Posttraumatic Stress Disorder (PTSD)

What are the symptoms of PTSD?

Who gets PTSD?

PTSD is also known as Post-traumatic Stress Syndrome (PTSS) and is not caused by normal, everyday stress.[1] PTSD can occur at any age, it can occur during childhood, adolescence, adulthood and old age.[1]:272-277


PTSD causes different people to react in very different ways, and it can be very disabling. "The disturbance, regardless of its trigger, causes clinically significant distress or impairment in the individual’s social interactions, capacity to work or other important areas of functioning." [18]

Recovery from PTSD

Recovery rates vary: the DSM-5 states around 50% of adults with PTSD may recover within 3 months but some people have PTSD for over a year. In some cases, PTSD has continued for over 50 years,[1]:277 for example in Vietnam war veterans and Holocaust survivors. Santiago et al. (2013) reviewed many studies of PTSD, finding that 50% recovered within 2 years.

As the graph shows, a third of people exposed to trauma develop PTSD (33%), and recovery is significantly quicker in people exposed to unintentional trauma, for example natural disasters, life-threatening illness or accidents.[8] Factors know to hinder recover, or worsen symptoms after trauma include:

• reminders of the original trauma
• normal 'life stressors', for example unemployment, illness or bereavement
• new traumatic experiences
• worsening physical declining health or cognitive function (in older people)
• social isolation can worsen symptoms [1]:277

See also: Treatments for PTSD

Causes

Causes of PTSD: 10 common causes. Only a small percentage of people with PTSD are traumatized by combat. source: Spence et al. (2011). PLoS ONE 6(7): e21864.

Being female doubles the risk of a person developing PTSD; the reasons for this are not yet understood.[1]

The type of trauma experienced strongly affects the risk of developing PTSD; many studies show that rape causes the highest rates of PTSD,[1],[3] with over 50% of rape survivors affected.

Combat/military service is a less common cause of PTSD than many people expect, as the graph shows (based on research from Australian adults with PTSD in 2011).[45]

Rates of PTSD vary according to the type and duration of military service, along with many other factors affecting all trauma survivors, including the number of previous types of trauma experienced (both civilian and military), physical injuries sustained, whether there was social support after the trauma.[45]

Dissociative PTSD subtype

There are three key groups of symptoms in PTSD, intrusion symptoms (such as flashbacks) and emotional numbing, are dissociative in nature. [23], [24] Emotional numbing is often referred to as "psychic numbing" or "emotional anesthesia". Dissociative symptoms which occur which occur within PTSD do not necessarily mean a Dissociative Disorder is present since the additional criteria for Dissociative Disorders are often not be met; however, PTSD is a common additional diagnosis for people with complex Dissociative Disorders including dissociative identity disorder.[20]:298

Dissociative symptoms, such as subjective sense of numbing or detachment, reduced awareness of an individuals surroundings, derealization, depersonalization, and dissociative amnesia, are cardinal features of posttraumatic stress disorder. [24]

PTSD with dissociative features

In the DSM-5 diagnostic criteria this as an optional specifier for PTSD, meaning some people will have these additional symptoms:

• With dissociative symptoms (with either depersonalization or derealization). [1]:272, [21]:1145

This is commonly referred to as the dissociative sub-type of PTSD, although it is actually a specifier in the DSM-5, and as described above all PTSD involves some dissociative features, so there is not a "non-dissociative PTSD". The dissociative sub-type involves depersonalization or derealization rather than just additional dissociation, and is clinically different from severe PTSD.
The criteria were summarized by Friedman (2013):28 as follows:

• All the PTSD criteria are met
• "High levels of depersonalization or derealization" are also present
• Dissociative symptoms are not linked to substance use or another medical condition
• it is found in both children and adults

A substantial study of data from the World Mental Health Surveys found that people with the Dissociative sub-type of PTSD had a higher number of major psychiatric disorders (comorbid DSM-IV "Axis I" disorders, for example depression, anxiety, excludes personality disorders).[14] They were also more likely to have a history of child abuse and neglect than those with "regular" PTSD.[6] Wolf et al. (2012) studied both men and women with PTSD, finding that repeated sexual assault or abuse was more common in people with the dissociative sub-type of PTSD, both child sexual abuse and adult sexual trauma. The women in this sample were more likely than the men to have avoidant or borderline personality disorder diagnoses in addition to PTSD.
Responses to trauma differ in people with the dissociative sub-type of PTSD, Most people with PTSD react to a personalized "trauma-script" with high levels of psychological distress and related physiological reactions, and greater reexperiencing symptoms (such as flashbacks), but those with the dissociative sub-type showed dissociative symptoms but lacked the other these symptoms. [6] For example, they had less awareness of surroundings/zoned out, felt depersonalized or experienced derealization. Brain activity also differed between the two groups.[6]

PTSD in Preschool Children

Infants and children aged six years old or younger can be diagnosed with PTSD, but young children's thinking and ability to express themselves in words is limited. This means both their symptoms and diagnostic criteria are slightly different from those in adults or older children.
Most of the research on Preschool PTSD involved three- to six-year-olds, with some studies also including younger children.[13] Babies and toddlers can have PTSD: the minimum age for diagnosis is one year old.[1]:272-274

The criteria for Posttraumatic Stress Disorder for Children 6 Years and Younger are "developmentally sensitive". Some of the changes from the main PTSD criteria include:

• constricted play is an example of "diminished interest in significant activities"
• social withdrawal or behavioral changes can indicate "feelings of detachment or estrangement.
• extreme temper tantrums are now included with "irritability or outbursts of anger"
• intrusive symptoms such as flashbacks and intrusive thoughts do not always manifest overt distress in preschool children
  Scheeringa (2014) states that "while distressed reactions are common, parents also commonly reported no affect or what appeared to be excitement" [13]
• fewer avoidance symptoms are included because avoidance is internalized, and harder to detect by observation, for example in pre-verbal children

Developmental Trauma Disorder is a quite well-known term used to refer to Complex PTSD symptoms in children. [11] Like Complex PTSD it is caused by repeated and/or prolonged periods of trauma, for example child abuse by a familiar person. It was not included in the final DSM-5. [1]

Research has shown preschool children with PTSD have "impaired functioning" in many different areas of life, and the symptoms and impairment are stable in the long-term.[5] Very young children do not simple "bounce back" from PTSD. A study of 70 three- to six-year-olds directly by Hurricane Katrina found that children who stayed in New Orleans had significantly higher rates of PTSD than children who were evacuees (62.5%, compared to 43.5%).[12] None of the children who did not develop PTSD developed other mental disorders as a result of the trauma. The children were much more likely to have developed PTSD than their parents/caregivers; the "caregivers' rate of PTSD was 35.6%, of which 47.6% was new post-Katrina". This means that the hurricane's impact nearly doubled the rate of PTSD in the adults, compared to before the trauma.

Effects of PTSD on children

Most children who develop PTSD also develop additional mental disorders (comorbid disorders) as a result of the trauma. In the case of Hurricane Katrina, the most common additional disorders were Oppositional Defiant Disorder and Separation Anxiety Disorder A study of children 2–6 years old, and 7–10 years old, all traumatized by car crashes/motor vehicle accidents, found many differences between parents' and their children's reports of the trauma and its impact. This shows that relying solely on information from a parent of a traumatized child rather than the child leads to missing key information when assessing PTSD.[7] Given the subjective nature of the experience this is not surprising.
Effective treatments for infants and very young children with PTSD include Cognitive Behavioral Therapy (CBT), long-term, relationally-based therapy (e.g., in cases of interpersonal violence such as child abuse), Play Therapy, Eye Movement Desensitization and Reprocessing (EMDR), and others. Trauma treatment methods need to be developmentally-appropriate to the child's age.
See also: Dissociative form of PTSD
See also: Trauma and abuse

Delayed PTSD

PTSD with delayed expression occurs when the criteria for PTSD are not met for at least 6 months after the trauma; in some cases the onset of PTSD can be years after the trauma. This has been well documented and researched.[18]

A recent systematic review of 19 group studies indicated that delayed accounted for 38.2 and 15.3%, respectively of military and civilian cases of PTSD.[124] PTSD in the absence of any prior symptoms was extremely rare; this analysis found that delayed usually involved subsyndromal PTSD symptoms that later escalated to the full syndrome (possibly because of breakdown of very effective avoidance that previously worked to suppress reexperiencing symptoms and emotions for some period of time).[124] Delayed onset PTSD very uncommon after natural disasters, but it is not clear whether it is more likely to occur following military rather than non-military trauma.[25]

Complex PTSD

Complex PTSD, sometimes referred to as C-PTSD, or Disorders of Extreme Stress Not Otherwise Specified (DESNOS), is caused by repeated traumatic events. It is not a separate clinic diagnosis in psychiatry but has previously been described in the DSM-IV section "PTSD and its Associated Features" in the DSM-IV (APA, 2000), and "Enduring Personality Change after Catastrophic Events" (EPCACE in the ICD-10, WHO (1992).[26].

There is a significant relationships between Complex PTSD symptoms and a history of sexual abuse, which is supported by a number of different studies.[27] Developmental Trauma Disorder (DTD) is the child equivalent to Complex PTSD. [11]
More information: Complex PTSD

Chronic and Severe PTSD

This section refers to research from PTSD resulting from a single trauma caused by physical or sexual assault/rape, rather than multiple traumas, although severe and persistent PTSD can be caused by either.

Chronic PTSD refers to PTSD which lasts 3 months or longer, PTSD lasting under 3 months is known as Acute PTSD; this classification was used in the DSM-IV diagnostic manual, but was removed by the DSM-5 changes.[18]:12, [1]:272 Chronic PTSD can vary in severity from mild to severe, but for many people is severe.Acute PTSD can also be severe.

Negative views linked to persistent, chronic PTSD include:

• Nowhere is safe
• I cannot rely on other people
• I can’t trust my own judgments
• I am going mad
• It was my fault [2]

For example, persistently holding oneself responsible for causing the trauma or not avoiding it, or negative self-judgments about one's instinctive reactions during or after the trauma are linked to a longer duration of PTSD symptoms. These common negative beliefs are a symptoms of the trauma itself,[1]:272 and not an objective truth, sometimes these beliefs can be encouraged by people who wish to maintain their view of a "just world" rather than accept that a similar trauma could happen to them. People who are able to find some positive, for example, recognizing their own ability to have survived both the trauma and the horror of PTSD for so long, and identify positive qualities they did not have or were not aware of before, have a shorter duration to their PTSD. This has been referred to as Post-traumatic Growth (PTG). Besides the factors negative beliefs above, avoiding trauma reminders and seeking safety in order to control PTSD have been associated with more persistent PTSD.[2],[28],[29]

Severe PTSD
The diagnosis of PTSD does not include any description of what counts as mild, moderate or severe,[1]:272 but PTSD assessment tools are available to determine this. Factors during the time of trauma that lead to more severe PTSD:

• sense of hopelessness
• emotional detachment
• confusion [2]

A person's "perceived life threat" and "injury threat" during the trauma were found to be significantly correlated with PTSD severity at 4, 6 and 9 months after the trauma.[2] The person's perceived lack of control during the trauma was related to initial PTSD severity. Dunmore et al. (2001) found that the severity of a physical or sexual assault affected only the initial severity of PTSD, and the number of assailants affected only the longer-term severity (as measured at 9 months); other assault characteristics like time of day, duration of assault and relationship with the assailant were not found to be linked with the severity or persistence of PTSD (although most participants in the research were assaulted by a stranger at night, in a single traumatic event only). [2]

• See also: Complex PTSD for PTSD from multiple in erpersonal traumas, including child abuse
• See also: Treatment for PTSD, which includes a medication overview
• See also: PCL-5 PTSD checklist test to help assess PTSD

PTSD caused by Medical Trauma

PTSD can be caused by "exposure to actual or threatened death or serious injury" either by experiencing it yourself, or by witnessing it.[1] This includes medical illness or events, for example being diagnosed with a serious or potentially terminal illness like cancer or HIV, or witnessing the effect someone else's medical treatment and/or death.[21]:143

PTSD, physical illness and cancer

Posttraumatic stress disorder has been studied in patients with heart problems, hemorrhage and stroke, childbirth, miscarriage, abortion and gynecological procedures, intensive care treatment, HIV infection, cancer and other conditions; with Favaro et al. (2011) finding that 12% of heart transplant recipients suffered PTSD as a result of the transplant. One study, which excluded cancer, found the highest rates were found in patients treated in Intensive Care Units (ICUs), and those with HIV infection. Wade et al. (2013) reviewed a number of studies of patients in critical care, and found risks of PTSD were higher with patients who were sedated for longer, were on mechanical ventilators for longer, were given benzodiazepines, experienced greater levels of fear and stress in the ICU and had frightening memories of admission. Tedstone and Tarrier (2003) found the severity of the physical illness did not predict the risk of PTSD. Posluszny et al. (2011) found that even the perceived threat of cancer caused PTSD; 15% of women with a non-life-threatening gynecologic disease met the diagnostic criteria for PTSD after gynecologic surgery which revealed they did not have cancer.[9]

Survivor Guilt and PTSD

DSM-5 diagnostic criteria

Code 309.81
Note: Slightly different criteria are used for PTSD in children aged 6 years old or younger.

A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the events(s) as it occurred to others.
3. Learning that the traumatic events(s) occurred to a close family member or close friend. In cases of actual or threatened by death of a family member or friend, the events(s) must have been violent or accidental.
4. Experiencing repeated or extreme exposure to adversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse). This does not apply to exposure through electronic media, television, movies, or pictures unless this exposure is work related."

B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s) occurred:

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). In children older than 6, there may be frightening dreams without recognizable content.
2. Recurrent distressing dreams in which the content and/or effect of the dream are related to the traumatic event(s).
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the trauma event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings). In children, trauma-specific reenactment may occur in play.
4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s)."

C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following.

1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

D. Negative alterations in cognitions and mood associated with the traumatic events(s), beginning or worsening after the traumatic event(s), as evidenced by two (or more) of the following:

1. Inability to remember an important aspect of the traumatic events(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).
2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., "I am bad," "no one can be trusted," "the world is completely dangerous," "my whole nervousness system is permanently ruined.").
3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.
4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
5. Markedly diminished interest or participation in significant activities.
6. Feelings of detachment or estrangement from others.
7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).

E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following.

1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.
2. Reckless or self-destructive behavior
3. Hypervigilance
4. Exaggerated startle response
5. Problems with concentration
6. Sleep disturbances

F. Criteria B, C, D and E last more than 1 month.
G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
H. The disturbance is not attributable to the effects of a substance (e.g., medication, alcohol) or another medical condition.
Specify whether:

• With dissociative features

1. Depersonalization
2. Derealization

Specify if:

• With delayed expression
• This must be specified if the full criteria are not met until at least 6 months after the traumatic event; the criteria may be partially met during this time. [1]:272-274

ICD-10 diagnostic criteria

Changes between the DSM-IV & DSM-5

Posttraumatic stress disorder, along with Acute Stress Disorder, have moved from the Anxiety Disorders section to the newly created Trauma- and Stressor-Related Disorders, which recognizes that the symptoms are broader than Anxiety alone. [1] Young children now have separate diagnostic criteria, with the diagnosis being called Posttraumatic Stress Disorder for Children 6 Years and Younger. [1]:272 Chronic and Acute specifiers, which related to the duration of symtoms, are removed.
Negative alterations in cognitions and mood associated with the traumatic events(s) is a new category of symptoms, although some of these were previously included as Avoidance symptoms.

• Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., "I am bad," "the world is completely dangerous")
• erroneous self-blame or blaming others for the trauma
• negative mood states (e.g., fear, horror, anger, guilt, or shame)
• reckless and maladaptive behavior, e.g. example reckless driving
• the irritability symptoms has criterion been changed to aggressive behavior, which includes verbal aggression but does not refer to violence[18] [1]:272-274
• illusions and hallucinations have been removed from the examples of trauma symptoms listed in one criteria
• the DSM-IV delayed onset specifier has been reworded to delayed expression; this is used when symptoms were delayed for at least 6 months after the trauma. Some PTSD symptoms may begin immediately after the trauma. [1]:273-274

The only significant symptom removed is the optional symptom A sense of a foreshortened future, which means the person doesn't expect to have a career, marriage, children, or a normal life span
A new sub-type has been added, the PTSD dissociative sub-type, which has "prominent dissociative symptoms" which can be either Depersonalization (feeling detached from one’s own mind and/or body), or Derealization (experiencing the world as unreal, dreamlike or having distorted perceptions). [1]
Confusingly, the Dissociative form of PTSD is described as a "sub-type" but the diagnostic criteria lists "with dissociative symptoms" is a specifier instead of a sub-type. [1]

PTSD Illusions and Hallucinations

The DSM-5 clearly states that "illusions and hallucinations" can be PTSD symptoms. A particular type of auditory pseudo-hallucination, hearing your own thoughts spoken out loud in one or more voices, which may be described as hearing voices, is a recognized feature of PTSD. Paranoia (paranoid ideation) is also a possible result of PTSD.[1]:276

This improves upon the "Notes on flashbacks and psychotic hallucinations" section which was in the additional information in the PTSD section of the DSM-IV-TR and stated the importance of distinguishing between flashbacks and psychotic hallucinations:

"Flashbacks in Posttraumatic Stress Disorder must be distinguished from illusions, hallucinations, and other perceptual disturbances that may occur in Schizophrenia, other Psychotic Disorders, Mood Disorder with Psychotic features, a delirium, Substance-Induced Disorders, and Psychotic Disorders Due to a General Medical Condition." [22]:467

Traumatic Bereavement and PTSD

This happens when PTSD is caused by the death of a loved one in sudden or distressing circumstances, e.g. suicide, murder or witnessing the death in traumatic circumstances.
See Traumatic Bereavement

Denial of PTSD

People with posttraumatic stress disorder may experience denial about the condition, in addition to amnesia, avoidance, minimization of the effects of the trauma and/or cognitive impairment. Each of these can affect whether the person will be diagnosed with PTSD, and the severity determined. "Collateral reports" can be used to add information from spouses/partners, friends or family and from prior medical reports. The spouse/partner (S/P) Mississippi scale was developed to aid collateral assessment [30]:264-265
Some clinicians may at times minimize the effects of the trauma, or fail to recognize trauma which is not in the given examples of types of trauma for diagnosis (e.g., threatened death, serious injury, war, rape or sexual violence or witnessing a major trauma). Cash (2006) states that even a clinician who is aware of the trauma and PTSD symptoms may deny the PTSD diagnosis. Writing in 1997, Cash stated that "most mental health professionals do not receive much (if any) training or experience with [trauma] disorders during their graduate training."[1]:290 [31]:4-5 This could be because PTSD was not given a separate category in the DSM until 1980; although "traumatic stress" was included from the first edition.

Comorbid disorders

It is typical for people with PTSD to have other disorders which are caused by the effects of the trauma.[45] Approximately 80% of people also have other mental disorders, and a persistent "negative mood" or inability to feel positive emotions is part of the diagnostic criteria. Unsurprisingly, Depression (Major Depressive Disorder and other forms), Anxiety Disorders and Substance Misuse (alcoholism, addiction to or misuse of drugs, including prescription medication) are the most common disorders.[45] Many people with Borderline Personality Disorder have PTSD, and a history of childhood physical or sexual abuse is fairly common in people with PTSD.[20]:685 Most people with Dissociative Identity Disorder also have PTSD, although rates of Dissociative Identity Disorder and Dissociative Disorders are significantly lower than PTSD. Dissociative Identity Disorder is caused by childhood trauma only.[20]:278

PTSD and Suicide Risk

The suicide risk is increased in people who have experienced trauma, with those who have PTSD being at greater risk of suicide compared to those who did not develop PTSD after the trauma. PTSD is associated with both suicide attempts and suicidal ideation. [20]:278, 803

Traumatic Brain Injury, ASD & PTSD

Major or Mild Neurocognitive Disorder Due to Traumatic Brain Injury, commonly known as Traumatic Brain Injury (TBI) is a neurocognitive disorder (NCD), which results from physical injury to the head. TBI causes some people mental/behavioral symptoms (e.g., depression, personality changes like aggression) as well as neurological/cognitive symptoms (e.g., impaired concentration).[1]:264, [1]:266-276 It can be comorbid with PTSD when the trauma involves a physical head injury, e.g., bomb blasts, physical assault, or auto accidents. [1]:323 Many symptoms overlap with PTSD; the combination of TBI and PTSD is particularly common in military veterans. [38]

Some symptoms of Traumatic Brain Injury which are not present in PTSD include loss of consciousness immediately after injury, primarily cognitive symptoms, symptoms begin immediately after injury (no gradual or delayed onset), "persistent disorientation", and confusion. Symptoms of PTSD that do not occur in TBI include reexperiencing (e.g., flashbacks), and avoidance symptoms. [1]:323, [20]:280 Traumatic brain injury is either "a traumatically induced structural injury" or "physiological disruption of brain function", caused as a result of an external force. [37]

Acute stress disorder (ASD) may occur immediately before PTSD, and the symptoms are similar. Acute Stress Disorder is diagnosed only within a month of a traumatic event, and PTSD is only diagnosed if symptoms exist for longer than that. ASD is a risk factor for PTSD.

History of PTSD

Posttraumatic Stress Disorder first become an official diagnosis in 1980, when it was included in the Anxiety Disorders section of the DSM-III psychiatric manual.[32] Before 1980 the symptoms of Posttraumatic Stress was represented in both the DSM-I (in 1952) [33],[34] and the DSM-II (1968), and in medical literature under a variety of different names.[35], [39]
See also: History of PTSD

See also: Acute stress disorder
See also: Treatment for PTSD
See also: Trauma and abuse