Post-Traumatic Stress Disorder (PTSD) is a mental health condition that develops after exposure to trauma. This trauma can range from violence, injury, and death (such as in war) to sexual assault, the threat of injury, natural disasters, and childhood abuse. It is estimated that up to 80 percent of people will experience a traumatic event in their lives, and between 5 and 10 percent of these will develop PTSD.
Signs and Symptoms
The signs and symptoms of PTSD are divided into several categories, which also make up the diagnostic criteria.
- Stressor: The traumatic event itself, which can be experienced directly by the patient, witnessed, or indirectly through exposure to details (e.g., police work) or learning that a loved one experienced the trauma.
- Intrusive Symptoms:
- Recurrent, distressing thoughts related to the trauma.
- Nightmares.
- Dissociative reactions (e.g., flashbacks) with a lack of awareness of surroundings.
- Intense distress and physical manifestations like tachycardia and hypertension when exposed to reminders of the trauma.
- Avoidance: Avoiding stimuli related to the trauma, such as people or places that serve as reminders.
- Mood and Cognitive Alterations:
- Inability to recall certain aspects of the trauma.
- Distorted sense of self or cognition, including self-blame.
- Common feelings of fear and guilt.
- Anhedonia, or a reduction in activities that were previously enjoyable.
- Reactivity:
- Aggressive behavior with little to no trigger.
- Hypervigilance.
- Difficulty concentrating or sleeping.
- Reckless behavior.
Diagnosis
According to the DSM-5, for a PTSD diagnosis:
- The trauma criteria must be met.
- One or more intrusive symptoms.
- Avoidance symptoms.
- Two or more negative alterations in mood.
- Two or more alterations in arousal and reactivity.
Symptoms must be present for more than one month, cause impairment in social, school, or occupational life, and not be attributable to substances or other medical conditions. If symptoms last less than one month, it is defined as acute stress disorder. Complex PTSD, seen in patients exposed to prolonged trauma, includes additional symptoms such as emotional dysregulation and a disturbed sense of identity.
Causes
The exact cause of PTSD is not clear but involves changes in neurotransmitters and hormones, particularly disturbances in the hypothalamic-pituitary-adrenal (HPA) axis and adrenergic systems. Normally, corticotropin-releasing hormone (CRH) is released from the hypothalamus, stimulating the release of adrenocorticotropic hormone (ACTH) from the pituitary gland, which then causes cortisol release from the adrenal glands. Cortisol acts systemically and suppresses CRH and ACTH via negative feedback. In PTSD, cortisol levels are low while CRH levels remain high, leading to increased noradrenaline and a heightened sympathetic nervous system response. This response can manifest as tachycardia, hypertension, increased startle response, and arousal. Some studies also report reduced GABA activity and increased glutamate activity, linked to dissociation and derealization.
Risk Factors
PTSD risk factors include:
- Gender (higher in females).
- Pre-existing mental illnesses (e.g., anxiety, depression).
- Childhood adversities.
- Lack of social support.
- Type and severity of trauma (e.g., assault-based traumas).
- Environmental factors (e.g., healthcare workers frequently exposed to secondary trauma).
Treatment
Early treatment following trauma exposure is associated with better outcomes. The first-line therapy for PTSD is psychotherapy, particularly Cognitive Behavioral Therapy (CBT), which is effective in 60 to 80 percent of cases. CBT helps adjust negative thoughts, feelings, and behaviors that prevent patients from enjoying a good quality of life. Another option is Eye Movement Desensitization and Reprocessing (EMDR), involving eye movements and audio tones to help process traumatic memories.
Medications are also useful:
- Antidepressants: Selective serotonin reuptake inhibitors (SSRIs) like paroxetine and sertraline, or serotonin and norepinephrine reuptake inhibitors (SNRIs) like venlafaxine.
- Anxiolytics: Clonidine, an alpha agonist, reduces trauma-related nightmares. Trazodone or promethazine can help with insomnia.
- Antipsychotics: Some studies show better outcomes when antipsychotics like risperidone are added to antidepressant therapy.