1

Posttraumatic Stress Disorder

Background: Posttraumatic stress disorder (PTSD) is a pathological

anxiety that usually occurs after an individual experiences or witnesses
severe trauma that constitutes a threat to the physical integrity or life of the
individual or of another person. The individual initially responds with intense
fear, helplessness, or horror. The person later develops a response to the
event that is characterized by persistently reexperiencing the event, with
resultant symptoms of numbness, avoidance, and hyperarousal. These
symptoms result in clinically significant distress or functional impairment. To
meet the full criteria for PTSD, these symptoms should be present for a
minimum of 1 month following the initial traumatic event. The events
experienced may be natural disasters, violent personal assaults, war, severe
automobile accidents, or the diagnosis of a life-threatening condition. For
children, a developmentally inappropriate sexual experience may be
considered a traumatic event, even though it may not have actually involved
violence or physical injury. PTSD can be acute (symptoms lasting <3 mo),
chronic (symptoms lasting >3 mo), or of delayed onset (6 mo elapses from
event to symptom onset).

Frequency:

• In the US: PTSD has a lifetime prevalence of 8-10% and

accounts for considerable disability and morbidity. One study found the
prevalence of PTSD in a sample of adolescent boys to be 3.7% and
adolescent girls to be 6.3%. Approximately 30% of men and women who
have spent time in a war zone experience PTSD.

Mortality/Morbidity:

• In various studies, a direct relationship is observed between the

severity of the trauma and the risk for PTSD.
 2
• Individuals with the disorder may have an increased risk of impulsive
behavior or suicide. Victims of sexual assault are at especially high risk for
developing mental health problems and committing suicide.

• One of the most pivotal observations in relation to the development of

PTSD in adults who were traumatized as children is the association between
early trauma exposure and subsequent retraumatization

Sex:

• Females may be at a higher risk than males. An epidemiologic survey

of adult women indicates alarmingly high rates of traumatic events,
particularly those events relating to being victims of crimes. Sexual assault
probably has the most impact on women, and trauma from combat probably
has the most impact on men.

Age:

• PTSD can occur in persons of any age, including children. Symptoms

usually begin within 3 months of the event, although a delay of months or
years may occur before symptoms appear.

One study found that nearly half (48%) of the patients in general
medical practices with PTSD were receiving no mental health treatment at
the time of intake to the study. The most common reason patients gave for
not receiving medication was the failure of physicians to recommend such
treatment. The information elicited from the interview with the patient must
satisfy certain diagnostic criteria to make the formal diagnosis. As with many
diagnoses, PTSD can be subclinical, in which the criteria are almost but not
fully met. Diagnosis is based on criteria from the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition, Text Revision. The mental status
examination should routinely consist of questions about exposure to trauma
 3

or abuse.

The first criterion has 2 components, as follows:

o Experiencing, witnessing, or being confronted with an event

involving serious injury, death, or a threat to a person's physical integrity

o A response involving helplessness, intense fear, or horror

(sometimes expressed in children as agitation or disorganized behavior)

The second major criterion involves the persistent reexperiencing of the

event in one of several ways. This may involve thoughts or perception,
images, dreams, illusions, hallucinations, dissociative flashback episodes, or
intense psychological distress or reactivity to cues that symbolize some
aspect of the event. However, children reexperience the event through
repetitive play, not through perception like adults.

The third diagnostic criterion involves avoidance of stimuli that are

associated with the trauma and numbing of general responsiveness; this is
determined by the presence of 3 or more of the following:

• Avoidance of thoughts, feelings, or conversations that are

associated with the event
• Avoidance of people, places, or activities that may trigger
recollections of the event
• Inability to recall important aspects of the event
• Significantly diminished interest or participation in important
activities
• Feeling of detachment from others
• Narrowed range of affect
• Sense of having a foreshortened future
 4

The fourth criterion is symptoms of hyperarousal, and 2 or more of the

following symptoms are required to fulfill this criterion:

• Difficulty sleeping or falling asleep

• Decreased concentration
• Hypervigilance
• Outbursts of anger or irritable mood
• Exaggerated startle response

Fifth, the duration of the relevant criteria symptoms should be more

than 1 month, as opposed to acute stress disorder, for which the criterion is a
duration of less than 1 month.

Finally, the disturbance is a cause of clinically significant distress or

impairment in functioning.

Children may have different reactions to trauma than adults. For

children aged 5 years or younger, typical reactions can include a fear of
being separated from a parent, crying, whimpering, screaming, immobility
and/or aimless motion, trembling, frightened facial expressions, and
excessive clinging. Parents may also notice regressive behaviors. Children of
this age tend to be strongly affected by their parents' reactions to the
traumatic event.

Children aged 6-11 years may show extreme withdrawal, disruptive

behavior, and/or an inability to pay attention. Regressive behaviors,
nightmares, sleep problems, irrational fears, irritability, refusal to attend
school, outbursts of anger, and fighting are also common. The child may
have somatic complaints with no medical basis. Schoolwork often suffers.
Also, depression, anxiety, feelings of guilt, and emotional numbing are often
present. Adolescents aged 12-17 years may have responses similar to
 5

adults.

• General appearance may be affected. Patients may appear disheveled

and have poor personal hygiene.
• Behavior may be altered. Patients may appear agitated, and their startle
reaction may be extreme.
• Orientation is sometimes affected. The patient may report episodes of
not knowing the current place or time, even though this may not have
been evident during the interview.
• Memory may be affected. Patients may report forgetfulness, especially
concerning the specific details of the traumatic event.
• Concentration is poor.
• Impulse control is poor.
• Speech rate and flow may be altered.
• Mood and affect may be changed. Patients may have feelings of
depression, anxiety, guilt, and/or fear.
• Thoughts and perception may be affected. Patients may be more
concerned with the content of hallucinations, delusions, suicidal ideation,
phobias, and reliving the experience; certain patients may become
homicidal.

Causes: PTSD is caused by experiencing, witnessing, or being

confronted with an event involving serious injury, death, or threat to the
physical integrity of an individual, along with a response involving
helplessness and/or intense fear or horror. The more severe the trauma and
the more intense the acute stress symptoms, the higher the risk for PTSD.
When these events involve an individual with a physiologic vulnerability
based on genetic (inherited) contributions and other personal characteristics,
PTSD results. These personal characteristics include prior exposure to
trauma, childhood adversity (eg, separation from parents), and preexisting
 6

anxiety or depression.
Many different drugs have been used to treat specific symptoms of
PTSD, such as benzodiazepines for anxiety, anticonvulsants for impulsivity
and emotional lability, and clonidine for nightmares. However, the principal
agents of treatment have been the various antidepressants and beta-
blockers. Most medication trials on PTSD have involved male combat
veterans. Results of recent studies on civilians show fluoxetine to be
effective. Recent studies suggest that fluoxetine demonstrates some efficacy
for all 3 symptom clusters.

Further Inpatient Care:

• Inpatient care is necessary only if the patient becomes suicidal or

because of the presence of complicating comorbid conditions that may
require inpatient treatment (eg, depression, substance abuse).
Hospitalization is also indicated if the patient becomes homicidal.

Further Outpatient Care:

• Having experienced trauma, some patients with PTSD may be

socially uncomfortable. Encouragement over time may be helpful to keep
them therapeutically engaged, which yields optimal medical and psychiatric
benefit.

Prognosis:

• Prognosis is difficult to determine because it varies significantly

from patient to patient. Some individuals who do not receive care gradually
recover over a period of years. Many individuals who receive appropriate
medical and psychiatric care recover completely (or nearly completely).
Rarely, even with intensive intervention, individuals experience worsening
symptoms and kill themselves. In patients with PTSD who are receiving
 7

treatment, the average duration of symptoms is 36 months, compared with

64 months for those patients who do not receive treatment.

• More than one third of patients who have PTSD never fully
recover.

• Factors associated with a good prognosis include rapid

engagement of treatment, early and ongoing social support, avoidance of
retraumatization, positive premorbid function, and an absence of other
psychiatric disorders or substance abuse.