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, primarily trauma-focused cognitive-behavioral therapy, and sometimes adjunctive pharmacologic therapy.
In the United States, lifetime prevalence of PTSD is estimated at 6 to 7%, with a 12-month prevalence of approximately 5% (1, 2). Estimates for other countries vary widely, with lifetime prevalence ranging from 1 to 12% (3).
Traumatic events that lead to PTSD typically threaten death or injury. 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 can only be diagnosed when it occurs within the first month after a trauma, PTSD can only be diagnosed at least 1 month after the trauma. Acute stress disorder can develop directly into PTSD, or PTSD can develop months or even years after the trauma without preceding problems being obvious.
General references
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
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed, Text Revision. American Psychiatric Association Publishing; 2022.
3. Shalev A, Liberzon I, Marmar C. Post-Traumatic Stress Disorder. N Engl J Med. 2017;376(25):2459-2469. doi:10.1056/NEJMra1612499
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
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.
Sometimes PTSD patients also develop ritual activities to reduce anxiety, and many self-medicate with alcohol or drugs. Up to 60% of people with PTSD develop a substance use disorder (1).
Symptoms and signs reference
1. Back SE, Jarnecke AM, Norman SB, Zaur AJ, Hien DA. State of the Science: Treatment of comorbid posttraumatic stress disorder and substance use disorders. J Trauma Stress. 2024;37(6):803-813. doi:10.1002/jts.23049
Diagnosis of PTSD
Psychiatric assessment
To meet the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision (DSM-5-TR) criteria for 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):
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 and/or significantly impair social or occupational functioning and not be attributable to the physiologic effects of a substance use or another general medical disorder.
PTSD with dissociative symptoms is diagnosed when, in addition to the symptoms of PTSD, there is evidence of depersonalization (feeling detached from one's self or body) and/or derealization (experiencing the world as unreal or dreamlike). Several other disorders can also involve the overlap of dissociative symptoms with response to trauma, including acute stress disorder with dissociative symptoms, dissociative amnesia, dissociative identity disorder, and complex PTSD (a form of PTSD arising from chronic or repeated trauma) (2).
PTSD is often overlooked. The trauma may not be obvious to the clinician, and the patient may avoid discussing painful memories. PTSD often includes a complex combination of cognitive, affective, behavioral, and somatic symptoms, and an accurate PTSD diagnosis can help the patient feel understood. PTSD often co-occurs with a variety of other diagnoses, including depressive, anxiety, and substance use disorders (3). Identification of all relevant diagnoses is an important component of developing a comprehensive treatment plan.
Diagnosis references
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed, Text Revision. American Psychiatric Association Publishing; 2022.
2. Maercker A, Cloitre M, Bachem R, et al. Complex post-traumatic stress disorder. Lancet. 2022;400(10345):60-72. doi:10.1016/S0140-6736(22)00821-2
2. Shalev A, Liberzon I, Marmar C. Post-Traumatic Stress Disorder. N Engl J Med. 2017;376(25):2459-2469. doi:10.1056/NEJMra1612499
Treatment of PTSD
Psychotherapy
Pharmacotherapy
Treatment of coexisting psychiatric disorders, including substance use disorders and major depression
Self-care
Self-care is crucial during and after a crisis or trauma. Self-care includes:
Personal safety
Physical health
Mindfulness
Maintenance of schedule and social engagement.
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 safety for themselves and their loved ones to the extent 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 mindfulness training (specifically, mindfulness-based stress reduction) has been shown to be beneficial to patients with PTSD (1, 2).
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). Some otherwise normal activities, however, can be counterproductive. For example, if following the news is likely to lead to reexperiencing the trauma, it is generally best to minimize that exposure.
Psychotherapy
Therapeutic style and rapport is important in the treatment of PTSD (3). 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.
Trauma-focused cognitive-behavioral therapy (CBT) has the most robust evidence for efficacy for most people with PTSD (4, 5). As is true for acute stress disorder, this form of psychotherapy includes the following components:
Patient education is an important initial step. Normalization and explanation of the stress response is often helpful, as is a reminder that symptoms should improve.
Cognitive restructuring helps correct maladaptive thoughts the patient might have about the trauma or personal response to the trauma.
Exposure to traumatic memories or safe reminders of traumatic experiences is an important—if difficult—part of the psychotherapy. Through reexperiencing, the patient is better able to emotionally process material that had previously been experienced as overwhelming.
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.
Relaxation and stress management techniques, including breathing, yoga, and meditation, can relieve symptoms and also prepare patients for treatment that involves stress-inducing exposure to memories of the trauma.
Eye movement desensitization and reprocessing (EMDR) is a form of exposure therapy that may also be used (6). 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.
Pharmacotherapy
Evidence for pharmacotherapy in PTSD is less robust than that for trauma-focused psychotherapy (7). Most often, medications are used to treat co-existing psychiatric disorders, or especially prominent PTSD symptoms, such as depression or anxiety.
Selective serotonin reuptake inhibitors (SSRIs) improve PTSD symptoms (8, 9). Prazosin appears helpful in reducing nightmares (). Prazosin appears helpful in reducing nightmares (9). A brief course of sedating medications can help with insomnia. Psychedelics (such as MDMA, ketamine, and psilocybin) are under study as well (). A brief course of sedating medications can help with insomnia. Psychedelics (such as MDMA, ketamine, and psilocybin) are under study as well (10).
(See Treatment of Acute Stress Disorder for a discussion of interventions immediately or shortly after the traumatic event.)
Treatment references
1. Wal A, Chellammal HSJ, Verma R, et al. The Role of Non-Pharmacological Interventions in Attenuating Anxiety and Stress Symptoms in PTSD: A Systematic Review.
2. Polusny MA, Erbes CR, Thuras P, et al. Mindfulness-Based Stress Reduction for Posttraumatic Stress Disorder Among Veterans: A Randomized Clinical Trial. JAMA. 2015;314(5):456-465. doi:10.1001/jama.2015.8361
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. Bisson JI, Roberts NP, Andrew M, Cooper R, Lewis C. Psychological therapies for chronic posttraumatic stress disorder (PTSD) in adults. Cochrane Database System Rev. 2013, Issue 12. Art. No.: CD003388. DOI: 10.1002/14651858.CD003388.pub4
5. Shalev A, Liberzon I, Marmar C. Post-Traumatic Stress Disorder. N Engl J Med. 2017;376(25):2459-2469. doi:10.1056/NEJMra1612499
6. 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
7. 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
8. Williams T, Phillips NJ, Stein DJ, Ipser JC. Pharmacotherapy for post traumatic stress disorder (PTSD). Cochrane Database Syst Rev. 2022, Issue 3. Art. No.: CD002795. DOI: 10.1002/14651858.CD002795.pub3.
9. 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. . 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
10. 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
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