Posttraumatic Stress Disorder (PTSD)

Description

• Posttraumatic stress disorder (PTSD) is an anxiety disorder defined as a reaction that can occur after exposure to an extreme traumatic event involving death, threat of death, serious physical injury, or a threat to physical integrity.
• This reaction has three cardinal characteristics:
  • Reexperiencing the trauma
  • Avoidance of anything related to the traumatic event and/or numbing of general responsiveness
  • Increased arousal
• Traumatic events that may trigger PTSD include natural/human disasters, serious accidents, war, sexual abuse, rape, torture, terrorism, hostage taking, or being diagnosed with life-threatening disease.
• PTSD can be:
  • Acute: symptoms lasting <3 months
  • Chronic: symptoms lasting ≥3 months
  • Delayed: onset 6 months after trauma exposure, <5% of cases
  • Subclinical: waxing and waning course

Epidemiology

• ~30% of men and women who have spent time in a war zone experience PTSD.
• 4 of the 6 trauma types associated with highest population proportions of lifetime PTSD episodes are related to intimate partner sexual violence.
• 16% children and adolescents exposed to trauma develop PTSD.

Incidence
~7.7 million American adults aged ≥18 years (3.5% of this age group) are diagnosed with PTSD each year.

Prevalence
Lifetime prevalence for PTSD ranges from 6.8% to 12.3% in the general population.

Etiology and Pathophysiology

• Biologic dimensions: Hyperactivity/hypersensitivity of catecholamine pathways and overactivity/oversensitivity of the central opioid pathways is seen; the amygdala and hippocampus dysfunction, with possible atrophy from overexposure to catecholamines, serotonergic dysregulation, glutamatergic dysregulation, and increased thyroid activity
• Learning theory: Life-threatening fear is classically conditioned by event exposure; any internal or external cue reminiscent of the event produces an intense “fight or flight” fear response. The person avoids cues that trigger fear. This avoidance maintains fear.
• Cognitive theories: These models suggest that severe trauma becomes represented in complex memory structures. The activation of these memories triggers intense thoughts and emotions that are pathologic (causing personal discomfort and dysfunction).
• Psychodynamic theory: Traumatic memories overwhelm defense mechanisms. Repeated recall of the traumatic event with associated fear is an effort to understand the event in a less threatening way.

Genetics
Monozygotic twins exposed to combat in Vietnam were at increased risk of the co-twin having PTSD compared with twins who were dizygotic.

Risk Factors

• Pretrauma environment:
  • Female gender
  • Younger age
  • Psychiatric history
  • Sexual abuse
• Peritrauma environment:
  • Severity of the trauma
  • Peritrauma emotionality
  • Perception of threat to life
  • Perpetration of the trauma
• Posttrauma environment:
  • Perceived injury severity
  • Medical complications
  • Perceived social support
  • Persistent dissociation from traumatic event
• Subsequent exposure to trauma-related stimuli

General Prevention

• Trauma-focused cognitive-behavioral therapy (CBT) and modified prolonged exposure delivered within weeks of a potentially traumatic event for people showing signs of distress have the most evidence in the treatment of acute stress and early PTSD symptoms and the prevention of PTSD.

Commonly Associated Conditions

• Major depressive disorder
• Alcohol/substance abuse
• Panic disorder
• Obsessive-compulsive disorder
• Agoraphobia and/or social phobia
• Traumatic brain injury
• Smoking (especially with assaultive trauma)
• Major neurocognitive disorders, dementia, or amnesia

Pediatric Considerations
Oppositional defiant disorder and separation anxiety are common comorbid conditions.