmacological treatments for sleep abnormalities.11,12
- Mental Status Examination
- General appearance may be affected. Patients may appear disheveled and have poor personal hygiene.
- Behavior may be altered. Patients may appear agitated, and their startle reaction may be extreme.
- Orientation is sometimes affected. 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. Patients may report forgetfulness, especially concerning the specific details of the traumatic event. A recent pilot study suggests memory abnormalities may not be limited to the traumatic event itself.13
- Concentration is poor.
- Impulse control is poor.
- Speech rate and flow may be altered.
- 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.
Causes
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. The more severe the trauma and the more intense the acute stress symptoms, the higher the risk for PTSD. 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.
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 - Proximity to, severity of, and duration of exposure to the trauma
- Characteristics of the individual - 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 - Availability of social support, emergence of avoidance or numbing, hyperarousal, and reexperiencing symptoms. For reexperiencing symptoms, specifically, a pilot monozygotal twin study shows that patients with PTSD have impaired extinction of novel conditioned fear stimuli.16
More on Posttraumatic Stress Disorder |
 Overview: Posttraumatic Stress Disorder |
| Differential Diagnoses & Workup: Posttraumatic Stress Disorder |
| Treatment & Medication: Posttraumatic Stress Disorder |
| Follow-up: Posttraumatic Stress Disorder |
| References |
| Next Page » |
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Further Reading
Keywords
PTSD, posttraumatic stress disorder, post-traumatic stress disorder, post-traumatic stress syndrome, posttraumatic stress syndrome, stress syndrome, stress disorder, anxiety disorder, anxiety, suicide, impulsive behavior, impulse control, violence, violent assault, sexual assault, combat disorder, shell shock, rape, traumatic memory, trauma witness, trauma exposure, traumatic reaction, depression, depressive disorders, alcohol abuse, drug abuse, alcoholism, combat neurosis
