Posttraumatic Stress Disorder (PTSD)
When terrible things happen, many people are lastingly affected; in some, the effects are so persistent and severe that they are debilitating and constitute a disorder. Generally, events likely to evoke PTSD are those that invoke feelings of fear, helplessness, or horror. These events may be experienced directly (eg, as a serious injury or the threat of death) or indirectly (eg, witnessing others being seriously injured, killed, or threatened with death; learning of events that occurred to close family members or friends). Combat, sexual assault, and natural or man-made disasters are common causes of PTSD.
Lifetime prevalence approaches 9%, with a 12-month prevalence of about 4%.
Symptoms of PTSD can be subdivided into categories: intrusions, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity. Most commonly, patients have frequent, unwanted memories replaying the triggering event. Nightmares of the event are common.
Less common are transient waking dissociative states in which events are relived as if happening (flashback), sometimes causing patients to react as if in the original situation (eg, loud noises such as fireworks might trigger a flashback of being in combat, which in turn might cause patients to seek shelter or prostrate themselves on the ground for protection).
Patients avoid stimuli associated with the trauma and often feel emotionally numb and disinterested in daily activities.
Sometimes symptoms represent a continuation of acute stress disorder, or they may occur separately, beginning up to 6 months after the trauma. Sometimes full expression of symptoms is delayed, occurring many months or even years after the traumatic event.
Depression, other anxiety disorders, and substance use are common among patients with chronic PTSD.
In addition to trauma-specific anxiety, patients may experience guilt because of their actions during the event or because they survived when others did not.
Diagnosis is clinical based on criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).
To meet the criteria for diagnosis, patients must have been exposed directly or indirectly to a traumatic event and have symptoms from each of the following categories for a period ≥ 1 month.
Intrusion symptoms (≥ 1 of the following):
Having recurrent, involuntary, intrusive, disturbing memories
Having recurrent disturbing dreams (eg, nightmares) of the event
Acting or feeling as if the event were happening again, ranging from having flashbacks to completely losing awareness of the present surroundings
Feeling intense psychologic or physiologic distress when reminded of the event (eg, by its anniversary, by sounds similar to those heard during the event)
Avoidance symptoms (≥ 1 of the following):
Negative effects on cognition and mood (≥ 2 of the following):
Memory loss for significant parts of the event (dissociative amnesia)
Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world
Persistent distorted thoughts about the cause or consequences of the trauma that lead to blaming self or others
Persistent negative emotional state (eg, fear, horror, anger, guilt, shame)
Markedly diminished interest or participation in significant activities
A feeling of detachment or estrangement from others
Persistent inability to experience positive emotions (eg, happiness, satisfaction, loving feelings)
Altered arousal and reactivity (≥ 2 of the following):
In addition, manifestations must cause significant distress or significantly impair social or occupational functioning and not be attributable to the physiologic effects of a substance use or another medical disorder.
A wide variety of psychotherapies have been successfully used to treat posttraumatic stress disorder (PTSD). SSRI or other drug therapy is often used as well.
If untreated, chronic PTSD often diminishes in severity without disappearing, but some people remain severely impaired.
The primary form of psychotherapy used, exposure therapy, involves exposure to situations that the person avoids because they may trigger recollections of the trauma. Repeated exposure in fantasy to the traumatic experience itself usually lessens distress after some initial increase in discomfort.
Eye movement desensitization and reprocessing (EMDR) is a form of exposure therapy. For this therapy, patients are asked to follow the therapist's moving finger while they imagine being exposed to the trauma.
Stopping certain ritual behaviors, such as excessive washing to feel clean after a sexual assault, also helps.
SSRIs may reduce anxiety and/or depression. Prazosin appears helpful in reducing nightmares. Mood stabilizers and atypical antipsychotics are sometimes prescribed, but support for their use is scant.
Because the anxiety is often intense, supportive psychotherapy plays an important role. Therapists must be openly empathic and sympathetic, recognizing and acknowledging patients’ mental pain and the reality of the traumatic events. Early in treatment, many patients need to learn ways to relax and control anxiety (eg, mindfulness, breathing exercises, yoga) before they can tolerate the exposure that tends to be a focus of PTSD treatment.
For survivor guilt, psychotherapy aimed at helping patients understand and modify their self-critical and punitive attitudes may be helpful.