The essential feature of post traumatic stress disorder (PTSD) is the development of characteristic symptoms following exposure to one or more traumatic events. In some individuals, fear-based re-experiencing, emotional, and behavioral symptoms may predominate.

In other people with post traumatic stress disorder, anhedonic or dysphoric mood states and negative cognitions may be most distressing. In some other individuals, arousal and reactive-externalizing symptoms are prominent, while in others, dissociative symptoms predominate. Finally, there are some individuals with post traumatic stress disorder who exhibit combinations of these symptom patterns.

The directly experienced traumatic events in Criterion A (see Diagnostic Criteria below) include, but are not limited to, exposure to war as a combatant or civilian, threatened or actual physical assault (e.g., physical attack, robbery, mugging, childhood physical abuse), threatened or actual sexual violence (e.g., forced sexual penetration, alcohol/drug-facilitated sexual penetration, abusive sexual contact, noncontact sexual abuse, sexual trafficking), being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war, natural or human-made disasters, and severe motor vehicle accidents (American Psychiatric Association, 2013, p. 274).




The traumatic event can be reexperienced in various ways. Commonly, the individual has recurrent, involuntary, and intrusive recollections of the event. Intrusive recollections in post traumatic stress disorder are distinguished from depressive rumination in that they apply only to involuntary and intrusive distressing memories.

The emphasis is on recurrent memories of the event that usually include sensory, emotional, or physiological behavioral components. A common reexperiencing symptom is distressing dreams that replay the event itself or that are representative or thematically related to the major threats involved in the traumatic event.

Stimuli associated with the trauma are persistently avoided. The individual commonly makes deliberate efforts to avoid thoughts, memories, feelings, or talking about the traumatic event and to avoid activities, objects, situations, or people who arouse recollections of it.

Individuals with post traumatic stress disorder may be quick tempered and may even engage in aggressive verbal and/or physical behavior with little or no provocation. They may also engage in reckless or self-destructive behavior such as dangerous driving, excessive alcohol or drug use, or self-injurious or suicidal behavior (American Psychiatric Association, 2013, p. 275).




Symptoms of Post Traumatic Stress Disorder (PTSD)

Re-experiencing symptoms include:

  • Flashbacks—reliving the trauma over and over, including physical symptoms like a racing heart or sweating
  • Bad dreams
  • Frightening thoughts

Avoidance symptoms include:

  • Staying away from places, events, or objects that are reminders of the traumatic experience
  • Avoiding thoughts or feelings related to the traumatic event

Arousal and reactivity symptoms include:

  • Being easily startled
  • Feeling tense or “on edge”
  • Having difficulty sleeping
  • Having angry outbursts

Cognition and mood symptoms include:

  • Trouble remembering key features of the traumatic event
  • Negative thoughts about oneself or the world
  • Distorted feelings like guilt or blame
  • Loss of interest in enjoyable activities

(NIMH » Post-Traumatic Stress Disorder, 2020)

Causes of Post Traumatic Stress Disorder (PTSD)

Risk (and protective) factors are generally divided into pre-traumatic, peritraumatic, and post traumatic factors.

Pre-traumatic factors

Temperamental. These include childhood emotional problems by age 6 years (e.g., prior traumatic exposure, externalizing or anxiety problems) and prior mental disorders (e.g., panic disorder, depressive disorder, post traumatic disorder, or obsessive-compulsive disorder).

Environmental. These include lower socioeconomic status; lower education; exposure to prior trauma (especially during childhood); childhood adversity (e.g., economic deprivation, family dysfunction, parental separation or death); cultural characteristics (e.g., fatalistic or self-blaming coping strategies); lower intelligence; minority racial/ethnic status; and a family psychiatric history. Social support prior to event exposure is protective.

Genetic and physiological. These include female gender and younger age at the time of trauma exposure (for adults). Certain genotypes may either be protective or increase risk of post traumatic stress disorder after exposure to traumatic events (American Psychiatric Association, 2013, p. 277).

Peritraumatic factors

Environmental. These include severity (dose) of the trauma (the greater the magnitude of trauma, the greater the likelihood of post traumatic stress disorder), perceived life threat, personal injury, interpersonal violence (particularly trauma perpetrated by a caregiver or involving a witnessed threat to a caregiver in children), and, for military personnel, being a perpetrator, witnessing atrocities, or killing the enemy. Finally, dissociation that occurs during the trauma and persists afterward is a risk factor.

Post traumatic factors

Temperamental. These include negative appraisals, inappropriate coping strategies, and development of acute stress disorder.

Environmental. These include subsequent exposure to repeated upsetting reminders, subsequent adverse life events, and financial or other trauma-related losses. Social support (including family stability, for children) is a protective factor that moderates outcome after trauma (American Psychiatric Association, 2013, p. 278).




Diagnostic Criteria

Note: The following criteria for post traumatic stress disorder apply to adults, adolescents, and children older than 6 years. For children 6 years and younger, see the corresponding criteria below.

A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

  1. Directly experiencing the traumatic event(s).
  2. Witnessing, in person, the event(s) as it occurred to others.
  3. 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.
  4. 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:

1. 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.

2. Recurrent distressing dreams in which the content and/or effect of the dream are related to the traumatic event(s).

Note: In children, there may be frightening dreams without recognizable content.

3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reaction 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.

4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

5. 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:

  1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
  2. 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:

  1. 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).
  2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”).
  3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.
  4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
  5. Markedly diminished interest or participation in significant activities.
  6. Feelings of detachment or estrangement from others.
  7. 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:

  1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.
  2. Reckless or self-destructive behavior.
  3. Hypervigilance.
  4. Exaggerated startle response.
  5. Problems with concentration.
  6. 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.

Specify whether:

With dissociative symptoms: The individual’s symptoms meet the criteria for post traumatic stress disorder, and in addition, in response to the stressor, the individual experiences persistent or recurrent symptoms of either of the following:

  1. Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly).
  2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted).

Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g., blackouts, behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures).

Specify if:

With delayed expression: If the full diagnostic criteria are not met until at least 6 months after the event (although the onset and expression of some symptoms may be immediate).

(American Psychiatric Association, 2013, pp. 271–272)

Post Traumatic Stress Disorder for Children 6 Years and Younger

A. In children 6 years and younger, exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

1. Directly experiencing the traumatic event(s).

2. Witnessing, in person, the event(s) as it occurred to others, especially primary caregivers.

Note: Witnessing does not include events that are witnessed only in electronic media, television, movies, or pictures.

3. Learning that traumatic event(s) occurred to a parent or caregiving figure.

B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).

Note: Spontaneous and intrusive memories may not necessarily appear distressing and may be expressed as paly reenactment.

2. Recurrent distressing dreams in which the content and/or effect of the dream are related to the traumatic event(s).

Note: It may not be possible to ascertain that the frightening content is related to the traumatic event.

3. Dissociative reactions (e.g., flashbacks) in which the child 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.) Such trauma-specific reenactment may occur in play.

4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

5. Marked physiological reactions to reminders of the traumatic event(s).

C. One (or more) of the following symptoms, representing either persistent avoidance of stimuli associated with the traumatic event(s) or negative alterations in cognitions and mood associated with the traumatic event(s), must be present, beginning after the event(s) or worsening after the event(s):

Persistent Avoidance of Stimuli

1. Avoidance of or efforts to avoid activities, places, or physical reminders that arouse recollections of the traumatic event(s).

2. Avoidance of or efforts to avoid people, conversations, or interpersonal situations that arouse recollections of the traumatic event(s).

Negative alterations in Cognitions

3. Substantially increased frequency of negative emotional states (e.g., fear, guilt, sadness, shame, confusion).

4. Markedly diminished interest or participation in significant activities, including constriction of play.

5. Socially withdrawn behavior.

6. Persistent reduction in expression of positive emotions.

D. 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:

  1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects (including extreme temper tantrums).
  2. Hypervigilance.
  3. Exaggerated startle response.
  4. Problems with concentration.
  5. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

E. The duration of the disturbance is more than 1 month.

F. The disturbance causes clinically significant distress or impairment in relationships with parents, siblings, peers, or other caregivers or with school behavior.

G. The disturbance is not attributable to the physiological effects of a substance (e.g., medication or alcohol) or another medical condition.

Specify whether:

With dissociative symptoms: The individual’s symptoms meet the criteria for post traumatic stress disorder, and the individual experiences persistent or recurrent symptoms of either of the following:

  1. Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly).
  2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted).

Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g., blackouts) or another medical condition (e.g., complex partial seizures).

Specify if:

With delayed expression: If the full diagnostic criteria for post traumatic stress disorder are not met until at least 6 months after the event (although the onset and expression of some symptoms may be immediate).

(American Psychiatric Association, 2013, pp. 272–274)



Prevalence of Post Traumatic Stress Disorder (PTSD)

In the United States, projected lifetime risk for post traumatic stress disorder using DSM-IV criteria at age 75 years is 8.7%. Twelve-month prevalence among U.S. adults is about 3.5%. Lower estimates are seen in Europe and most Asian, African, and Latin American countries, clustering around 0.5%-1.0%.

Rates of post traumatic stress disorder are higher among veterans and others whose vocation increases the risk of traumatic exposure (e.g., police, firefighters, emergency medical personnel). Highest rates of post traumatic stress disorder are found among survivors of rape, military combat and captivity, and ethnically or politically motivated internment and genocide.

Compared with U.S. non-Latino whites, higher rates of post traumatic stress disorder have been reported among U.S. Latinos, African Americans, and American Indians, and lower rates have been reported among Asian Americans, after adjustment for traumatic exposure and demographic variables (American Psychiatric Association, 2013, p. 276).

Comorbidity of Post Traumatic Stress Disorder (PTSD)

Individuals with post traumatic stress disorder are 80% more likely than those without it to have symptoms that meet diagnostic criteria for at least one other mental disorder (e.g., depressive, bipolar, anxiety, or substance use disorders). Comorbid substance use disorder and conduct disorder are more common among males than among females.

Among U.S. military personnel and combat veterans who have been deployed to recent wars in Afghanistan and Iraq, co-occurrence of post traumatic stress disorder and mild TBI is 48%.

Although most young children with post traumatic stress disorder also have at least one other diagnosis, the patterns of comorbidity are different than in adults, with oppositional defiant disorder and separation anxiety disorder predominating.

Finally, there is considerable comorbidity between post traumatic stress disorder and major neurocognitive disorder and some overlapping symptoms between these disorders (American Psychiatric Association, 2013, p. 280).

Suicide Risk

Traumatic events such as childhood abuse increase a person’s suicide risk. Post traumatic stress disorder is associated with suicidal ideation and suicide attempts, and presence of the disorder may indicate which individuals with ideation eventually make a suicide plan or actually attempt suicide (American Psychiatric Association, 2013, p. 278).

Gender-Related Diagnostic Issues

Post traumatic stress disorder is more prevalent among females than among males across the lifespan. Females in the general population experience post traumatic stress disorder for a longer duration than do males. At least some of the increased risk for post traumatic stress disorder in females appears to be attributable to a greater likelihood of exposure to traumatic events, such as rape, and other forms of interpersonal violence. Within populations exposed specifically to such stressors, gender differences in risk for post traumatic stress disorder are attenuated or nonsignificant (American Psychiatric Association, 2013, p. 278).

Post Traumatic Stress Disorder Treatment

There are various forms of treatment that can treat the many symptoms associated with post traumatic stress disorder. Among those forms of treatment are psychotherapy (talk therapy) and psychiatric medication. In talk therapy, you will learn how to identify what triggers your symptoms and how to manage them. There are different types of talk therapy for post traumatic stress disorder.

Medicines can help with the symptoms of post traumatic stress disorder too. Antidepressants may help control symptoms such as sadness, worry, anger, and feeling numb inside. Other medicines can help with sleep problems and nightmares (Post-Traumatic Stress Disorder, n.d.).


References:

  • American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5 (5th ed.). American Psychiatric Publishing.
  • National Center for PTSD. (n.d.). VA.gov | Veterans Affairs. U.S. Department of Veteran Affairs. Retrieved November 5, 2020, from https://www.ptsd.va.gov/
  • NIMH » Post-Traumatic Stress Disorder. (2020, November 5). National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml
  • Post-Traumatic Stress Disorder. (n.d.). Medline Plus. Retrieved November 5, 2020, from https://medlineplus.gov/posttraumaticstressdisorder.html
  • Post-traumatic stress disorder (PTSD) – Symptoms and causes. (2018, July 6). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/post-traumatic-stress-disorder/symptoms-causes/syc-20355967
  • Symptoms of PTSD | Anxiety and Depression Association of America, ADAA. (n.d.). Anxiety and Depression Association of America. Retrieved November 5, 2020, from https://adaa.org/understanding-anxiety/posttraumatic-stress-disorder-ptsd/symptoms
  • What Is Posttraumatic Stress Disorder? (n.d.). American Psychiatric Association. Retrieved November 5, 2020, from https://www.psychiatry.org/patients-families/ptsd/what-is-ptsd