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Topics: PTSD

Posttraumatic stress disorder (PTSD) is manifested by a cluster of symptoms that commonly occur after a traumatic event.

PTSD is just one potential aftermath of a traumatic event, which DSM-5 describes as an event in which a person is directly or indirectly exposed to threat of death, actual or threatened serious injury, or actual or threatened sexual violence.

Many people who experience a traumatic event go on to have brief symptoms of depression, sleep problems, anxiety symptoms, or increased substance use (Kessler RC et al, Arch Gen Psychiatry 1995;52(12):1048–1060). But others will develop persistent posttraumatic symptoms, lasting over a month and causing impairments in functioning.

These symptoms fall into four clusters, and to meet criteria for PTSD, an individual must have at least one symptom from the first two clusters and at least two symptoms from each of the second two clusters:

1. Intrusion symptoms (including flashbacks, nightmares, intrusive thoughts of the trauma, dissociation, or psychological or physiological distress—such as an increase in heart rate and blood pressure—when reminded of the trauma)
2. Avoidance (both avoiding reminders and thinking about the trauma)
3. Negative changes in mood and thinking (including inability to remember the traumatic event, blaming oneself for the event, or feeling persistently afraid, angry, or ashamed)
4. Negative changes in arousal and reactivity (eg, irritability, hypervigilance, sleep disturbances, poor concentration)

How Common is PTSD?

While we generally think of traumatic experiences as rare, more than half of adults in the US report having experienced a traumatic event (such as a life-threatening accident or assault, witnessing someone being shot or badly beaten, being in a fire or a life-threatening natural disaster, etc.) (Kessler 1995 op.cit and Kessler RC et al, Arch Gen Psychiatry 2005;62(6):617–627). Not all of them will go on to develop PTSD. Some experience brief symptoms as mentioned, while others will experience depression, substance use disorders, or panic attacks.

PTSD occurs most commonly after violent assault, but can also occur after a sudden loss of a loved one, an acute medical illness such as a stroke, or even an experience of psychotic symptoms. The national prevalence of PTSD is estimated at 6.8% (Kessler 2005 op.cit), but an individual may be at greater or lesser risk for PTSD depending on a number of factors, including the type of trauma, age at the time, frequency (single incident or repeated traumatic events), the individual’s prior experiences of trauma and mental illness and available supports, and possible genetic vulnerability factors (Yehuda R, Can J Psychiatry 1999;44(1):34–39).

PTSD is more common in women than men, but this may have to do more with women being exposed more to certain types of traumatic experiences (such as sexual assault and domestic abuse) than men. Men and women who experience accidents, natural disasters, or sudden loss of loved ones experience similar rates of PTSD, suggesting that it is not an issue of women being more psychologically vulnerable.

PTSD occurs often in children, particularly after witnessing the assault or murder of a parent, witnessing a violent crime, or experiencing physical or sexual abuse or warfare (Salmon K and Bryant RA, Clin Psychol Rev 2002;22(2):163–188). Posttraumatic symptoms may present somewhat differently in children, particularly young children, than in adolescents and adults, which is reflected in DSM-5. For instance, a child might experience frightening dreams without recognizable content, have regression of developmental milestones, or engage in repetitive play in which aspects of the trauma are expressed.

While some individuals recover from PTSD spontaneously, for many, without treatment the symptoms persist for years. Those who have experienced previous traumas or who lack social support are particularly vulnerable to persistent illness.

Comorbid conditions are also very common with PTSD, particularly depression, substance abuse, and anxiety disorders in adolescents and adults, and behavioral problems and regressed behavior in children. Treatment of these comorbid conditions is not usually effective without simultaneous treatment of the PTSD.

Are There Different Types of PTSD?

There are likely two discrete types of PTSD: one with predominant intrusion and hyperarousal symptoms and another with predominantly avoidant and dissociative symptoms (Lanius RA et al, Am J Psychiatry 2010;167(6):640–647).

Longstanding interpersonal trauma, such as child abuse or domestic violence, can lead to a more pervasive, longstanding type of PTSD called complex PTSD. This produces broad difficulties with attention, emotion, self-perception, interpersonal relationships, and self-regulation in addition to the core symptoms of PTSD (Herman JL. Trauma and Recovery. New York: Basic Books; 1992).

Treatment of PTSD

The most effective treatment for PTSD is psychotherapy. The key ingredients of effective psychotherapy for PTSD include psychoeducation about trauma and its effects, providing safety and support, and then helping patients to confront painful memories of the trauma. Therapies that do not specifically address the trauma are not usually effective (Bisson J and Andrew M. Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews 2007, CD003388). (See “Four Evidence-Based Treatments for PTSD” for more details on effective psychotherapies.)

Medications can be useful adjuncts to therapy, and may include antidepressants and specialized medications, such as prazosin (Minipress) for the treatment of nightmares. Medications such as beta-blockers may be useful to prevent PTSD, if given immediately after a traumatic event, though more research on this is needed.

TCRBH’s Take: PTSD can be especially difficult to diagnose and treat for several reasons, among which may be the presence of coexisting conditions and the variable time frames in which symptoms develop. Also, depending on the type of trauma and type of exposure, it’s important to assess for traumatic brain injury. There is evidence that indicates that PTSD is associated with an elevated risk of suicide, so it is especially important to focus on safety right from the start of treatment (and to start treatment as early as possible). And it’s important to understand the cultural or other meaningful contexts of the individual’s life. That is, to treat a veteran with PTSD, you should understand military culture. Similarly, it’s important to understand how being of a particular ethnicity, gender, or age, for example, effects that individual’s experience.