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.
- 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
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
Oppositional defiant disorder and separation anxiety are common comorbid conditions.
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