Definition
Post-traumatic stress disorder is a condition in which a person experiences a serious event, such as war, torture, natural disaster, or accident, and is left feeling frightened by the event, distressed by the constant re-experiencing of the event, and expends energy trying to escape from it, which negatively affects normal social life.
Causes
The primary cause of PTSD is the traumatic event itself, but not everyone who experiences a traumatic event develops the disorder. In the general population, 60% of men and 50% of women experience a significant event, but the actual lifetime prevalence of the disorder is around 6.7%. Psychological and biological precursors to the event are thought to be involved in the development of the disorder.
Risk factors associated with the development of the condition include
1) the presence of psychological trauma experienced in childhood
2) Personality disorders or problems
3) Inadequate emotional support from family and peers
4) Being female
5) Having a genetic predisposition to psychiatric disorders
6) Recent change to a stressful life
7) Excessive alcohol consumption
Other psychological causes are explained by the psychoanalytic model, in which unresolved psychological conflicts related to childhood trauma are reawakened by current events, and the cognitive-behavioural model, in which conditioned stimuli consistently elicit a fear response and the behaviour of avoiding them causes the problem.
Biological factors have been implicated, including the neurotransmitters dopamine, norepinephrine, and benzodiazepine receptors and the function of the hypothalamic-pituitary-adrenal axis.
There are reports of increased function of the norepinephrine system and the hypothalamic-pituitary-adrenal axis in patients with PTSD, as well as evidence of an overactive autonomic nervous system, as evidenced by increased blood pressure and heart rate and abnormal sleep architecture. Some researchers have suggested that the disorder has etiological similarities to depressive and panic disorders.
Symptoms
The main symptoms of PTSD are re-experiencing the traumatic event and avoidance of situations and stimuli associated with it.
Symptoms may begin as early as one month after the event or even more than a year later. Patients may experience dissociative phenomena, panic attacks, or perceptual abnormalities such as auditory hallucinations.
Associated symptoms may include aggressive tendencies, impulse control disorders, depression, and substance abuse. Cognitive problems such as difficulty with concentration and memory may also be present.
Diagnosis/Testing
PTSD is diagnosed by a mental health professional through an examination, interview, history taking, and questioning.
According to the diagnostic criteria in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the following criteria must be met.
Note: These criteria apply to adults, adolescents, and children 7 years of age and older. For children 6 years of age or younger, see the applicable criteria below.
A. Experience actual or threatened death, serious injury, or exposure to sexual violence in one or more of the following ways
- direct experience of the traumatic event(s)
- vividly witnessing the event(s) occurring to others
- learning that the traumatic event(s) happened to a family member, close relative, or close friend
Note: The actual or threatened death of a family member, relative, or friend must have occurred if the event(s) were violent or sudden. 4. - experience of repeated or excessive exposure to aversive details of the traumatic event(s) (e.g., first responders dealing with dead bodies, police officers repeatedly exposed to details of child abuse)
Note: Exposure through electronic media, television, film, or photography does not apply unless the exposure was work-related.
B. Invasive symptoms related to the traumatic event(s), which began after the traumatic event(s) occurred, are manifested by one or more of the following
- involuntary, intrusive repetition of distressing memories related to the traumatic event(s).
Note: In children 7 years of age and older, repetitive play involving themes or features of the traumatic event(s). - Recurrent distressing dreams in which the dream content and affects are related to the traumatic event(s).
Note: In children, this may present as frightening dreams with unknown content. - Dissociative reactions (e.g., flashbacks) in which the person acts or feels as if the traumatic event(s) are recurring (these reactions occur on a continuum and, at their most extreme, the person may be completely unaware of their current surroundings).
Note: In children, trauma-related re-enactments may occur through play. - experiencing extreme or persistent psychological distress when exposed to internal or external cues that symbolise or resemble the traumatic event(s).
- exhibits a marked physiological response when exposed to internal or external cues that symbolise or resemble the traumatic event(s).
C. Persistent avoidance of stimuli related to the traumatic event(s), beginning after the traumatic event(s) occurred, is manifested by one or more of the following
- avoidance of, or efforts to avoid, distressing memories, thoughts, or feelings about or closely related to the traumatic event(s).
- avoidance of, or efforts to avoid, people, places, conversations, behaviours, objects, situations, etc. that are reminders of, or closely related to, distressing memories, thoughts, or feelings about the traumatic event(s).
D. Negative changes in cognition and mood related to the traumatic event(s) that began or worsened after the traumatic event(s) occurred, manifested by two or more of the following
- inability to remember important parts of the traumatic event(s) (not due to other causes such as head trauma, alcohol, drugs, etc. and typically due to dissociative amnesia)
- persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “I can’t trust anyone,” “the world is totally dangerous,” “my entire nervous system is permanently damaged”)
- blaming oneself or others by having a persistently distorted perception of the cause or effect of the traumatic event(s)
- experiencing persistently negative emotional states (e.g., fear, anger, guilt, shame)
- shows markedly decreased interest or participation in major activities
- feeling distant or estranged from others.
- persistent difficulty experiencing positive emotions (e.g., inability to feel happy, content, or loved)
E. Marked changes in arousal and reactivity related to the traumatic event(s) that began or worsened after the traumatic event(s) occurred, including at least two of the following
- outbursts of arousal and anger, typically expressed as verbal or physical aggression toward people or objects (despite little or no provocation)
- reckless or self-destructive behaviour
- hyperarousal
- exaggerated startle response
- difficulty concentrating
- sleep difficulties (difficulty falling asleep or staying asleep or restless sleep)
F. The impairment (diagnostic criteria B, C, D, or E) has been present for at least one month.
G. The impairment results in clinically significant distress or impairment in a social, occupational, or other important area of functioning; or
H. The impairment is not due to the physiological effects of a substance (e.g., therapeutic drugs or alcohol) or another medical condition.
Specify one of the following
Dissociative symptoms: The individual’s symptoms meet the criteria for PTSD and, in addition, in response to stress, the individual experiences persistent or recurrent symptoms that include the following
- derealisation: persistent or recurrent experiences of being detached from one’s own mental processes or body and feeling as if one is an outside observer (e.g., feeling like one is in a dream, having a sense of unreality about oneself or one’s body, or having a sense of time passing slowly)
- unreality: a persistent or recurrent experience of the unreality of the surroundings (e.g., experiencing the world around the individual as unreal, dreamlike, distant, or distorted).
Note: To use this subtype, the dissociative symptoms must not be due to the physiological effects of a substance (e.g., temporary memory loss, behaviour under the influence of alcohol) or another medical condition (e.g., complex partial seizures).
Including post-traumatic stress disorder in children 6 years of age and younger
A. In a child 6 years of age or younger, exposure to actual or threatened death, serious injury, or sexual violence is manifested in one (or more) of the following ways
- direct experience of the traumatic event(s)
- vividly witnessing the event(s) happen to others, especially the primary caregiver.
Note: This does not include witnessing through electronic media, television, film, or photography. - learned that the traumatic event(s) occurred to a parent or caregiver.
B. The presence of invasive symptoms related to the traumatic event(s) that began after the traumatic event(s) occurred is indicated by one (or more) of the following
- recurrent, involuntary, intrusive distressing memories of the traumatic event(s)
Note: Spontaneous, intrusive memories do not necessarily have to be distressing and may manifest as playful reenactments. - recurrent distressing dreams in which the dream content and affects are related to the traumatic event(s)
Note: It may not be possible to be certain whether the frightening content of the dream is related to the traumatic event or not.
Dissociative reactions (e.g., flashbacks) that cause the child to feel and act as if the traumatic event(s) are being replayed (such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of the current surroundings) Specific reenactments of the trauma may occur in play.
- extreme or prolonged psychological distress when exposed to internal or external cues that symbolise or resemble the traumatic event(s)
- a marked physiological response to being reminded of the traumatic event(s).
C. There is one (or more) of the following symptoms that represent persistent avoidance of stimuli related to the traumatic event(s) or negative changes in cognition and emotion related to the traumatic event(s) that began or worsened after the traumatic event(s) occurred
Persistent avoidance of stimuli
- avoidance or efforts to avoid activities, places, or physical reminders of the traumatic event(s)
- avoidance or efforts to avoid people, conversations, or interpersonal situations that remind you of the traumatic event(s).
Negative changes in cognition
- a marked increase in the frequency of negative emotional states (e.g., fear, guilt, sadness, shame, confusion)
- markedly decreased interest or participation in major activities, including decreased play
- socially withdrawn behaviour
- persistent decrease in positive emotional expression
D. Changes in arousal and reactivity related to the traumatic event(s), which began or worsened after the traumatic event(s) occurred, are evident in two (or more) of the following
- irritable behaviour and outbursts of anger (with little or no stimulus), typically expressed as verbal or physical aggression toward people or objects (including extreme outbursts of anger)
- hyperarousal
- exaggerated startle response
- problems with concentration
- sleep disturbances (e.g., difficulty getting or staying asleep or restless sleep)
E. The duration of the impairment must be at least one month.
F. The impairment causes clinically significant distress or impairment in the child’s relationship with parents, siblings, peers, or other caregivers, or in school performance.
G. The impairment is not due to the physiological effects of a substance (e.g., medication or alcohol) or another medical condition.
Specify one of the following
Dissociative symptoms: The individual’s symptoms meet the criteria for PTSD and the individual experiences persistent or recurrent symptoms that include the following
- derealisation: persistent or recurrent experiences of being detached from one’s own mental processes or body and feeling as if one is an outside observer (e.g., feeling like one is in a dream, having a sense of unreality about oneself or one’s body, or having a sense of time passing slowly).
- unreality: a persistent or recurrent experience of the unreality of the surroundings (e.g., experiencing the world around the individual as unreal, dreamlike, distant, or distorted).
Note: To use this subtype, the dissociative symptoms must not be due to the physiological effects of a substance (e.g., temporary amnesia) or another medical condition (e.g., complex partial seizures).
Specify if
Delayed onset: when all diagnosic criteria are met at least 6 months after the event (although the onset and expression of some symptoms may occur immediately after the event).
The first consideration in the diagnosis of PTSD is to rule out the possibility that the symptoms were caused by brain damage at the time of the incident. Tests to assess the extent of brain damage, such as brain magnetic resonance imaging, may be necessary.
Substance abuse, such as alcohol, and underlying medical conditions, such as epilepsy, should also be evaluated, and tests such as an electroencephalogram may be necessary.
Patients with anxiety disorders, depressive disorders, pain disorders, and substance abuse should be considered for PTSD as it can be misdiagnosed as other psychiatric disorders.
Treatment
Emotional support and encouragement to talk about the traumatic event are the first things that should be offered to the person who has experienced it. Teaching coping skills, such as relaxation techniques, is also a good treatment option. The person should also be educated about the condition and its treatment.
The treatment of PTSD, as with other disorders, is a combination of medication and psychotherapy, with SSRIs (selective serotonin reuptake inhibitors) being the first choice for medication, as they improve symptoms similar to those of depression and other anxiety disorders, as well as symptoms unique to PTSD.
Psychotherapeutic treatments may include psychodynamic psychotherapy. Other psychotherapies include behavioural therapy, cognitive therapy, and hypnotherapy.
Progression/Complications
Symptoms of PTSD can occur as soon as a week after a traumatic event and as long as 30 years later. The severity of symptoms changes over time and is intensified during times of stress.
If left untreated, 30% of people will return to normal on their own, while 40% will continue to experience mild symptoms. About 20 per cent experience moderate symptoms and 10 per cent have no improvement and even worsening of symptoms.
In general, people who develop the disease at a very young age or, conversely, at an older age experience more difficulties than middle-aged people.
The prognosis is poor when other conditions are present, and the prognosis is good when there are good existing social relationships.
Prevention
There is no known way to prevent PTSD.
Diet and lifestyle
There are no specific dietary recommendations for PTSD.