Merck Manual

Please confirm that you are a health care professional

honeypot link

Posttraumatic Stress Disorder (PTSD)

By

John W. Barnhill

, MD, New York-Presbyterian Hospital

Reviewed/Revised Aug 2023
View PATIENT EDUCATION
Topic Resources

Posttraumatic stress disorder (PTSD) is a disabling disorder that develops after exposure to a traumatic event. It is characterized by intrusive thoughts, nightmares, and flashbacks; avoidance of reminders of the trauma; negative cognitions and mood; hypervigilance and sleep disturbance. Diagnosis is based on clinical criteria. Treatment includes psychotherapy and sometimes adjunctive pharmacologic therapy.

Combat, sexual assault, and natural or man-made disasters are common causes of PTSD. PTSD can lead to serious social, occupational, and interpersonal dysfunction.

While acute stress disorder (ASD) Acute Stress Disorder (ASD) Acute stress disorder is a brief period of intrusive recollections occurring within 4 weeks of witnessing or experiencing an overwhelming traumatic event. Diagnosis is based on clinical criteria... read more can only be diagnosed within the first month after a trauma, PTSD can only be diagnosed at least 1 month after the trauma. ASD can develop directly into PTSD, or PTSD can develop months or even years after the trauma without preceding problems being obvious.

General reference

  • 1. Goldstein RB, Smith SM, Chou SP, et al: The epidemiology of DSM-5 posttraumatic stress disorder in the United States: Results from the National Epidemiologic Survey on Alcohol and Related Conditions-III. Soc Psychiatry Psychiatr Epidemiol 51(8):1137-1148, 2016. doi: 10.1007/s00127-016-1208-5

Symptoms and Signs of PTSD

Symptoms of PTSD can be subdivided into 4 categories:

  • Intrusions

  • Avoidance

  • Negative alterations in cognition and mood

  • Alterations in arousal and reactivity

Overview of Posttraumatic Stress Disorder
VIDEO

Intrusions: Intrusions are unwanted memories or nightmares that replay the triggering event. Intrusions can take the form of "flashbacks," which can be triggered by sights, sounds, smells, or other stimuli. For example, a loud noise might trigger the memory of an assault, leading the person to throw himself to the ground in a panic.

Avoidance: People with PTSD might avoid reminders of the trauma, such as particular parts of town or previously favorite activities.

Negative alterations in cognition and mood: Cognitive and mood changes include disinterest and detachment, distorted cognitions, anhedonia, inappropriate self-blame, and depression.

Alterations in arousal and reactivity: People with PTSD can demonstrate excessive arousal, irritability, and reactivity, or they may seem numb and distant.

A dissociative subtype of PTSD Dissociative Subtype of Posttraumatic Stress Disorder The diagnosis of dissociative subtype of posttraumatic stress disorder (PTSD) is made in patients who meet all the diagnostic criteria for PTSD and also experience persistent or recurrent dissociative... read more has been recognized. This includes all of the symptoms mentioned above, plus depersonalization (feeling detached from one's self or body) and/or derealization (experiencing the world as unreal or dreamlike).

Diagnosis of PTSD

  • Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, Text Revision (DSM-5-TR) criteria

To meet DSM-5-TR criteria for diagnosis of PTSD, 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 (1 Diagnosis reference Posttraumatic stress disorder (PTSD) is a disabling disorder that develops after exposure to a traumatic event. It is characterized by intrusive thoughts, nightmares, and flashbacks; avoidance... read more ).

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 psychological 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):

  • Avoiding thoughts, feelings, or memories associated with the event

  • Avoiding activities, places, conversations, or people that trigger memories of the event

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):

  • Difficulty sleeping

  • Irritability or angry outbursts

  • Reckless or self-destructive behavior

  • Problems with concentration

  • Increased startle response

  • Hypervigilance

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.

The dissociative subtype of PTSD is diagnosed when, in addition to all of the symptoms mentioned above, there is evidence of depersonalization (feeling detached from one's self or body) and/or derealization (experiencing the world as unreal or dreamlike).

Diagnosis reference

  • 1. Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision (DSM-5-TR). American Psychiatric Association Publishing, Washington, DC, pp 301-313.

Treatment of PTSD

Self-care

Self-care is crucial during and after a crisis or trauma. Self-care includes:

  • Personal safety

  • Physical health

  • Mindfulness

Personal safety is fundamental. After a trauma, people are better able to process the experience when they know that they and their loved ones are safe. It can be difficult, however, to gain complete safety during ongoing crises such as domestic abuse, war, or an infectious pandemic. During such ongoing difficulties, people should seek the guidance of experts on how they and their loved ones can be as safe as possible.

Physical health can be put at risk during and after traumatic experiences. As much as possible, the at-risk person should try to maintain a healthy schedule of eating, sleeping, and exercise. Substances and medications that sedate (eg, benzodiazepines) and intoxicate (eg, alcohol) should be used sparingly, if at all.

A mindful approach to self-care aims to reduce the stress, boredom, anger, sadness, and isolation that traumatized people typically experience. If circumstances allow, at-risk individuals should make and follow a normal daily schedule, remain involved with their family and community, and practice familiar hobbies (or develop new ones).

It is useful to limit the amount of time spent on news and instead shift to other activities (eg, read a novel, do a puzzle, paint a picture, make cookies for a housebound neighbor).

Psychotherapy

Trauma-focused cognitive-behavioral therapy (CBT) has the most robust evidence for efficacy for most people with PTSD (1 Treatment references Posttraumatic stress disorder (PTSD) is a disabling disorder that develops after exposure to a traumatic event. It is characterized by intrusive thoughts, nightmares, and flashbacks; avoidance... read more ). As for acute stress disorder (ASD), this form of psychotherapy includes patient education, cognitive restructuring, and therapeutic exposure to recollections of the traumatic experience. Cognitive processing therapy is a type of CBT that involves talking through the implications of traumatic experiences and putting negative thoughts about oneself and the traumatic experiences into perspective, seeing them as different from the actual trauma.

Prolonged exposure is another effective psychotherapy that involves addressing a series of traumatic memories while managing the psychophysiologic response to them with techniques such as controlled breathing, thereby gradually desensitizing the impact of the memories.

Eye movement desensitization and reprocessing (EMDR) is a form of exposure therapy that may also be used (2 Treatment references Posttraumatic stress disorder (PTSD) is a disabling disorder that develops after exposure to a traumatic event. It is characterized by intrusive thoughts, nightmares, and flashbacks; avoidance... read more ). For this therapy, patients are asked to follow the therapist's moving finger while they imagine being exposed to the trauma. While some experts think that the eye movements themselves help with desensitization, others attribute its efficacy mainly to the exposure rather than the eye movements.

Therapeutic style is important in the treatment of PTSD (3 Treatment references Posttraumatic stress disorder (PTSD) is a disabling disorder that develops after exposure to a traumatic event. It is characterized by intrusive thoughts, nightmares, and flashbacks; avoidance... read more ). Warmth, reassurance, and empathy are some of the nonspecific factors that may be unusually important when working with people suffering from such core PTSD symptoms as shame, avoidance, hypervigilance, and detachment.

Pharmacotherapy

Evidence for pharmacotherapy in PTSD is less robust than that for trauma-focused psychotherapy (4 Treatment references Posttraumatic stress disorder (PTSD) is a disabling disorder that develops after exposure to a traumatic event. It is characterized by intrusive thoughts, nightmares, and flashbacks; avoidance... read more ). Most often, medications are used to treat co-existing psychiatric disorders, or especially prominent PTSD symptoms, such as depression or anxiety.

Treatment references

  • 1. Bisson J, Andrew M: Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database Syst Rev  (3):CD003388, 2007. doi: 10.1002/14651858.CD003388.pub3

  • 2. Wilson G, Farrell D, Barron I, et al: The use of eye-movement desensitization reprocessing (EMDR) therapy in treating post-traumatic stress disorder—A systematic narrative review. Front Psychol;9:923, 2018. doi: 10.3389/fpsyg.2018.00923

  • 3. Howard R, Berry K, Haddock G: Therapeutic alliance in psychological therapy for posttraumatic stress disorder: A systematic review and meta-analysis. Clin Psychol Psychother 29(2):373-399, 2022. doi: 10.1002/cpp.2642

  • 4. Wright LA, Sijbrandij M, Sinnerton R, et al: Pharmacological prevention and early treatment of post-traumatic stress disorder and acute stress disorder: A systematic review and meta-analysis. Transl Psychiatry 9(1):334, 2019. doi: 10.1038/s41398-019-0673-5

  • 5. Stein DJ, Ipser JC, Seedat S: Pharmacotherapy for post traumatic stress disorder (PTSD). Cochrane Database Syst Rev 22006(1):CD002795, 2006. doi: 10.1002/14651858.CD002795.pub2

  • 6. Khachatryan D, Groll D, Booij L: Prazosin for treating sleep disturbances in adults with posttraumatic stress disorder: a systematic review and meta-analysis of randomized controlled trials. Gen Hosp Psychiatry 39:46-52, 2016. doi: 10.1016/j.genhosppsych.2015.10.007

  • 7. Krediet E, Bostoen T, Breeksema J, et al: Reviewing the potential of psychedelics for the treatment of PTSD. Int J Neuropsychopharmacol. 23(6):385-400, 2020. doi: 10.1093/ijnp/pyaa018

Drugs Mentioned In This Article

Drug Name Select Trade
Minipress
Depacon, Depakene, Depakote, Depakote ER, Stavzor
Abilify, Abilify Asimtufii, Abilify Discmelt, Abilify Maintena, Abilify Mycite, Aristada
Ketalar
View PATIENT EDUCATION
NOTE: This is the Professional Version. CONSUMERS: View Consumer Version
quiz link

Test your knowledge

Take a Quiz! 
iOS ANDROID
iOS ANDROID
iOS ANDROID
TOP