Overview
Posttraumatic Stress Disorder is an anxiety disorder, symptoms of which may be experienced after an individual undergoes, witnesses, or learns about the occurrence of a severely distressing event such as death, serious injury, or violence.
The disorder is characterized by significant psychological distress as a result of heightened anxiety, emotionality, fear, as well as flashbacks and nightmares pertaining to the context of the trauma.
Posttraumatic Stress Disorder can lead to serious consequences in social, occupational, and other functional aspects of an individualโs life, and can also lead to a heightened risk of suicide.
There is a female preponderance in the prevalence of Posttraumatic Stress Disorder. The disorder may develop at any age upon encounter with traumatic situations, and the onset is typically within the first three months after the experience.
A number of socio-demographic, genetic, neurochemical, neuroanatomical, cognitive, and environmental factors are associated with the disorder. Posttraumatic Stress Disorder is, more often than not, linked with at least one comorbidity.
Psychosocial intervention is often considered to be the first line of treatment for the disorder, and has been positively linked to the management of symptoms. Pharmacological treatment modalities are also considered to have efficacy.
Signs and Symptoms
The signs and symptoms of Posttraumatic Stress Disorder may include:
- Recurrent and involuntary memories of traumatic event
- Distressing dreams related to the trauma context
- Flashbacks where one feels transported back into the context of the trauma
- Psychological distress upon exposure to cues symbolizing the event
- Physical reactions to cues symbolizing the event
- Avoiding being in the place of the event
- Avoiding people who were present during the event
- Avoiding thoughts or memories related to the event
- Inability to remember important aspects of the event
- Having exaggerated negative beliefs about oneself or others
- Blaming oneself or others for the traumatic event and its consequences
- Feelings of fear, horror, guilt, or shame
- Reduced interest in activities previously considered important
- Feeling detached or estranged from others
- Inability to experience positive emotions
- Irritability and angry outbursts
- Impulsive or self-destructive behavior
- Overly startled reactions
- Problems with concentration
- Sleep disturbances
- Depersonalization โ a sense of being detached from oneโs own body
- Derealization โ Experiences of unreality or a dreamlike state
Risk Factors
Posttraumatic Stress Disorder is more prevalent among females than among males, and is also experienced for longer durations by females.
This increased risk may be attributable to a higher likelihood of women to face traumatic events, such as domestic abuse or rape.
The disorder may occur among anybody beginning after the first year of life, and the onset of symptoms typically occurs within three months of the experience of a traumatic event.
A higher prevalence of the disorder exists among individuals whose occupation involves the possibility of exposure to trauma, such as veterans, emergency medical professionals, firefighters, police, and so on.
Demographic factors implicated as risk factors include lower socioeconomic status, unemployment, lower intelligence, and minority status.
Posttraumatic Stress Disorder is a consequence of the experience of significant trauma, though it is unclear why some people develop the disorder and others donโt.
Certain factors have been implicated in trying to understand what brings about the onset of Posttraumatic Stress Disorder. Of these, the severity of the traumatic experience is often considered to be an instrumental aspect in determining the likelihood of development of Posttraumatic Stress Disorder.
Further, increased fear of perceived threat to self because of the traumatic event may translate into a higher risk of occurrence.
Biological factors also have a considerable implication in the development of Posttraumatic Stress Disorder. A significant genetic contribution is associated, including heritable personality traits.
The genetic variation that may increase likelihood of the occurrence of Posttraumatic Stress Disorder is comparable to the factors associated in the development of major depressive disorder, generalized anxiety disorder, and panic disorder.
There is a heightened physiological response to cues related to the traumatic event, observable often in the form of elevated heart rate and skin conductance.
These responses are looked at through a conditioning and sensitization framework, wherein individuals are conditioned to respond to trauma-related cues through physiological behavior because of the same reactions during the experience of trauma.
Studies have speculated that the development of Posttraumatic Stress Disorder may be a result of the failure to adequately desensitize and extinguish this response to trauma cues.
There is evidence of stress-induced damage to the hippocampus as a result of stress, as well as reduced volume of the ventromedial prefrontal cortex.
While not directly associated with the development of Posttraumatic Stress Disorder, studies have implicated that these neuroanatomical abnormalities may have some influence on how we perceive contextual cues, and may also affect the ability to carry out the extinction of responses to trauma cues.
Exaggerated activation of the amygdala, which is involved in threat detection and fear response, has also been detected in trauma response.
Abnormalities in the hypothalamic-pituitary-adrenal axis have been linked to atypical stress response that is often present in individuals with the disorder. Lower cortisol levels, higher glucocorticoid receptor density, dexamethasone suppression, and increased negative feedback are factors commonly considered.
Temperamental factors also come into play in the developmental course of Posttraumatic Stress Disorder.
Prior to the experience of trauma, pre-existing mental conditions such as panic disorder, depressive disorders, or obsessive-compulsive disorder may exacerbate risk.
Childhood adversity including separation among parents, dysfunctional family environment, and economic difficulties, as well as self-blaming coping strategies, and a history of psychiatric illness in the family are considered to be associated environmental factors contributing to an increased likelihood of Posttraumatic Stress Disorder.
A major risk of developing comorbidities is associated with the occurrence of Posttraumatic Stress Disorder. Individuals with the disorder are 80% more likely to show symptoms of other mental health conditions including depressive and bipolar disorders, anxiety, and substance use disorder.
Substance use disorder and conduct disorder are more prevalent among males. Children may be at a greater risk of developing oppositional defiant disorder and separation anxiety.
Diagnosis
1. A major part of the diagnostic process involved in assessing Posttraumatic Stress Disorder involves evaluating the traumatic experience (or experiences) that the individual has been through.
This can be particularly challenging, owing to the negative affect including feelings of unease, self-blame, and shame that may accompany the discussion of such events.
Gathering data to contribute to the clinical history may be done either by means of structured clinical interviews, or with the help of self-report questionnaires and measures to assess various dimensions of past experiences. For deeper insight, clinicians may administer a combination of both.
While diagnosing Posttraumatic Stress Disorder in children, it is common for the clinician to initially begin with a joint parent and child meeting in order to provide an overview of the process.
The patient and their caregivers may then be separately interviewed with the help of structured questionnaires and interviews, as well as through self-report measures.
Holistic questioning may also account for the presence of comorbidities, which are highly likely to occur, especially in children.
The DSM-5 provides the following diagnostic criteria for the diagnosis of Posttraumatic Stress Disorder:
Note: The following criteria apply to adults, adolescents, and children older than 6 years.
A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of 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).
Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.
B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
- Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.
- Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).
Note: In children, there may be frightening dreams without recognizable content.
- Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)
Note: In children, trauma-specific reenactment may occur in play.
- Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
- Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:
- 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 associated with the traumatic event(s).
D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
- 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 (e.g., โI am bad,โ โNo one can be trusted,โ โThe world is completely dangerous,โ โMy whole nervous system is permanently ruinedโ).
- 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).
E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
- 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.
- Hyper-vigilance
- Exaggerated startle response.
- Problems with concentration.
- Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.
G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
H. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.
Specifications are made on the basis of whether the individual presents with symptoms of either depersonalization or derealization. If the onset of symptoms occurs immediately, but full diagnostic criteria remain to be met, a specification of โwith delayed expressionโ may be made.
A separate list of diagnostic criteria has been collated for the determination of Posttraumatic Stress Disorder among children younger than 6 years of age.
Treatment
The mainstay of Posttraumatic Stress Disorder treatment is psychotherapy, in various forms. While psychosocial modalities are considered to be the first line of management, pharmacological interventions have also been developed.
The main focus of psychosocial interventions for Posttraumatic Stress Disorder is typically the trauma and any memories, thoughts, and emotions associated with it.
Cognitive Behavioral Therapy and Cognitive Behavioral Therapy-Mixed treatments have shown efficacy in improving symptoms, and usually involve psychoeducation with regards to trauma, creating a narrative, fixing negative cognitive beliefs, and understanding misappraisals and mending them.
Behavioral aspects may involve trying to manage agitation upon exposure to trauma, and this is often done through real life exposure to reminders of the traumatic experience in a control setting.
Exposure Therapy in itself can be instrumental in helping the individual effectively deal with trauma cues, and reduce the impact of flashbacks and nightmares relating to the content of the traumatic experience.
Other psychosocial interventions may include Cognitive Restructuring, Stress Inoculation and other Coping Skills Therapy, Eye Movement Desensitization and Reprocessing, Hypnotherapy, Interpersonal Therapy, Family Based Therapy, Psychodynamic Theory, and Narrative Exposure Therapy.
The most common form of pharmacological treatment for Posttraumatic Stress Disorder is usually with the help of antidepressants, including SSRIs (Selective Serotonin Reuptake Inhibitors), SNRIs (Serotonin and Norepinephrine Reuptake Inhibitors), and MOAIs (Monoamine Oxidase Inhibitors).
Other forms of medication may include antipsychotics, anticonvulsants, and benzodiazepines. The efficacy of fluoxetine, paroxetine, sertraline, topiramate, risperidone, and venlafaxine has been acknowledged.
The use of combination treatment may be considered in cases of treatment resistant Posttraumatic Stress Disorder.
Better outcomes are associated with the administration of both psychosocial and pharmacological interventions, as well as early intervention. Having a strong support system is usually linked to a good prognosis.
Differential Diagnosis
1. Adjustment disorders: In adjustment disorders, the stressor can be of any severity or type. The diagnosis of an adjustment disorder is used when the response to a stressor that meets PTSD Criterion A but does not meet all other PTSD criteria.
2. Other posttraumatic disorders and conditions: If the response pattern to the extreme stressor meets the criteria for another mental disorder, these diagnoses should be given instead of, or along with PTSD. Because, the diagnosis of PTSD requires the exposure to trauma to occur before the onset of the symptoms.
3. Acute stress disorder: Acute stress disorder is distinguished from PTSD because the symptom pattern in acute stress disorder is restricted to a duration of 3 days to 1 month following exposure to the traumatic event.
4. Anxiety disorders and obsessive-compulsive disorder: In OCD, there are recurrent intrusive thoughts, but they are not related to an experienced traumatic event, compulsions are usually present, and other symptoms of PTSD or acute stress disorder are typically absent.
Neither the arousal and dissociative symptoms of panic disorder nor the avoidance, irritability, and anxiety of generalized anxiety disorder are associated with a specific traumatic event. The symptoms of separation anxiety disorder are clearly related to separation from home or family, rather than to a traumatic event.
5. Major depressive disorder: Major depression may or may not be preceded by a traumatic event and should be diagnosed if other PTSD symptoms are absent.
6. Personality disorders: Interpersonal difficulties that had their onset, or aggrevated, after exposure to a traumatic event may be an indication of PTSD, rather than a personality disorder.
7. Dissociative disorders: Dissociative amnesia, dissociative identity disorder, and depersonalization-derealization disorder may or may not be preceded by exposure to a traumatic event or may or may not have co-occurring PTSD symptoms.
8. Conversion disorder: New onset of somatic symptoms within the context of posttraumatic distress might be an indication of PTSD rather than conversion disorder.
9. Psychotic disorders: Flashbacks in PTSD must be distinguished from illusions, hallucinations, and other perceptual disturbances that may occur in schizophrenia, brief psychotic disorder, and other psychotic disorders; depressive and bipolar disorders with psychotic features; delirium; substance/medication-induced disorders; and psychotic disorders due to another medical condition.
Traumatic brain injury. When a brain injury occurs in the context of a traumatic event (e.g., traumatic accident, bomb blast, acceleration/deceleration trauma), symptoms of PTSD may appear.
Comorbidity
PTSD is found to be comorbid with depressive, bipolar, anxiety, or substance use disorders, substance use disorder and conduct disorder, major neurocognitive disorder, oppositional defiant disorder and separation anxiety disorder based on the trauma faced by the individual.
Specialist
Psychiatrists or clinical psychologists specializing in anxiety disorders and PTSD may be involved in the diagnosis and assessment of the disorder. Psychosocial treatment may be suggested depending on symptomatology, and specialists vary on the basis of the type of intervention.
Certified therapists and practitioners with adequate experience will be able to guide the patient through effective management.
