Post-Traumatic Stress Disorder (PTSD)
Summary
Post-Traumatic Stress Disorder (PTSD) is a debilitating psychiatric condition that develops after exposure to a traumatic event involving actual or threatened death, serious injury, or sexual violence. It is defined by a cluster of symptoms: Re-experiencing (flashbacks/nightmares), Avoidance of stimuli, Negative Cognitions/Mood, and Hyperarousal, persisting for more than 1 month and causing functional impairment. Symptoms lasting less than 1 month are classified as Acute Stress Disorder. Standard treatments include Trauma-Focused CBT and Eye Movement Desensitisation and Reprocessing (EMDR). A new diagnosis, Complex PTSD (CPTSD), arising from prolonged repetitive trauma, is now recognised in ICD-11. [1,2]
Key Facts
- Diagnostic Threshold: Symptoms must persist >1 month. (If less than 1 month = Acute Stress Disorder).
- Core Triad (ICD-11): 1) Re-experiencing, 2) Avoidance, 3) Hyperarousal (Threat Perception).
- Neurobiology: Failure of the Prefrontal Cortex (Rational) to inhibit the Amygdala (Fear) + Hippocampal atrophy (Memory processing failure).
- Debriefing: Single-session psychological "debriefing" immediately after trauma is NOT recommended and may increase PTSD risk.
- Complex PTSD: Includes PTSD symptoms PLUS "Distrubances in Self-Organisation" (DSO): emotional dysregulation, negative self-concept, and interpersonal difficulties.
Clinical Pearls
The "Flashback": This is not just a memory. It is a dissociative re-experiencing where the patient feels the trauma is happening right now in the present. It often has sensory components (smell, sound).
Sleep is Key: Nightmares and insomnia are hallmark symptoms. Treating sleep (e.g., with Prazosin for nightmares - off-label) can significantly improve quality of life.
Avoidance Maintains Trauma: By avoiding triggers, the brain never learns that the threat is gone. Therapy (CBT) works via graded exposure to extinguish the fear response.
Somatic Presentation: Patients may present with chronic pain, IBS, or headaches rather than disclosing the trauma. Always ask about trauma history in "medically unexplained symptoms".
Prevalence
- Lifetime Prevalence: ~7-8% in general population.
- Gender: Women (10%) > Men (4%).
- High Risk: Combat veterans (~15-30%), Rape victims (~50%), Emergency responders.
Risk Factors
- Pre-trauma: History of prior trauma, childhood adversity, low socioeconomic status, family history of psychiatric illness.
- Peri-trauma: Perceived life threat, dissociation during the event ("it felt like a dream").
- Post-trauma: Lack of social support, ongoing life stress.
Neuroanatomy
- Amygdala: Hyperactive. Detects threat everywhere. "Smoke detector that won't turn off".
- Hippocampus: Atrophic/Hypoactive. Fails to tag the memory as "In the Past". Result: Memory feels like "Present".
- Medial Prefrontal Cortex: Hypoactive. Fails to regulate/inhibit the amygdala fear response.
Neurochemistry
- Dysregulation of Noradrenaline (Hyperarousal).
- Dysregulation of Cortisol (HPA axis abnormalities).
DSM-5 Criteria Clusters
A. Stressor: Exposure to death, injury, sexual violence (Direct, Witnessing, or learning of close friend/family).
B. Intrusion (Re-experiencing):
C. Avoidance:
D. Negative Alterations in Cognition and Mood:
E. Hyperarousal:
Complex PTSD (CPTSD)
Mental State Examination (MSE)
- Appearance: May be hypervigilant, scanning the room.
- Behaviour: Startles easily.
- Mood: Anxious, Depressed, Irritable.
- Affect: Restricted or Labile.
- Thought Content: Preoccupation with trauma, Guilt ("Survivor guilt").
- Perception: Flashbacks (may appear to zone out).
- Risk: Suicide, Self-harm, Substance misuse.
Screening Tools
- PCL-5 (PTSD Checklist for DSM-5): Self-report. Score >33 suggests PTSD.
- IES-R (Impact of Event Scale - Revised).
- Clinician-Administered PTSD Scale (CAPS-5): Gold standard for diagnosis.
Physical
- Screen for comorbidities (BP, metabolic syndrome) as chronic stress affects physical health.
Management Algorithm
TRAUMA EXPOSURE
↓
SYMPTOM DURATION
↓
┌────────────┴────────────┐
< 4 WEEKS > 4 WEEKS
(Acute Stress) (PTSD)
↓ ↓
WATCHFUL WAITING TRAUMA-FOCUSED
- No debriefing PSYCHOTHERAPY
- Follow up at 1m (TFCBT or EMDR)
↓
Improvement?
NO → YES (Discharge)
↓
CONSIDER MEDICATION
(SSRI / Venlafaxine)
1. Acute Phase (less than 4 weeks)
- Do NOT improve formal therapy yet (natural recovery is common).
- Do NOT "Debrief".
- "Watchful Waiting": Monitor. Provide practical/social support. Treat insomnia/agitation symptomatically if severe.
2. Psychotherapy (First Line for PTSD)
NICE [3] recommends trauma-focused therapy be offered before medication.
- Trauma-Focused CBT (TF-CBT):
- Education about trauma.
- Exposure Therapy: Imaginal exposure (retelling the story) + In vivo exposure (visiting safe places previously avoided).
- Cognitive Restructuring: Challenging "stuck points" (e.g., "It was my fault").
- EMDR (Eye Movement Desensitisation and Reprocessing):
- Patient recalls trauma while making bilateral eye movements.
- Mechanism unclear (Dual attention? Working memory tax? REM sleep mimicry?).
- Evidence base is strong.
3. Pharmacotherapy (Second Line)
- Used if: Patient prefers meds, refuses therapy, or therapy fails.
- SSRIs: Sertraline, Paroxetine, Fluoxetine.
- SNRI: Venlafaxine.
- Antipsychotics: Quetiapine or Risperidone (adjunct for severe hyperarousal/psychosis symptoms).
- Prazosin (Alpha-blocker): Specific for PTSD nightmares (reduces noradrenergic tone).
- Substance Use Disorder: Alcohol/Drugs used for "numbing".
- Depression: High comorbidity (>50%).
- Suicide: Significantly elevated risk.
- Physical Health: Chronic stress linked to cardiovascular disease, autoimmune conditions, and chronic pain.
- Social: Relationship breakdown, unemployment.
- Untreated: Can become chronic and last decades. 30% recover spontaneously.
- Treated: Good response to TF-CBT/EMDR.
- CPTSD: Often requires longer, phased treatment (Phase 1: Safety/Stabilisation -> Phase 2: Trauma work -> Phase 3: Reintegration).
Key Guidelines
| Guideline | Organisation | Key Recommendations |
|---|---|---|
| NG116 | NICE (2018) | TF-CBT/EMDR first line. No debriefing. Venlafaxine/SSRI second line. |
| PTSD Guidelines | APA (USA) | Psychological treatments typically preferred over pharmacotherapy. |
| ICD-11 | WHO | Introduced "Complex PTSD" as separate diagnosis. |
Landmark Studies
1. Cochrane Review (Bisson et al, 2013)
- Result: TF-CBT and EMDR are superior to waitlist and standard care.
- Impact: Solidified psychological therapy as first line.
2. Review of Debriefing (Rose et al, 2002)
- Observation: Single-session debriefing did not prevent PTSD and increased risk in some.
- Impact: Practice of routine debriefing abandoned in clinical guidelines.
What is PTSD?
PTSD is a reaction to a very scary or life-threatening event. Normally, memories fade and feel like they are "in the past." In PTSD, the memory gets "stuck." Your brain acts as if the danger is still happening right now.
Symptoms
- Reliving it: Flashbacks or nightmares where you feel you are back there.
- Being on Guard: Feeling jumpy, looking for danger, unable to relax or sleep.
- Avoidance: Staying away from anything that reminds you of what happened.
What is EMDR?
Its a therapy where you think about the memory while moving your eyes back and forth (following the therapist's finger). It sounds strange, but it seems to help the brain "file away" the memory so it becomes a normal past memory instead of a terrifying present one.
Is it curable?
Yes. With the right therapy, the memory will not disappear, but it will stop hurting you. It will become just a story from your past, not something that controls your life.
Primary Sources
- Shalev A, et al. Post-traumatic stress disorder. N Engl J Med. 2017;376:2459-2469. PMID: 28636846.
- Maercker A, et al. Proposals for mental disorders specifically associated with stress in the ICD-11. Lancet. 2013;381:1683-1685. PMID: 23663951.
- NICE Guideline NG116. Post-traumatic stress disorder. 2018.
- Cusack K, et al. Psychological treatments for adults with posttraumatic stress disorder: A systematic review and meta-analysis. Clin Psychol Rev. 2016;43:128-141.
Common Exam Questions
- Psychiatry: "Patient witnessed a crash 2 weeks ago. Has nightmares. Diagnosis?"
- Answer: Acute Stress Reaction (or Disorder). NOT yet PTSD (less than 1 month). Management: Watchful waiting.
- Psychiatry: "First line treatment for PTSD >3 months duration?"
- Answer: Trauma-Focused CBT or EMDR. (Not drugs).
- Pharmacology: "Medication for PTSD nightmares?"
- Answer: Prazosin (alpha-1 antagonist).
- Mental Health: "What defines Complex PTSD?"
- Answer: PTSD symptoms + Affect Dysregulation + Negative Self-Concept + Relationship difficulties.
Viva Points
- Debriefing: Why is it bad? It may interfere with natural processing or re-traumatise highly aroused individuals before they are ready (Secondary traumatisation).
- EMDR: Be able to explain it simply (bi-lateral stimulation helps processing).
- Avoidance: Explain why avoidance maintains the disorder (prevents extinction learning).
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.