Posttraumatic stress disorder (PTSD) is a disabling disorder that develops after exposure to a traumatic event. It is characterized by intrusive thoughts, nightmares, and flashbacks; avoidance of reminders of the trauma; negative cognitions and mood; hypervigilance and sleep disturbance. Diagnosis is based on clinical criteria. Treatment includes psychotherapy and sometimes adjunctive pharmacologic therapy.
(See also Overview of Trauma- and Stressor-Related Disorders.)
Lifetime prevalence of PTSD approaches 9%, with a 12-month prevalence of approximately 4% (1).
Combat, sexual assault, and natural or man-made disasters are common causes of PTSD. PTSD can lead to serious social, occupational, and interpersonal dysfunction.
While acute stress disorder (ASD) can only be diagnosed within the first month after a trauma, PTSD can only be diagnosed at least 1 month after the trauma. ASD can develop directly into PTSD, or PTSD can develop months or even years after the trauma without preceding problems being obvious.
General reference
1. Goldstein RB, Smith SM, Chou SP, et al: The epidemiology of DSM-5 posttraumatic stress disorder in the United States: Results from the National Epidemiologic Survey on Alcohol and Related Conditions-III. Soc Psychiatry Psychiatr Epidemiol 51(8):1137-1148, 2016. doi: 10.1007/s00127-016-1208-5
Symptoms and Signs of PTSD
Symptoms of PTSD can be subdivided into 4 categories:
Intrusions
Avoidance
Negative alterations in cognition and mood
Alterations in arousal and reactivity
Intrusions: Intrusions are unwanted memories or nightmares that replay the triggering event. Intrusions can take the form of "flashbacks," which can be triggered by sights, sounds, smells, or other stimuli. For example, a loud noise might trigger the memory of an assault, leading the person to throw himself to the ground in a panic.
Avoidance: People with PTSD might avoid reminders of the trauma, such as particular parts of town or previously favorite activities.
Negative alterations in cognition and mood: Cognitive and mood changes include disinterest and detachment, distorted cognitions, anhedonia, inappropriate self-blame, and depression.
Alterations in arousal and reactivity: People with PTSD can demonstrate excessive arousal, irritability, and reactivity, or they may seem numb and distant.
A dissociative subtype of PTSD has been recognized. This includes all of the symptoms mentioned above, plus depersonalization (feeling detached from one's self or body) and/or derealization (experiencing the world as unreal or dreamlike).
Diagnosis of PTSD
Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, Text Revision (DSM-5-TR) criteria
To meet DSM-5-TR criteria for diagnosis of PTSD, patients must have been exposed directly or indirectly to a traumatic event and have symptoms from each of the following categories for a period ≥ 1 month (1).
Intrusion symptoms (≥ 1 of the following):
Having recurrent, involuntary, intrusive, disturbing memories
Having recurrent disturbing dreams (eg, nightmares) of the event
Acting or feeling as if the event were happening again, ranging from having flashbacks to completely losing awareness of the present surroundings
Feeling intense psychological or physiologic distress when reminded of the event (eg, by its anniversary, by sounds similar to those heard during the event)
Avoidance symptoms (≥ 1 of the following):
Avoiding thoughts, feelings, or memories associated with the event
Avoiding activities, places, conversations, or people that trigger memories of the event
Negative effects on cognition and mood (≥ 2 of the following):
Memory loss for significant parts of the event (dissociative amnesia)
Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world
Persistent distorted thoughts about the cause or consequences of the trauma that lead to blaming self or others
Persistent negative emotional state (eg, fear, horror, anger, guilt, shame)
Markedly diminished interest or participation in significant activities
A feeling of detachment or estrangement from others
Persistent inability to experience positive emotions (eg, happiness, satisfaction, loving feelings)
Altered arousal and reactivity (≥ 2 of the following):
Difficulty sleeping
Irritability or angry outbursts
Reckless or self-destructive behavior
Problems with concentration
Increased startle response
Hypervigilance
In addition, manifestations must cause significant distress or significantly impair social or occupational functioning and not be attributable to the physiologic effects of a substance use or another medical disorder.
The dissociative subtype of PTSD is diagnosed when, in addition to all of the symptoms mentioned above, there is evidence of depersonalization (feeling detached from one's self or body) and/or derealization (experiencing the world as unreal or dreamlike).
PTSD is often overlooked. The trauma may not be obvious to the clinician, and the patient may not be motivated to discuss a difficult topic. The trauma can lead to a complex swirl of cognitive, affective, behavioral, and somatic symptoms. Diagnosis is often further complicated by the existence of a co-occurring depressive disorder, anxiety disorder, and/or substance use disorder.
Diagnosis reference
1. Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision (DSM-5-TR). American Psychiatric Association Publishing, Washington, DC, pp 301-313.
Treatment of PTSD
Psychotherapy
Pharmacotherapy
Self-care
Self-care is crucial during and after a crisis or trauma. Self-care includes:
Personal safety
Physical health
Mindfulness
Personal safety is fundamental. After a trauma, people are better able to process the experience when they know that they and their loved ones are safe. It can be difficult, however, to gain complete safety during ongoing crises such as domestic abuse, war, or an infectious pandemic. During such ongoing difficulties, people should seek the guidance of experts on how they and their loved ones can be as safe as possible.
Physical health can be put at risk during and after traumatic experiences. As much as possible, the at-risk person should try to maintain a healthy schedule of eating, sleeping, and exercise. Substances and medications that sedate (eg, benzodiazepines) and intoxicate (eg, alcohol) should be used sparingly, if at all.
A mindful approach to self-care aims to reduce the stress, boredom, anger, sadness, and isolation that traumatized people typically experience. If circumstances allow, at-risk individuals should make and follow a normal daily schedule, remain involved with their family and community, and practice familiar hobbies (or develop new ones).
It is useful to limit the amount of time spent on news and instead shift to other activities (eg, read a novel, do a puzzle, paint a picture, make cookies for a housebound neighbor).
Psychotherapy
Trauma-focused cognitive-behavioral therapy (CBT) has the most robust evidence for efficacy for most people with PTSD (1). As for acute stress disorder (ASD), this form of psychotherapy includes patient education, cognitive restructuring, and therapeutic exposure to recollections of the traumatic experience. Cognitive processing therapy is a type of CBT that involves talking through the implications of traumatic experiences and putting negative thoughts about oneself and the traumatic experiences into perspective, seeing them as different from the actual trauma.
Prolonged exposure is another effective psychotherapy that involves addressing a series of traumatic memories while managing the psychophysiologic response to them with techniques such as controlled breathing, thereby gradually desensitizing the impact of the memories.
Eye movement desensitization and reprocessing (EMDR) is a form of exposure therapy that may also be used (2). For this therapy, patients are asked to follow the therapist's moving finger while they imagine being exposed to the trauma. While some experts think that the eye movements themselves help with desensitization, others attribute its efficacy mainly to the exposure rather than the eye movements.
Therapeutic style is important in the treatment of PTSD (3). Warmth, reassurance, and empathy are some of the nonspecific factors that may be unusually important when working with people suffering from such core PTSD symptoms as shame, avoidance, hypervigilance, and detachment.
Pharmacotherapy
Evidence for pharmacotherapy in PTSD is less robust than that for trauma-focused psychotherapy (4). Most often, medications are used to treat co-existing psychiatric disorders, or especially prominent PTSD symptoms, such as depression or anxiety.
Selective serotonin reuptake inhibitors (SSRIs) may reduce anxiety and/or depression (567).
Treatment references
1. Bisson J, Andrew M: Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database Syst Rev (3):CD003388, 2007. doi: 10.1002/14651858.CD003388.pub3
2. Wilson G, Farrell D, Barron I, et al: The use of eye-movement desensitization reprocessing (EMDR) therapy in treating post-traumatic stress disorder—A systematic narrative review. Front Psychol;9:923, 2018. doi: 10.3389/fpsyg.2018.00923
3. Howard R, Berry K, Haddock G: Therapeutic alliance in psychological therapy for posttraumatic stress disorder: A systematic review and meta-analysis. Clin Psychol Psychother 29(2):373-399, 2022. doi: 10.1002/cpp.2642
4. Wright LA, Sijbrandij M, Sinnerton R, et al: Pharmacological prevention and early treatment of post-traumatic stress disorder and acute stress disorder: A systematic review and meta-analysis. Transl Psychiatry 9(1):334, 2019. doi: 10.1038/s41398-019-0673-5
5. Stein DJ, Ipser JC, Seedat S: Pharmacotherapy for post traumatic stress disorder (PTSD). Cochrane Database Syst Rev 22006(1):CD002795, 2006. doi: 10.1002/14651858.CD002795.pub2
6. Khachatryan D, Groll D, Booij LGen Hosp Psychiatry 39:46-52, 2016. doi: 10.1016/j.genhosppsych.2015.10.007
7. Krediet E, Bostoen T, Breeksema J, et al: Reviewing the potential of psychedelics for the treatment of PTSD. Int J Neuropsychopharmacol. 23(6):385-400, 2020. doi: 10.1093/ijnp/pyaa018
