What is Posttraumatic Stress Disorder?

Posttraumatic Stress Disorder (PTSD) is characterized primarily by exposure to one or more traumatic events*, followed by the development of a characteristic set of symptoms that include intrusive recollections, avoidance of stimuli that cause recollections, negative impacts on one’s mood and thought processes, heightened arousal and reactivity, and, in some cases, dissociation. In every case, however, the trauma causes significant interference with the individual’s daily functioning, including their ability to succeed at work, manage relationships, and enjoy leisurely activities. About 9% of the U.S population will meet criteria for PTSD at some point in their lives, and a larger percentage will experience subclinical symptoms that may still warrant attention and respond to intervention.

*Examples of traumatic events include:

  • Threatened or actual physical assault
  • Threatened or actual sexual violence
  • Exposure to war as a civilian or combatant, or being a prisoner of war
  • Being kidnapped or taken hostage
  • Terrorist attack
  • Torture
  • Natural or human-made disasters
  • Catastrophic medical events
  • Severe motor vehicle accidents
  • Witnessing traumatic events happening to others
  • Learning of violent or accidental traumatic events involving loved ones.

 

Posttraumatic Stress Disorder Symptoms

The essential feature of PTSD is exposure to one or more traumatic events, followed by a combination of the following symptoms:

Intrusion symptoms:

  • Reexperiencing the event, such as intrusive and unwanted recollections or dreams.
  • Feeling as if the event were recurring in the present moment.
  • Psychological or physical distress in response to reminders of the event.

Avoidance symptoms:

  • Efforts to avoid internal experiences, such as memories, thoughts, or feelings of the event.
  • Efforts to avoid external reminders of the event, such as people, places, objects, or activities.

Cognitive and mood symptoms:

  • Inability to remember important aspects of the trauma
  • Exaggerated negative beliefs about oneself, others, or the world, such as trusting no one.
  • Distorted beliefs about the cause of the trauma, such as blaming oneself.
  • Persistent, negative emotional state, such as fear, anger, guilt, shame, or horror.
  • Diminished interest in activity one used to enjoy.
  • Feeling detached or estranged from others.
  • Inability to experience positive emotions, such as happiness, joy, tenderness, or intimacy.

Arousal and reactivity symptoms:

  • Verbal or physical aggression with little or no provocation.
  • Reckless or self-destructive behavior, such as alcohol abuse or self-injury.
  • Hypervigilance to potential threats.
  • Exaggerated startle response.
  • Poor concentration.
  • Sleep disturbance.

Dissociative symptoms:

  • Depersonalization, a detached or unreal sense of one’s self or body.
  • Derealization, an experience of the world or one's surrounding as dreamlike, distant, or unreal.

 

How Posttraumatic Stress Disorder is Diagnosed

A PTSD diagnosis is typically based on a clinical interview with a psychologist or other mental health provider, and may be augmented by one or more assessment measures (such as the Clinician-Administered PTSD Scale [CAPS-5]). These assessment procedures help determine whether PTSD is present, how severe it may be, and whether any other conditions (e.g., depression, substance dependence) may be contributing to the individual’s distress. A formal diagnosis is assigned by comparing the results of the assessment to the diagnostic criteria for PTSD (see below). A valid diagnosis always involves the clinical judgment of a qualified mental health provider and cannot be determined by testing alone.

 

Impact of Posttraumatic Stress Disorder on Daily Life

PTSD is associated with high levels of social, occupational, interpersonal, and physical disability.  Not everyone experiences these symptoms in the same way. For some, feelings of fear may predominate, whereas in others depressive symptoms may be strongest. Likewise, in some, arousal and reactivity symptoms may predominate, whereas other may be more prone to dissociation. Still others may experience a combination of dominant symptoms. These symptoms, when left untreated, also put the individual at risk for other problems, such as another anxiety disorder, depression, drug or alcohol abuse, and suicide.

 

Posttraumatic Stress Disorder is Treatable

The most effective treatment option for PTSD is cognitive behavioral therapy (CBT), primarily cognitive therapy and exposure therapy. Cognitive therapy can help you learn to think differently about the trauma, and also how to cope more effectively with unpleasant feelings. Exposure therapy can help reduce the fear and distress associated with remembering the trauma.

In addition to cognitive and exposure approaches, CBT-based relaxation, mindfulness, and sleep hygiene procedures can be used to help people with PTSD cope with their treatment.

Medication has been shown to be an effective component of PTSD treatment. For example, selective serotonin reuptake inhibitors (SSRIs), a type of antidepressant medication, help some people with PTSD feel less sad and worried. Talk to your physician to determine whether medications are right for you.

 

What to do Next

If you think you may meet criteria for Posttraumatic Stress Disorder:

 

Posttraumatic Stress Disorder Diagnostic Criteria

DSM-5 Code: 309.81

ICD-10 Code: F43.10

Note: These criteria apply to adults, adolescents, and children older than 6 years.

A:  Exposure to actual or threatened death, serious injury, or sexual violence in one or more of the following ways:

  1. Directly experiencing the traumatic event(s).
  2. Witnessing, in person, the event(s) as it occurred to others.
  3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
  4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse).

Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.

B:  Presence of one or more of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:

  1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).

Note: in children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.

      2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).     

Note: In children, there may be frightening dreams without recognizable content.

      3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)

Note: In children, trauma-specific reenactment may occur in play.

      4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

      5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

C:  Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the event(s) occurred, as evidenced by one or both of the following:

  1. Avoidance of or efforts to avoid distressing memories thoughts, or feelings about or closely associated with the traumatic event(s).
  2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories thoughts or feelings about or closely associated with the traumatic event(s).

D:  Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two or more of the following:

  1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).
  2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” The world is completely dangerous,” “My whole nervous system is permanently ruined”).
  3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame themselves or others.
  4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
  5. Markedly diminished interest or participation in significant activities.
  6. Feelings of detachment or estrangement from others.
  7. Persistent inability to experience positive emotions (e.g., happiness, satisfaction, or loving feelings).

E:  Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two or more of the following:

  1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.
  2. Reckless of self-destructive behavior.
  3. Hypervigilance.
  4. Exaggerated startle response.
  5. Problems with concentration.
  6. Sleep disturbance (e.g., difficulty falling asleep, or staying asleep, or restless sleep)

F:  Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.

G:  The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

H: The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

Specify whether:

With dissociative symptoms: The individual’s symptoms meet the criteria for posttraumatic stress disorder, and in addition, in response to the stressor, the individual experiences persistent or recurrent symptoms of either of the following:

  1. Depersonalization: Persistent or recurrent experiences of feeling detached from, and if one were an outside observer of, one’s mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly).
  2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted).

Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g., blackouts, behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures).

Specify if:

With delayed expression: If the full criteria are not met at least 6 months after the event (although the onset and expression of some symptoms may be immediate).