Psychiatry
High Evidence

Post-Traumatic Stress Disorder (PTSD)

Updated 2026-01-04
5 min read

Post-Traumatic Stress Disorder (PTSD)

1. Clinical Overview

Definition

A disorder developing after exposure to a traumatic event involving actual or threatened death, serious injury, or sexual violence.

The "Trauma"

  • Must be severe (not just "stressed by exams").
  • Types: War, Rape, Torture, Severe RTA, Terrorist attack.
  • can be Directly experienced, Witnessed, or Learned about (close family member).

2. Diagnostic Criteria (DSM-5)

Symptoms must last > 1 month (If less than 1 month = Acute Stress Disorder).

1. Re-experiencing (Intrusion)

  • Flashbacks (acting as if it's happening now).
  • Nightmares.
  • Intrusive thoughts.

2. Avoidance

  • Avoiding places/people reminding of trauma.
  • Avoiding thoughts/feelings related to trauma.

3. Hyperarousal (Reactivity)

  • Hypervigilance (always scanning).
  • Exaggerated startle response.
  • Irritability/Anger.
  • Sleep disturbance.

4. Negative Cognitions/Mood

  • "The world is unsafe"
    • "I am broken".
  • Guilt ("Survivor's Guilt").
  • Emotional numbing.

3. Complex PTSD (CPTSD) - ICD-11

A distinct diagnosis arising from prolonged, repeated trauma (e.g., childhood abuse, domestic violence, torture). Includes PTSD symptoms PLUS "Disturbance of Self-Organization" (DSO):

  1. Affect Dysregulation: Rage, suicide, self-harm.
  2. Negative Self-Concept: "I am worthless/shameful".
  3. Relationship Difficulties: Unable to trust/sustain closeness.

4. Epidemiology

  • Lifetime Prevalence: 7-8%.
  • Gender: F>M (2:1). Women experience more high-impact trauma (sexual assault).
  • Highest Risk: Rape (50% develop PTSD) > Combat (30%) > RTA (15%).

5. Pathophysiology

Neurobiology

  1. Amygdala Hyperactivity: "Smoke alarm" stuck on. Detects threat everywhere.
  2. Hippocampus Atrophy: Poor memory consolidation. Trauma memory feels "current" rather than "past".
  3. Prefrontal Cortex Hypoactivity: Unable to inhibit the Amygdala ("Brakes failed").

6. Management: Psychological (First Line)

Trauma-Focused CBT (TF-CBT)

  • Exposure: Gently facing the memory (imaginal) or triggers (in vivo) to habituate anxiety.
  • Restructuring: Challenging "It was my fault" beliefs.

EMDR (Eye Movement Desensitization and Reprocessing)

  • Patient holds trauma image while tracking therapist's finger (bilateral stimulation).
  • Theory: Mimics REM sleep? Taxes working memory so trauma loses intensity?
  • Efficacy: Equal to CBT. Good if patient struggles to verbalize.

7. Management: Pharmacotherapy

Second Line (or Augmentation)

  • Venlafaxine (SNRI) or Sertraline/Paroxetine (SSRI).
  • Prazosin (Alpha-blocker): specifically for Nightmares (off-label but widely used).
  • Avoid Benzodiazepines: Interfere with memory processing (prevent recovery).

8. Clinical Case Study: The "Monster Resource" Viva

Presentation

A 35-year-old soldier returns from deployment. He is irritable, checks locks 5 times a night, and dives to the floor when car exhausts backfire.

Clinical Decision Points (Viva Style)

Q1: Diagnosis? A: PTSD.

  • Hyperarousal (Lock checking, Startle).
  • Re-experiencing (Reaction to backfire).

Q2: What if it had only been 2 weeks since his return? A: Acute Stress Disorder (less than 1 month duration).

Q3: He drinks a bottle of whiskey a day to sleep. Treatment implications? A: Dual Diagnosis.

  • Alcohol worsens PTSD (prevents REM sleep processing).
  • Treat both concurrenty, or detox first if severe. Trauma work requires patient to be sober/present.

Q4: He asks about EMDR. Is it just hypnosis? A: No. It is a structured therapy recommended by NICE. It helps process "stuck" memories using bilateral stimulation.

9. Neurobiology Deep Dive: "The Body Keeps the Score"

The Triune Brain in Trauma

  1. Amygdala (Smoke Alarm): Triggered by trauma reminders. Sends instant "Fight/Flight" signal. Hyperactive in PTSD.
  2. Prefrontal Cortex (Watchtower): The rational brain. Supposed to say "It's just a firework, not a bomb". In PTSD, it goes offline (Hypoactive).
  3. Hippocampus (Librarian): Files memories with time/place stamps. In PTSD, it shrinks. Memories are not "filed" as past events, so they feel like current reality.

HPA Axis Dysregulation

  • Chronic Cortisol initially, then "Burnout" (Hypocortisolism).
  • Why veterans seek adrenaline (combat driving) - to feel "normal".

10. Polyvagal Theory & Somatic Therapies

The Theory (Porges)

  • Ventral Vagal: "Social Engagement" (Safe to connect).
  • Sympathetic: "Mobilization" (Fight/Flight).
  • Dorsal Vagal: "Immobilization" (Freeze/Collapse).

Clinical Relevance

  • Trauma survivors often oscillate between Sympathetic (Rage/Panic) and Dorsal Vagal (Numbing/Dissociation).
  • Goal: Return to Ventral Vagal safety.
  • Therapies: Yoga, Body-Work, Somatic Experiencing (Peter Levine).

Veterans

  • High rates of homelessness (Avoidance of authority/crowds).
  • Substance misuse (self-medication).
  • "Moral Injury": The psychological distress from actions that violate one's moral code (e.g., killing civilians). Distinct from PTSD.

Domestic Violence Survivors

  • "Battered Woman Syndrome" (Learned Helplessness).
  • Legal defence in murder cases? (Provocation vs Self-defence).

12. Paediatric PTSD

Presentation in Children

  • Pre-school: Re-enacting trauma in play (repetitive). Nightmares (without content). Regression (bed wetting).
  • School Age: "Omen formation" (belief they can predict bad things).
  • Adolescents: Acting out, substance use, self-harm.

Management

  • Trauma-Focused CBT.
  • Play Therapy.
  • Family Therapy: Address parental trauma too.

13. References (High-Yield List)

  1. NICE NG116 (2018). Post-traumatic stress disorder.
  2. Shalev A et al. Post-traumatic stress disorder. N Engl J Med. 2017.
  3. Herman JL. Complex PTSD: A syndrome in survivors of prolonged and repeated trauma. J Trauma Stress. 1992.
  4. Kessler RC et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders. Arch Gen Psychiatry. 2005.
  5. Van der Kolk BA. The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. 2014. (Seminal text).
  6. Porges SW. The Polyvagal Theory: Neurophysiological Foundations of Emotions... 2011.
  7. Foa EB et al. Prolonged exposure therapy for PTSD. 2007.
  8. Resick PA et al. Cognitive processing therapy for PTSD. 2016.
  9. Litz BT et al. Moral injury and moral repair in war veterans. Clin Psychol Rev. 2009.
  10. Brewin CR et al. A memory model of posttraumatic stress disorder. Psychol Rev. 2010.

14. Examination Focus (Monster Mode)

Common Exam Questions

  1. "Duration for PTSD vs Acute Stress?" → 1 month cut-off.
  2. "First line treatment?" → TF-CBT or EMDR.
  3. "Drug for nightmares?" → Prazosin.
  4. "CPTSD Triad?" → Dysregulation, Negative Self, Relationship problems.

"Do Not Miss" Red Flags

  1. Dissociative Identity Disorder: If severe early childhood abuse.
  2. Substance Misuse: Always screen.
  3. Suicide Risk: Very high, especially in "anniversary" periods.

Examiners' Pearls

  • Debriefing: Single session debriefing immediately after trauma is NOT recommended (can increase PTSD risk). "Watchful Waiting" for 4 weeks is better.
  • Cortisol: Paradoxically LOW in chronic PTSD (burned out HPA axis).

Medical Reviewer: Dr. P. Psych, Consultant Psychiatrist (Jan 2026) Last Updated: 2026-01-04