Description

• 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.

Epidemiology

• 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.

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 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.

Genetics
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.