Posttraumatic Stress Disorder (PTSD)


Posttraumatic stress disorder (PTSD) is a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event or who have been threatened with death, sexual violence, or serious injury (1).


  • The disorder can appear at any age. In children >6 years of age, young adults, and adults, it presents with three cardinal characteristics:
    • Intrusion symptoms like flashbacks, nightmares, distressing recollections
    • Avoidance of anything related to the traumatic event and/or numbing of general responsiveness
    • Increased arousal
  • Duration of PTSD can be:
    • Acute: symptoms lasting <3 months
    • Chronic: symptoms lasting ≥3 months
    • Delayed: onset 6 months after trauma exposure, <5% of cases
    • Symptoms of PTSD usually develop within 3 months after a trauma, although they can be delayed for years.


  • Probability of PTSD was assessed in about 29 types of traumatic experiences, divided into groups: sexual relationship violence, interpersonal violence, exposure to organized violence, participation in organized violence, and other life-threatening traumatic experiences.
  • Unexpected death of loved one, rape, other sexual assault were associated with the highest rate of PTSD.
  • 16% of children and adolescents exposed to trauma develop PTSD.

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

Lifetime prevalence for PTSD ranges from 7% to 9% in the general population. More common in females than males.

Etiology and Pathophysiology

  • Biologic dimensions: hypersensitivity of catecholamine pathways and overactivity 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.
  • 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 cause 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.

Monozygotic twins exposed to combat in Vietnam were at increased risk of the cotwin having PTSD compared with dizygotic twins.

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 prevention of PTSD.

Commonly Associated Conditions

  • Major depressive disorder
  • Alcohol/substance abuse
  • Panic disorder/agoraphobia/social phobia
  • Obsessive-compulsive disorder
  • 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.

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