Post-traumatic Stress Disorder (PTSD) in Adults

Therefore, PTSD should be diagnosed only when the individual experiences impairment or distress associated with the following symptoms in the aftermath of the traumatic experience:

• Intrusions, including recurrent, involuntary, distressing memories or dreams related to the traumatic event, flashbacks in which the individual feels or acts like the traumatic event is reoccurring,  intense or prolonged emotional distress in response to reminders of the traumatic event, or strong physiological reactions to reminders of the traumatic event.
• Avoidance of reminders of the traumatic event, including avoiding distressing thoughts, feelings, or memories related to the traumatic event, or avoidance of external situations (e.g., people; places) that are associated with the traumatic event.
• Negative changes in thoughts or moods following the traumatic event, including at least two of the following:
• Amnesia for important parts of the traumatic event (not explained by use of substances or head injury sustained during the trauma)
• Exaggerated and persistent negative views of oneself, others, or the world (e.g., “I can’t trust anyone,” “I’m damaged,” “the world is a dangerous and scary place”)
• Persistent and distorted blaming of oneself or others for the trauma
• Persistent negative emotional state (e.g., persistent fear, shame, or anger)
• Significant loss of interest or reduced participation in significant activities
• Feeling detached from other people
• Persistent inability to experience positive emotions (e.g., happiness, satisfaction, or love)
• Changes in autonomic arousal or reactivity following the traumatic event, including at least two of the following:
• Irritability or angry outbursts
• Reckless, impulsive, or self-destructive behavior
• Hypervigilance
• Exaggerated startle response
• Impaired concentration
• Sleep disturbances (e.g., difficulty falling asleep; disrupted sleep)

Many of these symptoms are normal responses to traumatic events, and will remit over time.  Therefore, PTSD is diagnosed only when the symptoms last one month or longer and lead to clinically significant distress or impairment.  Symptoms do not need to occur immediately following the trauma for a PTSD diagnosis to be warranted.  Some individuals experience a delayed onset of PTSD, in which symptoms do not begin until weeks, months, or longer following the trauma.  The specifier “with delayed onset” is applied when symptoms do not reach full diagnostic criteria until 6 months after the trauma.

PTSD may also be specified as occurring “with dissociative symptoms.”  Dissociative symptoms can include depersonalization, in which the person feels detached from him or herself or as though he or she is “out of body” in some way, or derealization, in which the person experiences his or her surroundings as dreamlike or unreal in some way.

Comorbidity of PTSD with substance use disorders has been explained in terms of self-medication (i.e., individuals use substances to medicate painful PTSD symptoms), although withdrawal states may exacerbate PTSD symptoms.

PTSD is characterized by abnormalities of brain function which are thought to contribute to symptoms.  In particular, evidence points to abnormalities in neuroendocrine systems (in particular the hypothalamic-pituitary-adrenal and hypothalamic-pituitary-thyroid axes), neurotransmitter systems (in particular norepinephrine, serotonin, and corticotropin-releasing factor), and certain brain regions (in particular the amygdala and hippocampus) that are thought to underlie hyperarousal and other symptoms associated with PTSD.  In addition, avoidance of trauma-related cues is thought to contribute to the persistence of PTSD by preventing fear extinction and new learning.  Similarly, avoidance of trauma-related memories is thought to exacerbate the frequency and intensity of those memories.  The disorder is thought to have a genetic component, although having a genetic predisposition to PTSD does not necessarily mean that someone will develop PTSD.

First Line Treatments

• Cognitive-behavioral therapy consists of gradually exposing the person to feared thoughts, situations, and activities, and helping the person to develop more accurate and helpful thoughts about him or herself, the trauma, and other people.  Specific cognitive-behavioral therapies with a high degree of research support include Prolonged Exposure, Cognitive Processing Therapy, Present-Centered Therapy, and Seeking Safety (for PTSD with comorbid substance use disorders).
• Antidepressant medications, specifically selective serotonin reuptake inhibitors (SSRIs), which are thought to help by improving the amount of serotonin in the brain.  Of note, some studies suggest that SSRIs may not be as effective as originally believed for veterans with combat-related PTSD. Nevertheless, SSRIs remain the first-line medication treatment for PTSD of all origins. Specific first-line medications for PTSD include:
• Fluoxetine
• Sertraline
• Paroxetine
• Fluvoxamine

For more information about drug prescribing in PTSD, click here.

Additional Treatments to Consider

In cases of nonresponse to first-line treatment, clinical research suggests that the following treatments are effective:

• Other medication strategies, specifically:

• Other antidepressant medications, specifically venlafaxine, amitriptyline, imipramine, nefazodone, mirtazapine, and phenelzine

• The beta-blocker propranolol

• The alpha-adrenergic antagonist prazosin, which specifically targets trauma-related sleep disruption and nightmares

• Atypical antipsychotic medications, specifically olanzapine, quetiapine, and risperidone

• Stress inoculation training, a form of cognitive-behavioral therapy in which the patient learns strategies for relaxation and managing stress

• Eye movement desensitization and reprocessing, a variation of cognitive-behavioral therapy that pairs imagery with back-and-forth eye movements (many researchers have questioned the additional value of this component)

In addition, research suggests that the following treatments are promising:

• Mood stabilizers, specifically lamotrigine and topiramate

• Acupuncture
• Meditation- or mindfulness-based treatments, including mindfulness-based stress reduction
• Aerobic exercise
• Hypnotherapy
• Psychodynamic therapy
• D-cycloserine augmentation of CBT