Post-Traumatic Stress Disorder (PTSD)
Trauma is a nonspecific term to describe deeply distressing or disturbing experiences. Trauma can be physical (e.g., bone fracture, head trauma, etc.) or emotional. Alterations in arousal, reactivity, mood, thoughts, and behaviors can occur following traumatic experiences. When these alterations are persistent or cause impairment in important areas of functioning, we use the term “trauma disorder.”
There are many types of trauma and not all of them are included in the Diagnostic and Statistical Manual (DSM). Each type of trauma has a different presentation and associated symptoms and in no way can we simplify traumatic experiences to one type (in other words, there is tremendous overlap). Below we review Post Traumatic Stress Disorder (PTSD) as described in DSM-5.
Post-Traumatic Stress Disorder (PTSD)
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
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
- 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 symptoms
- Short duration of 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).
- Exposure Therapy
- Mindfulness Based Therapies
- Cognitive Behavioral Therapy (CBT)
- Psychodynamic Psychotherapy
- Eye Movement Desensitization Reprocessing (EMDR)
- Family therapy
- Group therapy
- SSRIs: Sertraline (FDA Approved), Paroxetine (FDA Approved), Citalopram, Escitalopram, Fluoxetine
- SNRIs: Venlafaxine, Duloxetine
- Buspirone (as augmentation)
- Propranolol (hypervigilance)
- Prazosin (for trauma related nightmares)
- Ketamine Infusions
- MDMA with guided psychotherapy
- Transcranial Magnetic Stimulation (TMS)
- Electroconvulsive Therapy (ECT)
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.
- Arciniegas, Yudofsky, Hales (editors). The American Psychiatric Association Publishing Textbook Of Neuropsychiatry And Clinical Neurosciences.Sixth Edition.
- Bear, Mark F.,, Barry W. Connors, and Michael A. Paradiso. Neuroscience: Exploring the Brain. Fourth edition. Philadelphia: Wolters Kluwer, 2016.
- Cooper, J. R., Bloom, F. E., & Roth, R. H. (2003). The biochemical basis of neuropharmacology (8th ed.). New York, NY, US: Oxford University Press.
- Higgins, E. S., & George, M. S. (2019). The neuroscience of clinical psychiatry: the pathophysiology of behavior and mental illness. Philadelphia: Wolters Kluwer.
- Iversen, L. L., Iversen, S. D., Bloom, F. E., & Roth, R. H. (2009). Introduction to neuropsychopharmacology. Oxford: Oxford University Press.
- Levenson, J. L. (2019). The American Psychiatric Association Publishing textbook of psychosomatic medicine and consultation-liaison psychiatry. Washington, D.C.: American Psychiatric Association Publishing.
- Mendez, M. F., Clark, D. L., Boutros, N. N. (2018). The Brain and Behavior: An Introduction to Behavioral Neuroanatomy. United States: Cambridge University Press.
- Schatzberg, A. F., & DeBattista, C. (2015). Manual of clinical psychopharmacology. Washington, DC: American Psychiatric Publishing.
- Schatzberg, A. F., & Nemeroff, C. B. (2017). The American Psychiatric Association Publishing textbook of psychopharmacology. Arlington, VA: American Psychiatric Association Publishing.
- Neuroscience, Sixth Edition. Dale Purves, George J. Augustine, David Fitzpatrick, William C. Hall, Anthony-Samuel LaMantia, Richard D. Mooney, Michael L. Platt, and Leonard E. White. Oxford University Press. 2018.
- Blumenfeld, Hal. Neuroanatomy Through Clinical Cases. 2nd ed. Sunderland, Mass.: Sinauer Associates, 2010.
- Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY, US: Cambridge University Press.
- Stern, T. A., Freudenreich, O., Fricchione, G., Rosenbaum, J. F., & Smith, F. A. (2018). Massachusetts General Hospital handbook of general hospital psychiatry. Edinburgh: Elsevier.
- Hales et al. The American Psychiatric Association Publishing Textbook of Psychiatry. 6th Edition.
- Benjamin J. Sadock, Virginia A. Sadock. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. Philadelphia.