Post-Traumatic Stress Disorder
Summary
Post-Traumatic Stress Disorder (PTSD) is a psychiatric disorder that can develop after exposure to a traumatic event involving actual or threatened death, serious injury, or sexual violence. It is characterised by four symptom clusters: intrusive re-experiencing, avoidance, negative alterations in cognitions and mood, and hyperarousal. Symptoms must persist for more than one month and cause significant functional impairment. Treatment involves trauma-focused psychological therapies (CBT-TF, EMDR) as first-line, with medication as an adjunct or alternative.
Key Facts
- Prevalence: 3-6% lifetime; higher in high-risk groups
- Onset: Usually within 3 months of trauma; can be delayed
- Duration Criteria: Symptoms >1 month (acute stress disorder if <1 month)
- Treatment: Trauma-focused CBT and EMDR (first-line)
- Comorbidity: Depression (50%), anxiety, substance use
- Course: 50% recover within 3 months; some chronic
Clinical Pearls
High-Yield Points:
- Not everyone exposed to trauma develops PTSD (10-20%)
- Trauma-focused therapy is superior to general supportive therapy
- EMDR is equally effective as CBT-TF
- Medication is second-line (SSRIs if psychological therapy declined/unavailable)
- Complex PTSD (repeated trauma) requires longer treatment
- Screen for comorbid depression and substance use - very common
Why This Matters Clinically
PTSD is under-recognised in primary care and emergency settings, yet significantly impacts quality of life and increases suicide risk. Trauma-focused therapies are highly effective when delivered correctly. Early recognition and treatment can prevent chronicity. Understanding the difference between PTSD and acute stress disorder is important for appropriate management timing.
Prevalence and Incidence
| Metric | Value |
|---|---|
| Lifetime Prevalence | 3-6% (general population) |
| Trauma Exposure | 50-60% of adults experience trauma |
| Conditional Risk | 10-20% of trauma-exposed develop PTSD |
| Female:Male | 2:1 |
High-Risk Groups
| Group | Prevalence |
|---|---|
| Military veterans (combat) | 15-30% |
| Emergency service workers | 10-20% |
| Survivors of sexual assault | 30-50% |
| Accident survivors | 10-15% |
| Childhood abuse survivors | 20-40% |
Risk Factors for PTSD (After Trauma)
Pre-Trauma:
- Female sex
- Prior psychiatric history
- Prior trauma exposure
- Lower socioeconomic status
- Lower education
Peri-Trauma:
- Severity/duration of trauma
- Perceived life threat
- Interpersonal violence (vs accident)
- Dissociation during event
Post-Trauma:
- Lack of social support
- Additional life stressors
- Not talking about trauma
- Avoidance coping
Neurobiological Changes
Fear Conditioning:
- Trauma encodes fear memories in amygdala
- Neutral triggers become associated with threat
- Leads to flashbacks and hyperarousal
HPA Axis Dysregulation:
- Paradoxically low cortisol (enhanced negative feedback)
- Heightened noradrenergic activity
- Contributes to hyperarousal and startle
Prefrontal Cortex Dysfunction:
- Reduced prefrontal control over amygdala
- Difficulty distinguishing safe from unsafe
- Memory consolidation problems
Hippocampal Changes:
- Reduced hippocampal volume
- Impaired contextual memory
- Contributes to flashbacks occurring "out of time"
Memory Processing Model
Normal memory → processed and contextualised → stored as past event
Trauma memory → incompletely processed → stored fragmented → experienced as present
Treatment Target: Help brain process and contextualise the trauma memory
DSM-5/ICD-11 Symptom Clusters
1. Intrusion/Re-Experiencing:
2. Avoidance (Active):
3. Negative Alterations in Cognitions and Mood:
4. Hyperarousal/Alterations in Reactivity:
Duration and Functional Criteria
Complex PTSD (ICD-11)
PTSD symptoms PLUS:
Often associated with repeated, prolonged trauma (childhood abuse, captivity)
Differential Diagnosis
| Condition | Key Distinguishing Feature |
|---|---|
| Acute Stress Disorder | Symptoms 3 days to 1 month |
| Adjustment Disorder | Stressor not "traumatic" |
| Depression | No re-experiencing, less avoidance |
| Panic Disorder | Panic not linked to trauma |
| Phobia | Fear of specific object/situation |
Assessment
Specific PTSD Questions:
- Direct questions about trauma exposure
- Flashbacks and nightmares
- Avoidance behaviours
- Sleep, concentration, startle
Mental State:
- General: May appear anxious, guarded, hypervigilant
- Mood: Low, anxious, emotionally numb
- No psychotic features (unless trauma-related dissociation)
Screening Tools
- PCL-5: PTSD Checklist (20 items, self-report)
- IES-R: Impact of Events Scale - Revised
- TSQ: Trauma Screening Questionnaire (10 items)
Risk Assessment
- Suicide risk elevated
- Self-harm
- Risky behaviours
- Substance misuse
Purpose: Exclude Organic/Comorbid Conditions
| Investigation | Purpose |
|---|---|
| Drug screen | Exclude substance-induced |
| TFTs | Exclude thyroid dysfunction |
| Routine bloods | General health |
Psychological Screening
- Depression (PHQ-9)
- Anxiety (GAD-7)
- Alcohol use (AUDIT)
- Drug use (DUDIT)
First-Line: Trauma-Focused Psychological Therapy
Trauma-Focused CBT (CBT-TF):
- 8-12 sessions
- Includes psychoeducation, relaxation, cognitive restructuring
- Key component: imaginal or in-vivo exposure
- Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) are variants
EMDR (Eye Movement Desensitisation and Reprocessing):
- 8-12 sessions
- Bilateral stimulation (eye movements) while recalling trauma
- Effective as CBT-TF
- May be preferred by some patients
Key Principles:
- Offer within 3 months of trauma (if symptoms persistent)
- Do NOT use non-trauma-focused therapies as first-line (e.g., supportive counselling)
- Sessions typically weekly or twice weekly
Second-Line: Pharmacotherapy
Indications:
- Patient declines psychological therapy
- Psychological therapy not available/accessible
- Inadequate response to psychological therapy
- Severe comorbid depression
First-Line Medications:
| Drug | Dose | Notes |
|---|---|---|
| Sertraline | 25-200 mg | Off-label but NICE recommended |
| Venlafaxine | 75-225 mg | SNRI alternative |
| Paroxetine | 20-50 mg | FDA approved for PTSD |
Duration: At least 12 months if effective
Not Recommended:
- Benzodiazepines (can worsen PTSD, risk of dependence)
- Antipsychotics (limited evidence, reserved for specialists)
Management of Specific Symptoms
| Symptom | Approach |
|---|---|
| Nightmares | Prazosin (limited evidence) |
| Hyperarousal | Propranolol (adjunct) |
| Sleep | Sleep hygiene; short-term hypnotics cautiously |
| Dissociation | Grounding techniques |
Complex PTSD
- Longer course of therapy (16+ sessions)
- May need phase-based approach (stabilisation → trauma processing → integration)
- Often requires specialist trauma services
Psychiatric Comorbidity
| Comorbidity | Prevalence |
|---|---|
| Major Depression | 50% |
| Generalised Anxiety | 30% |
| Substance Use Disorder | 30-50% |
| Panic Disorder | 15% |
| Suicidal Ideation | High |
Physical Health
- Chronic pain
- Cardiovascular disease (stress-related)
- Autoimmune conditions
- Sleep disorders
Functional Impact
- Occupational impairment
- Relationship difficulties
- Social isolation
- Financial problems
Natural History
| Timeframe | Outcome |
|---|---|
| 3 months | ~50% spontaneous remission |
| 1 year | 30% still symptomatic |
| Chronic | 10-20% have persistent symptoms |
Prognostic Factors
Good Prognosis:
- Single incident trauma
- Early treatment access
- Strong social support
- No prior psychiatric history
- Good premorbid functioning
Poor Prognosis:
- Childhood trauma
- Complex/repeated trauma
- Delayed treatment
- Comorbid substance use
- Ongoing threat/instability
Key Guidelines
| Guideline | Organisation | Year |
|---|---|---|
| PTSD | NICE NG116 | 2018 |
| PTSD Clinical Practice | VA/DoD | 2023 |
| International Society for Traumatic Stress | ISTSS | 2019 |
Key Evidence
- Trauma-focused CBT: Strong evidence base (multiple RCTs)
- EMDR: Equivalent efficacy to CBT-TF
- SSRI/SNRI: Moderate effect size, second-line
- Benzodiazepines: NOT recommended (may worsen outcome)
What is PTSD?
PTSD is a mental health condition that can develop after experiencing or witnessing a terrifying event. Your brain gets "stuck" in threat mode, causing you to relive the trauma through flashbacks or nightmares, avoid reminders, and feel constantly on edge.
What are the symptoms?
- Flashbacks: Reliving the trauma as if it's happening again
- Nightmares: Disturbing dreams about the event
- Avoidance: Staying away from places, people, or thoughts that remind you of trauma
- Feeling on edge: Easily startled, trouble sleeping, always on guard
- Negative feelings: Guilt, shame, difficulty feeling positive emotions
How is it treated?
Talking therapies (most effective):
- Trauma-focused CBT: Helps you process the trauma and change unhelpful thoughts
- EMDR: Uses eye movements to help your brain process traumatic memories
Medication:
- Antidepressants can help if therapy isn't available or isn't enough
How long does treatment take?
Usually 8-12 weekly sessions. Most people improve significantly with treatment.
When to seek help
If symptoms have lasted more than a month or are getting worse, see your GP. Urgent help is needed if you're having thoughts of suicide or self-harm.
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NICE. Post-traumatic stress disorder (NG116). 2018. nice.org.uk
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American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). 2013.
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Bisson JI, et al. Psychological therapies for chronic post-traumatic stress disorder (PTSD) in adults. Cochrane Database Syst Rev. 2013;12:CD003388. PMID: 24338345
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VA/DoD. VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. 2023.
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. It does not replace professional medical judgement.