Post-Traumatic Stress Disorder (PTSD)
Trauma exposure plus intrusion, avoidance, negative cognition/mood, and arousal symptoms >1 month.
Also known as: PTSD, post-traumatic stress disorder, trauma response
Overview
A trauma- and stressor-related disorder developing after exposure to actual or threatened death, serious injury, or sexual violence (directly experienced, witnessed, learned about a close person, or repeated indirect exposure), characterized by intrusion, avoidance, negative alterations in cognition/mood, and alterations in arousal/reactivity persisting >1 month with functional impairment.
Epidemiology
Lifetime prevalence ~6-8% in the US; ~10% in women, ~4% in men. Higher in combat veterans (~10-20%), sexual assault survivors, refugees. Conditional probability after exposure varies by trauma type (highest for interpersonal violence).
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Risk factors
- Pre-trauma: prior psychiatric illness, childhood adversity, female sex, lower SES, family history
- Peri-trauma: severity, perceived life threat, peritraumatic dissociation, interpersonal violence
- Post-trauma: lack of social support, additional life stressors, ongoing threat
Pathophysiology
Dysregulated fear learning and extinction with amygdala hyperreactivity, reduced ventromedial prefrontal control, and hippocampal volume reduction. Elevated noradrenergic tone, altered HPA-axis with paradoxically low cortisol in some patients.
Clinical presentation
Symptoms
- Intrusion: recurrent intrusive memories, distressing dreams, flashbacks, intense distress or physiological reactivity to cues
- Avoidance: of trauma-related thoughts/feelings or external reminders
- Negative cognition/mood: inability to recall key aspects, persistent negative beliefs, distorted blame, persistent negative emotional state, anhedonia, detachment, inability to experience positive emotions
- Arousal/reactivity: irritability/anger, reckless or self-destructive behavior, hypervigilance, exaggerated startle, concentration problems, sleep disturbance
- Dissociative subtype: depersonalization or derealization
Signs / physical exam
- Hyperarousal observable as exaggerated startle, scanning behavior, irritability in interview
- PCL-5 score >=33 supports probable PTSD
Differential diagnosis
- Acute stress disorder — Same symptom clusters within first 3 days to 1 month after trauma
- Adjustment disorder — Stressor not meeting PTSD trauma criterion; subthreshold symptoms
- Major depressive disorder — May coexist; PTSD requires trauma exposure and intrusion phenomena
- Panic disorder — Spontaneous panic attacks not tied to trauma cues
- Complex PTSD (ICD-11) — Prolonged interpersonal trauma plus disturbances in self-organization (affect dysregulation, negative self-concept, relational disturbance)
- TBI — Confounding cognitive symptoms; can co-occur
- Substance-induced mood/anxiety — Symptoms in context of use or withdrawal
Diagnostic workup
Diagnostic criteria
DSM-5-TR: (A) Trauma exposure as defined; (B) >=1 intrusion symptom; (C) >=1 avoidance symptom; (D) >=2 negative cognition/mood symptoms; (E) >=2 arousal symptoms; (F) Duration >1 month; (G) Significant distress/impairment; (H) Not attributable to substance/medical condition. Specify dissociative subtype or delayed expression (>=6 months after event).
Labs
- TSH, CBC, BMP; urine drug screen if substance use suspected
- Sleep evaluation for nightmares and insomnia
Imaging
- Not routinely indicated
Diagnostic algorithm
| Cluster | Min # | Examples |
|---|---|---|
| B Intrusion | 1 | Flashbacks, nightmares, distress on cues |
| C Avoidance | 1 | Avoiding thoughts, places, people |
| D Negative cognition/mood | 2 | Negative beliefs, anhedonia, detachment |
| E Arousal/reactivity | 2 | Hypervigilance, startle, sleep disturbance |
Treatment
First-line
- Trauma-focused psychotherapy — prolonged exposure (PE), cognitive processing therapy (CPT), or eye movement desensitization and reprocessing (EMDR)
- SSRI — sertraline and paroxetine (FDA-approved), fluoxetine, escitalopram
- SNRI — venlafaxine XR
- Combine medication with trauma-focused therapy in moderate-to-severe symptoms
Second-line / adjunct
- Prazosin — alpha-1 antagonist for trauma-related nightmares (mixed evidence in recent VA trials but still widely used)
- Mirtazapine, nefazodone for sleep and depressive overlap
- Atypical antipsychotic augmentation (risperidone, quetiapine) for refractory cases or psychotic features
- AVOID benzodiazepines — worsen PTSD trajectory, interfere with extinction learning, dependence risk
Complications
- Suicide — substantially elevated risk, particularly with comorbid depression
- Substance use disorders (alcohol, opioids, cannabis)
- Comorbid depression, panic disorder, chronic pain
- Relationship and occupational disruption
- Cardiovascular morbidity
PANCE pearls
- Trauma criterion (A) is specific — vague life stressors (divorce, job loss) do not qualify; consider adjustment disorder instead.
- Benzodiazepines are contraindicated in PTSD per VA/DoD guidelines — they impair fear extinction and worsen long-term outcomes.
- Single-session psychological debriefing immediately after trauma does NOT prevent PTSD and may be harmful — avoid.
- Screen veterans and survivors of interpersonal violence routinely with PC-PTSD-5 or PCL-5.
References
- VA/DoD 2023 — VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder (2023)
- APA 2017 — American Psychological Association Clinical Practice Guideline for the Treatment of PTSD in Adults (2017)
- DSM-5-TR — American Psychiatric Association. DSM-5-TR (2022)
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