Post-Traumatic Stress Disorder (PTSD)
What are common signs and symptoms of Post Traumatic Stress Disorder (PTSD)?
Exposure to actual or threatened death, serious injury, or sexual violence in the following ways
- 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 close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
- Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse).
Intrusion symptoms such as
- Recurrent, involuntary, and intrusive distressing memories of of the traumatic event(s).
- Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).
- Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring (on a continuum).
- Intense or prolonged psychological distress at exposure to internal or external cues.
- Marked physiological reactions to internal or external cues.
Avoidance symptoms such as
- Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
- Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely with the traumatic event(s).
Negative alterations in cognitions and mood such as
- Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).
- Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world.
- Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.
- Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
- Markedly diminished interest or participation in significant activities.
- Feelings of detachment or estrangement from others.
- Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).
Marked alterations in arousal and reactivity such as
- Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.
- Reckless or self-destructive behavior.
- Exaggerated startle response.
- Problems with concentration.
- Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
Other symptoms that might occur include
- Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly).
- Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted).
- Panic Attacks
Terms Used Throughout History to Describe what we now call PTSD:
- Irritable Heart (Jacob DaCosta, 1871)
- Soldier’s Heart
- Effort Syndrome
- Neurocirculatory Asthenia
- Compensation Neurosis
- Shell Shock
- War Neurosis
- Battle Fatigue
- Vietnam Syndrome
Quick Facts about PTSD
- The highest rates of PTSD occur among survivors of rape, military combat and captivity, and ethnically or politically motivated internment and genocide
- Combat is the most common traumatic event for men
- Rape/sexual assault and physical assault are the most common traumatic events in women
- Natural disasters (earthquakes, storms, floods), terrorist attacks, mass killings, and child abuse are also common traumatic events
- PTSD has a familial pattern
- If left untreated, 30% of patients with PTSD will experience remission, 40% will develop mild symptoms, 20% will develop moderate symptoms, and 10% will develop severe symptoms
Good Prognostic Factors
The following are associated with better outcomes and responses to currently available treatments
- Rapid onset of post-traumatic symptoms
- Short duration of post-traumatic symptoms
- Good functioning prior to the traumatic event
- Strong social support
- Absence of substance use or other psychiatric disorders
The following, when present, are risk factors for developing Post Traumatic Stress Disorder
- Life-threatening traumatic event (i.e., intensity or severity of traumatic event)
- Longer duration of traumatic event (s)
- Proximity of traumatic event(s)
- Childhood trauma
- Borderline/antisocial/dependent/paranoid personality traits
- Inadequate support system
- Female gender
- Recent stressful life changes
- Recent excessive alcohol intake
NOTE: PTSD is more likely to occur in individuals who are single, divorced, widowed, socially withdrawn, or in lower socioeconomic statuses
Traumatized individuals may be at increased risk for developing the following
- Bipolar Disorder
- Panic Disorder
- Social Phobia
- Generalized Anxiety Disorder
- Alcohol Abuse/Dependency
- Substance Abuse/Dependency
- Cerebrovascular disease
- Congestive Heart Failure
- Peripheral Vascular Disease
- Myocardial Infarction (heart attacks)
- Hypothalamic Pituitary Adrenal (HPA) Axis Dysregulation (altered cortisol levels and biological rhythms)
- Decreased volume of the hippocampus has been reported in combat veterans
- Noradrenergic (Norepinephrine), Opioid, Glutamate, GABA, and Endocannabinoid dysregulation
- Sleep disturbances such as decreased REM latency (i.e., decreased time between falling asleep and the first Rapid Eye Movement Cycle).
Selective Serotonin Reuptake Inhibitors (e.g., Sertraline, Paroxetine, Citalopram, Escitalopram, Fluoxetine) and Serotonin Norepinephrine Reuptake Inhibitors (e.g., Venlafaxine, Duloxetine) are first line medications for post-traumatic stress disorder. Prazosin is often used for trauma-related nightmares. Propranolol (Inderal), Clonidine, Valproic Acid (Depakote), Buspirone (Buspar), Mirtazapine (Remeron), Trazodone (Desyrel), Amitriptyline (Elavil), and Nortriptyline (Pamelor) may also be prescribed. Medications primarily target intrusive thinking, ruminations, negative thoughts, mood reactivity, hypervigilance, aggression, irritability, impulsivity, insomnia, muscle tension, and panic attacks.
The algorithm below is from the Psychopharmacology Algorithms Project at the Harvard South Shore Psychiatry Residency Training Program
Project Leader: David Osser, MD
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While medication can be very important in the treatment of post-traumatic stress disorder, psychotherapy is equally (if not more) important and strongly recommended. Exposure therapy, mindfulness-based therapies, cognitive behavioral therapy, psychodynamic psychotherapy, psychedelic assisted psychotherapy, eye movement desensitization reprocessing (EMDR), family therapy, and group therapy are used to varying degrees.
Modalities such as neurofeedback, Transcranial Magnetic Stimulation (TMS), and ketamine infusion therapy are recommended if medication and traditional therapy are not beneficial (or only partially beneficial).
- Ketamine Infusions
- Ketamine Assisted Psychotherapy
- MDMA with guided psychotherapy
- Psychedelic Assisted Psychotherapy
- Transcranial Magnetic Stimulation (TMS)
- Electroconvulsive Therapy (ECT)