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Posttraumatic Stress Disorder (PTSD)

Posttraumatic stress disorder is a psychiatric illness characterized by overwhelming stress and anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder experienced after exposure Exposure ABCDE Assessment to a life-threatening event. Symptoms last more than 1 month and involve re-experiencing the event as flashbacks or nightmares, avoiding reminders of the event, irritability, hyperarousal, and poor memory Memory Complex mental function having four distinct phases: (1) memorizing or learning, (2) retention, (3) recall, and (4) recognition. Clinically, it is usually subdivided into immediate, recent, and remote memory. Psychiatric Assessment and concentration. Treatment is mainly based on CBT and eye movement desensitization. Pharmacological regimens, such as antidepressants, might be indicated in some cases.

Last updated: Nov 29, 2021

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Overview

Definition

Posttraumatic stress disorder is a severe, chronic psychiatric disorder that develops after experiencing or witnessing a traumatic event. The response to the trauma lasts more than 1 month and often includes severe fear manifesting as intrusive thoughts, flashbacks, or nightmares, which in turn negatively impact the patient’s life.

Epidemiology

  • Estimated prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency in the United States: approximately 8%–10%  (under-reported, as approximately 60% report experiencing significant trauma) 
  • Risk factors related to the development of PTSD:
  • Diagnosed in all age groups but most prevalent among young adults
  • ⅔ have other comorbid disorders: 
    • Mood disorders
    • Substance use disorders
    • Anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder disorders

Etiology and pathophysiology

Alterations in brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification physiology:

  • Many symptoms explained by an alteration in limbic system Limbic system The limbic system is a neuronal network that mediates emotion and motivation, while also playing a role in learning and memory. The extended neural network is vital to numerous basic psychological functions and plays an invaluable role in processing and responding to environmental stimuli. Limbic System: Anatomy:
    • Amygdala Amygdala Almond-shaped group of basal nuclei anterior to the inferior horn of the lateral ventricle of the temporal lobe. The amygdala is part of the limbic system. Limbic System: Anatomy (highly sensitive to trauma-related stimuli)
    • Hippocampus
    • Medial frontal Frontal The bone that forms the frontal aspect of the skull. Its flat part forms the forehead, articulating inferiorly with the nasal bone and the cheek bone on each side of the face. Skull: Anatomy cortex
  • Orbitofrontal cortex: 
    • Normally inhibits overactivation of limbic system Limbic system The limbic system is a neuronal network that mediates emotion and motivation, while also playing a role in learning and memory. The extended neural network is vital to numerous basic psychological functions and plays an invaluable role in processing and responding to environmental stimuli. Limbic System: Anatomy regions 
    • Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship show decreased inhibition by orbitofrontal cortex.
Ptsd brain

Brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification regions that are affected by PTSD

Image: “PTSD brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification” by The National Institute of Mental Health (NIMH). License: Public Domain

Alteration in functioning of neuro-hormonal and neuro-transmitter functioning:

  • Hypothalamic-pituitary-adrenal (HPA) axis Axis The second cervical vertebra. Vertebral Column: Anatomy
  • Noradrernergic system:
    • Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with PTSD may exhibit not only anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder, but also increased blood pressure, heart rate Heart rate The number of times the heart ventricles contract per unit of time, usually per minute. Cardiac Physiology, palpitations Palpitations Ebstein’s Anomaly, sweating, and tremors.
    • Increased 24-hour urine Urine Liquid by-product of excretion produced in the kidneys, temporarily stored in the bladder until discharge through the urethra. Bowen Disease and Erythroplasia of Queyrat epinephrine Epinephrine The active sympathomimetic hormone from the adrenal medulla. It stimulates both the alpha- and beta- adrenergic systems, causes systemic vasoconstriction and gastrointestinal relaxation, stimulates the heart, and dilates bronchi and cerebral vessels. Sympathomimetic Drugs concentration in those with PTSD
Major neurobiological processes in ptsd

Major neurobiological processes in PTSD:
HPA: hypothalamic-pituitary-adrenal
mPFC: medial prefrontal cortex

Image by Lecturio. License: CC BY-NC-SA 4.0

Clinical Presentation and Diagnosis

Traumatic event

  • E.g., threat of death, severe harm, or sexual assault Sexual Assault Sexual Abuse
  • Exposure Exposure ABCDE Assessment:
    • The patient personally experiences the traumatic event.
    • The patient witnesses a traumatic event affecting another person.
    • The patient learns about a close contact (family/friend) being exposed to trauma. 
    • Indirect exposure Exposure ABCDE Assessment to details of trauma (e.g., first responders)
    • Exposure Exposure ABCDE Assessment through media, pictures, or electronic devices does not qualify as trauma.

Diagnosis through clinical criteria

  • Intrusion symptoms:
    • Recurring, distressing, and involuntary memories from trauma 
    • Recurring nightmares related to trauma 
    • Dissociative reactions, such as flashbacks, in which the patient feels as if they are re-experiencing trauma
    • Marked physiological or psychological reaction to exposure Exposure ABCDE Assessment to internal/external cues that resemble trauma 
  • Avoidance behavior Avoidance behavior Specific Phobias:
    • Avoidance of memories related to traumatic event
    • Avoidance of places/people that may trigger Trigger The type of signal that initiates the inspiratory phase by the ventilator Invasive Mechanical Ventilation memories of traumatic event
  • Negative mood changes:
    • Inability to remember an important aspect of triggering event
    • Persistent negative beliefs about oneself
    • Distorted thoughts about cause of event
    • Persistent negative emotional state
    • Markedly diminished interest in participation in daily activities
    • Feeling of isolation and inability to experience positive emotions
  • Altered arousal:
    • Anger outbursts
    • Self-destructive behavior
    • Hypervigilance
    • Difficulty concentrating
    • Excessive startle reaction Startle Reaction Primitive Reflexes
    • Sleep Sleep A readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility. Physiology of Sleep disturbances
  • Duration and impact on life:
    • Symptoms must be present > 1 month.
    • Symptoms should significantly impair quality Quality Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. Quality Measurement and Improvement of life.
    • The use of mood-altering substances must be excluded.

Other tests

Diagnosis is clinical. Laboratory investigations or imaging studies are performed to exclude other medical conditions or for research Research Critical and exhaustive investigation or experimentation, having for its aim the discovery of new facts and their correct interpretation, the revision of accepted conclusions, theories, or laws in the light of newly discovered facts, or the practical application of such new or revised conclusions, theories, or laws. Conflict of Interest purposes.

  • Laboratory investigations might show: 
    • Decrease in cortisol Cortisol Glucocorticoids levels 
    • Elevated levels of norepinephrine Norepinephrine Precursor of epinephrine that is secreted by the adrenal medulla and is a widespread central and autonomic neurotransmitter. Norepinephrine is the principal transmitter of most postganglionic sympathetic fibers, and of the diffuse projection system in the brain that arises from the locus ceruleus. Receptors and Neurotransmitters of the CNS and epinephrine Epinephrine The active sympathomimetic hormone from the adrenal medulla. It stimulates both the alpha- and beta- adrenergic systems, causes systemic vasoconstriction and gastrointestinal relaxation, stimulates the heart, and dilates bronchi and cerebral vessels. Sympathomimetic Drugs
    • Elevated levels of endogenous opiates Opiates Opiates are drugs that are derived from the sap of the opium poppy. Opiates have been used since antiquity for the relief of acute severe pain. Opioids are synthetic opiates with properties that are substantially similar to those of opiates. Opioid Analgesics, which are related to blunted emotions 
  • MRI studies might show:
    • Hippocampal atrophy Atrophy Decrease in the size of a cell, tissue, organ, or multiple organs, associated with a variety of pathological conditions such as abnormal cellular changes, ischemia, malnutrition, or hormonal changes. Cellular Adaptation
    • Decreased corpus callosum size
    • Decreased prefrontal cortex size and action 
    • Increased amygdala Amygdala Almond-shaped group of basal nuclei anterior to the inferior horn of the lateral ventricle of the temporal lobe. The amygdala is part of the limbic system. Limbic System: Anatomy reactivity

Management

Psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy

  • Inhibit brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification regions known to cause symptoms 
  • Shortens course of recovery
  • Trauma-oriented CBT:
    • Individual or group based
    • Group therapy Group therapy A form of therapy in which two or more patients participate under the guidance of one or more psychotherapists for the purpose of treating emotional disturbances, social maladjustments, and psychotic states. Psychotherapy is especially successful for veterans and survivors of natural disasters.
  • Eye movement desensitization and reprocessing (EMDR):
    • New therapy
    • The patient is told to focus Focus Area of enhancement measuring < 5 mm in diameter Imaging of the Breast on the lateral movement of the clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship’s finger while visualizing the traumatic experience.
    • The patient processes the trauma while in a state of relaxation/distraction.

Pharmacotherapy

  • Selective serotonin Serotonin A biochemical messenger and regulator, synthesized from the essential amino acid l-tryptophan. In humans it is found primarily in the central nervous system, gastrointestinal tract, and blood platelets. Serotonin mediates several important physiological functions including neurotransmission, gastrointestinal motility, hemostasis, and cardiovascular integrity. Receptors and Neurotransmitters of the CNS reuptake inhibitors ( SSRIs SSRIs Serotonin Reuptake Inhibitors and Similar Antidepressants): 1st-line therapy (e.g., sertraline Sertraline A selective serotonin uptake inhibitor that is used in the treatment of depression. Serotonin Reuptake Inhibitors and Similar Antidepressants, paroxetine Paroxetine A serotonin uptake inhibitor that is effective in the treatment of depression. Serotonin Reuptake Inhibitors and Similar Antidepressants
  • Selective norepinephrine Norepinephrine Precursor of epinephrine that is secreted by the adrenal medulla and is a widespread central and autonomic neurotransmitter. Norepinephrine is the principal transmitter of most postganglionic sympathetic fibers, and of the diffuse projection system in the brain that arises from the locus ceruleus. Receptors and Neurotransmitters of the CNS reuptake inhibitors ( SNRIs SNRIs Serotonin Reuptake Inhibitors and Similar Antidepressants) (e.g., venlafaxine Venlafaxine A cyclohexanol and phenylethylamine derivative that functions as a serotonin and noradrenaline reuptake inhibitor (SNRI) and is used as an antidepressant agent. Serotonin Reuptake Inhibitors and Similar Antidepressants)
  • Atypical serotonergic agents (e.g., nefazodone Nefazodone Serotonin Reuptake Inhibitors and Similar Antidepressants
  • Alpha blockers ( prazosin Prazosin A selective adrenergic alpha-1 antagonist used in the treatment of heart failure; hypertension; pheochromocytoma; raynaud disease; prostatic hypertrophy; and urinary retention. Antiadrenergic Drugs) shown to decrease nightmares and insomnia Insomnia Insomnia is a sleep disorder characterized by difficulty in the initiation, maintenance, and consolidation of sleep, leading to impairment of function. Patients may exhibit symptoms such as difficulty falling asleep, disrupted sleep, trouble going back to sleep, early awakenings, and feeling tired upon waking. Insomnia while also lowering severity of daytime symptoms 
  • Long-term use of benzodiazepines Benzodiazepines Benzodiazepines work on the gamma-aminobutyric acid type A (GABAA) receptor to produce inhibitory effects on the CNS. Benzodiazepines do not mimic GABA, the main inhibitory neurotransmitter in humans, but instead potentiate GABA activity. Benzodiazepines and antipsychotics not recommended in PTSD ( benzodiazepines Benzodiazepines Benzodiazepines work on the gamma-aminobutyric acid type A (GABAA) receptor to produce inhibitory effects on the CNS. Benzodiazepines do not mimic GABA, the main inhibitory neurotransmitter in humans, but instead potentiate GABA activity. Benzodiazepines increase risk of drug dependence).

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Differential Diagnosis

  • Acute stress disorder Acute stress disorder Acute stress disorder describes stress reactions displayed after an individual has experienced a traumatic event. Symptoms last more than 3 days but less than 1 month and include re-experiencing the event as flashbacks or nightmares, avoidance of reminders of the event, irritability, hyperarousal, and poor memory and concentration. Acute Stress Disorder: stress reactions that present after an individual has experienced a life-threatening event. Symptoms last more than 3 days and less than 1 month and involve re-experiencing the event as flashbacks or nightmares, avoiding reminders, irritability, hyperarousal, and poor memory Memory Complex mental function having four distinct phases: (1) memorizing or learning, (2) retention, (3) recall, and (4) recognition. Clinically, it is usually subdivided into immediate, recent, and remote memory. Psychiatric Assessment and concentration. To qualify as acute stress, the traumatic event must have occurred within a month; for PTSD, it may happen at any point in the past. Symptoms last less than a month, unlike the longer duration in those with PTSD. 
  • Adjustment disorder Adjustment disorder Adjustment disorder is a psychological response to an identifiable stressor. The condition by emotional or behavioral symptoms that develop within 3 months of exposure, and do not last more than 6 months. Adjustment Disorder: psychological response to identifiable stressor, marked by emotional or behavioral symptoms that develop < 3 months from exposure Exposure ABCDE Assessment and lasting < 6 months. Adjustment disorder Adjustment disorder Adjustment disorder is a psychological response to an identifiable stressor. The condition by emotional or behavioral symptoms that develop within 3 months of exposure, and do not last more than 6 months. Adjustment Disorder differentiates itself from PTSD by having a less defined set of symptoms and lack of reactive symptoms to trauma (e.g., intrusion, negative mood, dissociative symptoms, arousal symptoms). Treatment involves CBT and pharmacological adjuncts ( SNRIs SNRIs Serotonin Reuptake Inhibitors and Similar Antidepressants, SSRIs SSRIs Serotonin Reuptake Inhibitors and Similar Antidepressants).
  • Brief psychotic disorder Brief psychotic disorder Brief psychotic disorder is the presence of 1 or more psychotic symptoms lasting more than 1 day and less than 1 month. An episode is often stress-related with a sudden onset, and the patient fully returns to baseline functioning after an episode. Brief Psychotic Disorder: presence of 1+ psychotic symptoms Psychotic symptoms Brief Psychotic Disorder lasting 1+ day and < 1 month. Brief psychotic disorder Brief psychotic disorder Brief psychotic disorder is the presence of 1 or more psychotic symptoms lasting more than 1 day and less than 1 month. An episode is often stress-related with a sudden onset, and the patient fully returns to baseline functioning after an episode. Brief Psychotic Disorder usually has sudden onset and is often stress related. The presence of psychotic symptoms Psychotic symptoms Brief Psychotic Disorder, such as delusions or hallucinations Hallucinations Subjectively experienced sensations in the absence of an appropriate stimulus, but which are regarded by the individual as real. They may be of organic origin or associated with mental disorders. Schizophrenia, distinguishes this diagnosis from acute stress disorder Acute stress disorder Acute stress disorder describes stress reactions displayed after an individual has experienced a traumatic event. Symptoms last more than 3 days but less than 1 month and include re-experiencing the event as flashbacks or nightmares, avoidance of reminders of the event, irritability, hyperarousal, and poor memory and concentration. Acute Stress Disorder. Also, there is a full return to baseline functioning after an episode of brief psychotic disorder Brief psychotic disorder Brief psychotic disorder is the presence of 1 or more psychotic symptoms lasting more than 1 day and less than 1 month. An episode is often stress-related with a sudden onset, and the patient fully returns to baseline functioning after an episode. Brief Psychotic Disorder. Treatment involves 2nd-generation antipsychotics and psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy
  • Panic disorder Panic disorder Panic disorder is a condition marked by recurrent and episodic panic attacks that occur abruptly and without a trigger. These episodes are time-limited and present with cardiorespiratory (palpitations, shortness of breath, choking), GI (nausea, abdominal distress), and neurologic (paresthesias, lightheadedness) symptoms. Panic Disorder: chronic psychological disorder marked by recurrent and episodic panic attacks that occur abruptly and without a trigger Trigger The type of signal that initiates the inspiratory phase by the ventilator Invasive Mechanical Ventilation. The episodes last from minutes to hours. Panic disorder Panic disorder Panic disorder is a condition marked by recurrent and episodic panic attacks that occur abruptly and without a trigger. These episodes are time-limited and present with cardiorespiratory (palpitations, shortness of breath, choking), GI (nausea, abdominal distress), and neurologic (paresthesias, lightheadedness) symptoms. Panic Disorder is associated with anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder or fear of having another attack or of its complications and some behavioral changes. Posttraumatic stress disorder can be distinguished by careful review of the onset of the anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder and arousal symptoms. Intrusive symptoms, as well as negative mood changes associated with PTSD, are often not present in panic disorder Panic disorder Panic disorder is a condition marked by recurrent and episodic panic attacks that occur abruptly and without a trigger. These episodes are time-limited and present with cardiorespiratory (palpitations, shortness of breath, choking), GI (nausea, abdominal distress), and neurologic (paresthesias, lightheadedness) symptoms. Panic Disorder.

References

  1. Sadock, BJ. Sadock, VA, & Ruiz, P. (2014). Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Chapter 11, Trauma and stressor-related disorders, pages 437–446. Philadelphia, PA: Lippincott Williams and Wilkins.
  2. Nutt, DJ, & Malizia, AL. (2004). Structural and functional brain changes in posttraumatic stress disorder. The Journal of clinical psychiatry, 65 Suppl 1, pages 11–17.
  3. Mann, SK, Marwaha, R. Posttraumatic stress disorder. [Updated 2021 Feb. 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK559129/

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