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Posttraumatic Stress Disorder
Introduction
Posttraumatic stress disorder (PTSD) is a common psychiatric disorder that can result after an individual experiences a traumatic event. PTSD has a broad clinical presentation but is characterized by symptoms impairing cognition, mood, somatic experience, and behavior. PTSD can cause chronic impairments, lead to comorbid psychiatric illness, and lead to an increased risk of suicide.[1]
PTSD was first included in the Diagnostic and Statistical Manual of Mental Disorders (DSM) 3rd edition, published in 1980.[2] The inclusion of PTSD in the DSM reflects the acknowledgment of the significant impact that exposure to traumatic events can have on an individual's mental health. The DSM criteria for PTSD involve experiencing a traumatic event, the presence of specific symptoms such as intrusive memories or nightmares, avoidance behaviors, negative changes in mood and cognition, and heightened arousal. The inclusion of PTSD in the DSM has contributed to better understanding, diagnosis, and treatment of individuals who have experienced trauma.[1] The management of PTSD is complex, as each case of trauma is individualized, and specific symptoms of PTSD vary from case to case. Prevention and treatment methods involve psychological interventions as well as pharmacotherapy.[3][4][5]
Etiology
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Etiology
Individuals who experience trauma may or may not develop long-term mental health sequela as a result of the trauma. However, the DSM-5-TR defines trauma as an essential characteristic of those who develop PTSD. Trauma (in the context of PTSD) is defined as exposure to actual or threatened death, serious injury, or sexual violence. This includes directly experiencing the traumatic event, witnessing a person experiencing trauma, or learning that the traumatic event occurred to a close family member or friend.[6]
There are various psychological theories proposed to explain trauma's capacity to cause PTSD. The shattered assumptions theory was proposed by Janoff-Bulman in 1992.[7] This theory suggests that traumatic events can change how individuals perceive themselves and the world as compared to their views before the traumatic experience. This theory has preliminary assumptions, including: "the world is benevolent," "the world is meaningful," and "the self is worthy." After trauma, the foundation for these inherited assumptions is weakened or "shattered."[7]
Psychodynamic psychology emphasizes the systematic study of how life experiences may relate to the current psychological forces on the mind, which impact behavior and emotions.[8] In 1890, Jean-Martin Charcot argued that psychological trauma was the origin of all mental illness.[9] Over time, this has been refuted, but it is acknowledged that trauma (and particularly early life trauma) can have a profound impact on the development of mental illness. A psychodynamic psychological view of posttraumatic stress relates particularly to unconscious decisions of trust. Individuals who experience trauma can have difficulty trusting that the world can be a safe place or trusting that individuals will not emotionally or physically harm them.[10]
Behavioral scientists have also contributed to understanding trauma's impact on cognitive processes. A conditioned response of learned fear can occur after exposure to a significant stimulus, which is usually the case in the context of PTSD. Individuals exposed to repeated traumas (such as those experiencing domestic or parental abuse) can develop a conditioned response to trauma.[11]
The presence or absence of support after trauma can both increase or decrease the risk of PTSD. Individuals who have a well-established support system are less likely to develop PTSD after a traumatic event. Likewise, individuals who feel isolated after trauma or have a poor social support system are more likely to develop an acute stress disorder and/or PTSD.[12] The risk of PTSD after a traumatic event is further increased by lower educational level, lower socioeconomic status, childhood adversity, gender, race, physical injury (including traumatic brain injury), and initial severity of the reaction to the trauma.[13][14][15][16][17]
Epidemiology
The lifetime prevalence of PTSD ranges from 6.1% to 9.2% from national samples of the general adult population of the United States and Canada.[18][13][19][20] The 1-year prevalence rates range from 3.5% to 4.7%.[20][21] In the Western Hemisphere, certain populations have been found to have a higher prevalence of PTSD, including indigenous peoples and refugees.[22][23][13] Lower prevalence rates of PTSD have been found outside of the Western Hemisphere, but the reason for lower PTSD rates in the Eastern Hemisphere is not well understood.[24]
Intentional trauma has been found to have a greater association with PTSD than accidental trauma or nonviolent trauma.[25][26] Repeated trauma and increasing duration of trauma exposure are also associated with a higher risk of PTSD.[27] Males and females both commonly develop PTSD after trauma, but females are known to be more predisposed to PTSD, with slight variations depending on the type of traumatic experience.[28]
Pathophysiology
The initial response to trauma is associated with the pathophysiology of PTSD. The response is characterized by a surge of adrenaline from sympathetic nervous system stimulation. Physiologically, this can lead to tachycardia, rising blood pressure, and further neuroendocrine responses such as the release of cortisol and other catecholamines.[29] When the trauma stimulus is prolonged or repeated, a conditioned behavioral response leading to acute stress disorder or PTSD can occur.
Neuroanatomically, the amygdala has significant responsibility for threat detection and fear response. Magnetic resonance imaging (MRI) studies of individuals with PTSD have revealed nonspecific findings, including reduced total brain volume, although the results are not consistent.[30][31] The amygdala is part of the ancient brain evolutionarily, meaning that its activation is primary and typically toned down by the frontal cortex as cognition and learned behaviors develop.[32] In patients with PTSD, the toning down capacity of the frontal lobe is dysregulated compared to those without PTSD. This observation may partially explain the imaging findings of reduced brain volume in those individuals with chronic PTSD. Neurotransmitter levels have been investigated in those with PTSD, including serotonin, dopamine, epinephrine, norepinephrine, glutamate, and gamma-aminobutyric acid (GABA).[33] Neurotransmitter levels in patients with PTSD have had inconsistent findings but still form the basis of an approach for treatment with psychotropic medications.[34]
History and Physical
The presentation of PTSD is variable in both the history of the illness and the clinical symptomatology. Trauma is broad, and risks for certain types of trauma vary depending on patient characteristics such as age, gender, geographic location, family and marital status, and presence of a physical disability.[35] Types of trauma include sexual assault, mass political conflict and displacement (refugee), military or combat exposure, physical injury, and medical illness.[17] Due to the broad range of possible traumas, it is essential to understand individual patient backgrounds and social history. Additionally, adult patients with PTSD commonly suffer from symptoms as a result of childhood trauma, which can be far in the distant past compared to the time of clinical evaluation.[36] Duration of symptoms since the traumatic event is significant to note as this distinguishes PTSD from other psychiatric disorders (such as acute stress disorder).[37]
Dissociative symptoms may be present in patients with PTSD, and when these symptoms are present, they must be distinguished from a prior dissociative disorder. Dissociative symptoms include the following:
- Depersonalization: Feeling disconnected from one's body and feeling "lost" or "floating above my body."
- Derealization: Feeling as if the surrounding world is not real, such as watching the world from a dreamlike state.[38]
Discussing trauma with patients who are being evaluated for PTSD requires an approach with sensitivity.[39] In the context of sexual assault trauma, the gender of the provider and patient should be taken into consideration, as many patients who are survivors of sexual assault may have difficulty being in an interview room alone with the gender of their perpetrator. Some patients can talk about past trauma with ease, while others are not able to discuss details without experiencing acute symptoms. When engaging in a discussion of trauma details, it is important to respect patient boundaries on the topic and ask how deeply or superficially the patient prefers to discuss the topic. These are foundational concepts of trauma-informed interventions.[39] Notably, the specific details of the trauma are usually not necessary for obtaining a PTSD diagnosis. Specific details of trauma are only necessary for certain types of psychotherapeutic treatments, which the patient should consent to before initiating. General questioning about symptoms related to trauma is usually an optimal approach for a first diagnostic interview where developing therapeutic rapport is essential.[40] General questions can include the following:
- Do you think about the traumatic event more than you would like to?
- Do you have nightmares or flashbacks related to the trauma?
- Do you avoid people or triggers associated with the trauma?
- Are you struggling with feelings of persistent sadness?
The mental status examination (MSE), conducted during psychiatric evaluations, is crucial in assessing individuals with PTSD.[41] However, it is necessary to note that the specific elements and findings of the examination can vary depending on each case of PTSD. Components of the MSE should include the following:
- Appearance: Scars, wounds, and other deformities may be present due to prior traumatic experiences.
- Attitude and Behavior: PTSD can commonly lead to hypervigilant behavior. Eye contact should observed.
- Affect: Patients with PTSD may present fearful, anxious, apathetic, or depressed. Affect may change depending on the conversation, and the range of affect should be observed. PTSD may present with constricted affect consistent with feeling numb.
- Thought content: Thought content should be evaluated to assess suicide ideations and self-harm behaviors.
- Thought process: For patients with persistent and exaggerated negative beliefs after trauma, the thought process may deviate from linear.
- Insight: Patients with PTSD commonly have a fair understanding of their illness, although specific populations of patients may minimize their symptoms. Patients with PTSD may have difficulty understanding how their PTSD symptoms relate to potential other psychiatric comorbidity (such as major depression, substance use disorders, and borderline personality disorder).
- Judgment: Judgment can be assessed in individuals with PTSD based on their clinical presentation as well as their ability to make rational decisions related to their treatment plan options.[42]
Physical examination findings in patients with PTSD are typically nonspecific and often do not reveal overt physiological abnormalities. While PTSD primarily manifests as a psychiatric condition, some individuals may exhibit physical symptoms related to heightened arousal or chronic stress. The exam findings may include increased heart rate, elevated blood pressure, muscle tension, and disrupted sleep patterns. While discussing the trauma specifically or during flashbacks, patients with PTSD may exhibit the above findings.
When patients are prescribed medications for PTSD that impact blood pressure (ie, clonidine, prazosin, and venlafaxine), it is essential to monitor blood pressure when considering medication adjustments.[43]
Evaluation
The psychiatric evaluation is the most important component of diagnosing PTSD. However, healthcare professionals can use validated rating scales to screen and diagnose PTSD, which is particularly helpful in settings where psychiatric specialists are not available. Self-report scales used in screening for PTSD include the PTSD Checklist for DSM-5 (PCL-5) and Trauma Symptom Checklist-40 (TSC-40).[44][45] The Clinician-Administers PTSD scale is also available as a 30-item structured interview.[46]
To obtain a formal diagnosis of PTSD, individuals must meet the diagnostic criteria specific in the DSM-5-TR. The diagnosis involves a thorough evaluation that considers multiple sources of information, including personal history, collateral information, and an MSE. This comprehensive assessment allows clinicians to assess the individual's symptoms, functioning, and overall presentation concerning the established diagnostic criteria.
The diagnostic criteria and specifications listed below apply to adults and children older than 6 years. A preschool subtype of PTSD for children 6 years and younger is included in the DSM-5.
Posttraumatic Stress Disorder DSM-5-TR Criteria
Criterion A: Stressor
Exposure to real or threatened death, injury, or sexual violence in 1 or more of the following ways:
- Direct exposure to the traumatic event
- Witnessing the trauma as it occurred to someone else
- Learning about a close family relative or close friend being exposed to actual or threatened trauma, accidental or violent death
- Indirect exposure to distressing details of the traumatic event (professionals repeatedly exposed to the details of child abuse, collecting human remains, or pieces of evidence). This does not include exposure through television, movies, electronic devices, or pictures.
Criterion B: Intrusion Symptoms
Presence of 1 or more of the following symptoms related to the traumatic event and began after the trauma occurred:
- Recurrent, involuntary, and intrusive thoughts associated with the traumatic event. In children older than 6 years, this may be expressed using repetitive play in which the aspects of the trauma are expressed.
- Distressing nightmares may be repetitive, and the dream's content is related to the traumatic event. Children may have frightening dreams where they may or may not recognize the content.
- Dissociative reactions, such as flashbacks, in which the individual may feel or act that the traumatic event is happening again. These reactions may occur as a continuum ranging from brief responses to complete loss of awareness of oneself or the surroundings. Children may reenact such events in the play.
- Intense or prolonged psychological distress on exposure to traumatic reminders
- Marked physiological reactivity such as increased heart rate and blood pressure on exposure to traumatic reminders
Criterion C: Avoidance
Persistent avoidance of the stimuli related to the traumatic event, as evidenced by 1 or both of the following:
- Avoidance or efforts to avoid distressing memories or thoughts associated with the traumatic event
- Avoidance or efforts to avoid external reminders such as people, places, activities, conversations, or situations that arouse distressing memories or thoughts related to the traumatic event
Criterion D: Negative Alterations in Mood
Negative alterations in mood and cognition that began or worsened after the traumatic event, as evidenced by 2 or more of the following:
- Inability to recall important aspects of the traumatic event. This can be due to dissociative amnesia, not due to head injury, drugs, or alcohol.
- Persistent and distorted negative beliefs or expectations about oneself or the world, such as "I am bad" or "The world is completely dangerous."
- Persistent distorted cognition leads the individual to blame self or others for causing the traumatic event
- Persistent negative emotional state, including fear, guilt, anger, or shame
- Markedly diminished interest in significant activities that used to be enjoyable
- Feeling alienated, estranged, or detached from others
- Persistent inability to experience a positive emotion such as happiness, satisfaction, or love
Criterion E: Alterations in Arousal and Reactivity
Trauma-related alterations in reactivity and arousal that began or worsened after the traumatic event, as evidenced by 2 or more of the following:
- Irritable or aggressive outbursts with little or no provocation
- Reckless or self-destructive behavior
- Hypervigilance
- Exaggerated startle response
- Problems in concentration
- Sleep disturbances (difficulty falling or staying asleep, restless sleep)
Criterion F: Duration
Persistence of symptoms in Criterion B, C, D, and E for more than 1 month
Criterion G: The disturbance causes significant functional impairment or distress in various areas of life, such as social or occupational.
Criterion H: The disturbance is not attributable to substance use, medication, or another medical illness.[47]
Two specifications
Two PTSD specifiers are noted in the DSM-5: delayed expression and dissociative symptoms. The complete diagnostic criteria for PTSD must be satisfied before either specifier can be assigned.
Delayed Expression: Full diagnostic criteria are not satisfied until at or after 6 months from the target trauma, although some symptom onset may occur sooner. In some instances, the affected individual does not meet the full criteria for PTSD until years after the trauma. Military members have higher rates of delayed expression PTSD.
Dissociative Symptoms: Higher levels of recurrent or persistent depersonalization (feeling outside one's body or mind) or derealization (experiencing that things are not real) symptoms exist. Individuals with the dissociative specification of PTSD tend to have higher levels of exposure to childhood and/or adult sexual assault. Generally, they are more symptomatic than those without the specification. These patients also exhibit higher rates of functional impairment, psychiatric comorbidity, and suicidality.
Treatment / Management
The treatment of PTSD requires a patient-specific approach, with the patient's consent for any treatment. Many patients with PTSD are unwilling to pursue treatment, and some patients have symptoms resistant to treatment. It may be necessary to use a combination of medications and therapy in certain patients; however, patients should be offered a choice of treatment preference between the two modalities. Therapy-based approaches are generally preferred, but patients with severe symptoms or comorbid illness may not be able to engage in meaningful therapy treatments initially and can be started on a medication treatment plan with an intent to integrate therapy in the future when the patient is more clinically stable.
Psychotherapeutic Approaches
Trauma-focused psychotherapy is the preferred treatment for PTSD. This includes cognitive behavioral therapy, exposure-based therapy, and eye movement desensitization and reprocessing therapy (EMDR).[3][48][49][50] Clinical studies of patients who receive trauma-focused psychotherapy have demonstrated greater improvement in symptoms compared to those who do not receive treatment.[3] When trauma-focused psychotherapy is compared against pharmacotherapy for PTSD, there may be slightly improved outcomes with therapy.[51][48](A1)
Cognitive behavioral therapy utilizes techniques to identify and correct distorted maladaptive beliefs, which can occur after a traumatic event. Specific techniques include education, relaxation exercises, the use of coping skills, and stress management.[52]
Exposure-based therapy is a technique most commonly used to treat anxiety disorders such as specific phobias. The method considers a conditioned fear response from learned behavior and involves a measured approach of reintroducing the stimulus to lead to fear extinction eventually. With regard to PTSD, this requires patient consent for treatment, is not an applicable option for certain cases, and requires an intense workload on the patient.[53]
EMDR was developed after recognizing that certain saccadic eye movements reduce the intensity of disturbing thoughts. These eye movements can be voluntarily adjusted while thinking about a distressing memory, reducing the anxiety associated with it. EMDR has been shown to desensitize traumatic memories and has improved the appraised validity of a positive self-belief in those with PTSD.[54][55] The therapeutic neural mechanisms of EMDR remain unclear.[56](A1)
Supportive psychotherapy can be helpful in individuals who are dealing with acute trauma and those who have acute stress disorder.[57](A1)
Medication Approaches
Selective serotonin reuptake inhibitors (SSRI) such as sertraline and paroxetine are FDA-cleared for the treatment of PTSD. Other SSRIs and selective serotonin and norepinephrine reuptake inhibitors (SNRI) are reasonable off-label alternatives. SSRIs have been found to reduce PTSD symptoms greater than placebo, but there is no strong evidence to differentiate the effectiveness of specific SSRIs and SNRIs.[4][5][58](A1)
For patients with prominent sleep disturbances or nightmares associated with PTSD, off-label medication treatment approaches are commonly used. Prazosin is commonly used as monotherapy or in combination with an on-label medication treatment such as an SSRI. Prazosin competitively inhibits postsynaptic alpha-adrenergic receptors, resulting in vasodilation of veins and arterioles, decreasing blood pressure. When used in PTSD-associated nightmares, the hypothesis for the mechanism of action is a toned-down sympathetic response, which can decrease the frequency or severity of nightmares. However, there are mixed results for prazosin efficacy for this specific use, and the findings are inconsistent.[59][60][61] Clonidine is occasionally used for similar purposes. In patients prescribed blood pressure medications for PTSD, monitoring blood pressure at clinical visits is important, as well as avoiding suddenly stopping the medication to avoid rebound hypertension. (A1)
Other medications are less commonly used for treating PTSD (off-label), but second-generation antipsychotics are occasionally used. This approach can be helpful in patients who have comorbid psychotic symptoms or treatment-resistant depression (in which antipsychotics are commonly used to augment SSRIs). Quetiapine has shown efficacy as a monotherapy for PTSD in military veterans.[62] Other antipsychotics used in other populations with PTSD have limited and mixed results.[63][64][65] (A1)
Novel Approaches
In 2020, the FDA cleared a class II medical device that uses the hardware of common smart-watches to monitor heart rate during sleep for individuals with PTSD with the goal of correlating physiologic response (biofeedback) to PTSD-related nightmares.[66](B3)
Differential Diagnosis
Potential differential diagnoses of PTSD are listed below.
Acute Stress Disorder
The symptoms of PTSD and acute stress disorder significantly overlap. The onset and duration of the symptoms help in making the final diagnosis. Acute stress disorder is diagnosed if the symptoms are present for less than 1 month.[37]
Dissociative Disorders
Primary dissociative disorders include dissociative identity disorder (DID), dissociative amnesia, and depersonalization/derealization disorder. DID entails the disruption of identity characterized by 2 or more distinct personality states. Dissociative amnesia describes an inability to recall important autobiographical information; notably, the information is usually of a traumatic or stressful nature, but for diagnosis of dissociative amnesia, there are no other symptoms of PTSD. Depersonalization/derealization disorder shares symptoms of dissociation with PTSD but is without the other symptomatology of PTSD.[67]
Major Depressive Disorder
Affective changes are common in PTSD, and major depressive disorder (MDD) can be a comorbid condition with PTSD. Diagnosis of MDD requires at least 1 major depressive episode, which is persistent decreased mood for at least 2 weeks.[68]
Adjustment Disorder
Adjustment disorder describes the development of emotional or behavioral symptoms in response to an identifiable stressor (not necessarily trauma), occurring within 3 months of the stressor's onset. The symptoms may not persist for more than an additional 6 months and are otherwise considered to be classified to a more fitting chronic psychiatric diagnosis.[69]
Other Psychiatric Disorders
PTSD is a disorder with a variable duration of symptoms. Over time, patients may no longer meet the diagnostic criteria for PTSD if their symptoms in this domain improve. However, they may still be suffering from other psychiatric disorders and receiving mental health care. Patients with a history of improved or resolved PTSD may over-attribute PTSD as a primary disorder despite no longer meeting the diagnostic criteria. Clinicians should be mindful to assess if PTSD is current, improved, resolved, or comorbid with other psychiatric disorders.[70]
Prognosis
PTSD outcomes vary broadly from case to case due to many factors. Those who engage in PTSD treatments tend to have improved outcomes compared to those who do not engage in treatment.[3][4][5] Chronic PTSD is common, with estimates that one-third of patients still have symptoms 1 year after diagnosis, and another third of patients still have symptoms 10 years after diagnosis.[26]
Positive psychology emphasizes psychological resilience after trauma and posttraumatic growth.[71] These concepts describe positive changes in self-perception, interpersonal relationships, and philosophy of life that can occur for individuals who recover from trauma and PTSD. These strengths can lead to increased self-awareness, self-confidence, open attitudes, and appreciation for life.[72] Posttraumatic growth is optimal but not a guaranteed outcome; in fact, it may even be an uncommon outcome. Research in positive psychology applications to trauma disorders remains limited and in need of further study.[73][74]
Complications
Although they can resolve, PTSD symptoms may also lead to the development of other psychiatric comorbidity. Trauma is a known risk factor for MDD, borderline personality disorder, anxiety disorders, substance use disorders, psychotic disorders, and more.[75] Patients with PTSD are at increased risk for suicide and should have regular screenings for suicidal ideation by clinicians.[1] Individuals with PTSD are more likely to experience occupational problems than those without PTSD and have higher rates of disability.[76] Additionally, those with a history of sexual trauma report higher rates of problems with intimate relationships.[77][76]
Deterrence and Patient Education
Deterrence and prevention strategies for PTSD focus on minimizing the impact of traumatic events and mitigating the development of persistent psychological distress. Primary prevention efforts involve promoting resilience, coping skills, and social support networks to enhance individuals' ability to cope with stressors effectively. Clinician awareness for patient populations who may need screening for PTSD is essential for the detection of illness. Military personnel and veterans should be systematically screened for PTSD.[78] Primary care providers should be mindful of patients presenting with new anxiety, fear, and insomnia, which can be a result of trauma.[79] Community-based education on trauma-informed practices and early intervention initiatives can contribute to creating environments that reduce the risk of trauma exposure and mitigate its effects.
Secondary prevention emphasizes timely and targeted interventions for individuals at higher risk, such as those with a history of trauma or in high-stress professions, to prevent the escalation of symptoms. Integrating trauma-focused mental health awareness into various sectors, including education, healthcare, and emergency services, is essential for fostering a culture of prevention and support. By addressing risk factors and promoting resilience on individual and societal levels, the aim is to reduce the incidence and severity of PTSD, ultimately contributing to better mental health outcomes.
Enhancing Healthcare Team Outcomes
PTSD is a common but complex psychiatric condition that can result after an individual experiences a traumatic event. Patients with PTSD benefit from referral to psychiatric specialists when available, but screening tools are available for clinicians in all settings to use in patients with whom they suspect PTSD. Physicians, advanced care practitioners, nurses, pharmacists, physical and occupational therapists, social workers, and other healthcare professionals are essential in making a collective commitment to enhancing patient-centered care, outcomes, patient safety, and team performance related to PTSD.
Proficiency in trauma-informed care and evidence-based interventions for PTSD is crucial. Clinicians should be adept at conducting comprehensive assessments, differentiating PTSD presentations, and tailoring therapeutic approaches to individual needs. Treatment involves psychotherapeutic interventions, primarily cognitive-behavioral therapy and pharmacotherapy, focusing on SSRIs with some evidence for the use of other medication classes. Including the patient's perspective and determining the appropriate care goals with an individual with PTSD is essential when using a trauma-informed approach.
A strategic approach involves the development and implementation of interdisciplinary care plans that address the multifaceted nature of PTSD. This includes collaboration on prevention strategies, early intervention, and long-term management, considering both pharmacological and psychological treatments. Ethical considerations emphasize sensitivity to the unique experiences of individuals with PTSD, respecting confidentiality, and maintaining cultural competence. Professionals should prioritize autonomy and informed consent while delivering patient-centered care.
Interprofessional communication is pivotal for a holistic approach. Clear and empathetic communication ensures a shared understanding of patients' needs, fostering a collaborative environment that integrates perspectives from diverse healthcare disciplines. Care coordination involves aligning efforts across the healthcare team to provide seamless and continuous support for patients with PTSD. This includes facilitating referrals, sharing relevant information, and ensuring a patient's journey through the healthcare system is cohesive and patient-centric. Collaboration with social workers, therapists, and family to optimize the social factors in a patient's life can offer significant stability to individuals with PTSD.
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