Post-Traumatic Stress Disorder (PTSD) & Other Trauma-related Disorders

Post-traumatic stress disorder (PTSD) is a condition marked by increased stress and anxiety following a traumatic or stressful event. A diagnosis of PTSD can apply to adults, adolescents and children. A person can be diagnosed with PTSD if exposed to actual or threatened death, serious injury or sexual violence in one or more of the following ways:

• Directly experiencing the traumatic event(s).
• Witnessing, in person, the event(s) occur to others.
• Learning that a violent or accidental traumatic event(s) occurred to a close family member or close friend.
• Experiencing repeated or extreme exposure to adverse details of the traumatic event (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse).
• Duration of symptoms more than 1 month

Epidemiology of PTSD

• About 8 percent of the general population is estimated to have PTSD. An additional 5 to 15 percent may experience partial symptoms of PTSD.
• The lifetime incidence of PTSD is estimated to be 9 to 15 percent. In women, the lifetime prevalence rate is 10 percent, versus 4 percent in men.
• An estimated 30 percent of men develop full-blown PTSD after serving in war, and an additional 22.5 percent develop most symptoms of PTSD.

Symptoms of PTSD

• A diagnosis of PTSD requires the presence of one or more of the following symptoms for more than 1 month:
• Recurrent, involuntary and intrusive distressing memories of the traumatic event(s).
• Recurrent distressing dreams related to the traumatic event(s).
  Flashbacks in which the individual feels or acts as if the traumatic event(s) is recurring. (Children may reenact trauma-specific events).
• Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
• Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

In addition, a diagnosis of PTSD requires that the affected individual demonstrates the following traits for more than 1 month:

• Avoidance of distressing memories, thoughts or feelings closely associated with the traumatic event(s).
• Avoidance of people, places, objects and situations that arouse distressing memories, thoughts or feelings closely associated with the traumatic event(s).
• Negative thoughts and mood associated with the traumatic event(s), beginning or worsening after the event(s), as evidenced by two or more of the following:
  o Inability to remember an important aspect of the traumatic event(s).
  o Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I’m a bad person,” “No one can be trusted,” The world is completely dangerous,” “My whole nervous system is permanently ruined”).
  o Persistent, distorted thoughts about the cause of consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.
  o A persistent negative emotional state, such as fear, horror, anger, guilt or shame.
  o Markedly diminished interest or participation in significant activities.
  o Feelings of detachment or estrangement from others.
  o Persistent inability to experience positive emotions, such as happiness, satisfaction or loving feelings.
• Marked changes in behavior beginning or worsening after the traumatic event(s), as evidenced by two or more of the following:
  o Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.
  o Reckless or self-destructive behavior.
  o Hypervigilance.
  o Exaggerated startle response.
  o Problems with concentration.
  o Sleep disturbance, such as restlessness or difficulty falling/staying asleep.

Effective treatments for PTSD include both psychotherapy and pharmacotherapy.

Psychotherapy
Psychotherapeutic approaches for patients with PTSD include behavior therapy, cognitive therapy, hypnosis, and eye movement desensitization and reprocessing (EMDR). In addition to individual therapy, group therapy and family therapy can be effective approaches. Group therapy offers the advantages of sharing of traumatic experiences and support from other group members. Family therapy often helps sustain a marriage or partnership through periods of exacerbated symptoms.

Pharmacotherapy
Selective serotonin reuptake inhibitors (SSRIs) such as sertraline (Zoloft) and paroxetine (Paxil) reduce symptoms from all PTSD symptoms and are considered first-line treatments for PTSD. Other drugs shown to be effective include tricyclic drugs imipramine (Tofranil) and amitriptyline (Elavil). Other drugs that may be useful in the treatment of PTSD include monoamine oxidase inhibitors (MAOIs) and anticonvulsants.

Yes. Approximately two-thirds of individuals with PTSD have at least two other mental health disorders. Common comorbid conditions include depressive disorders, substance-related disorders, anxiety disorders, and bipolar disorders. These disorders make people more vulnerable to develop PTSD.

Like post-traumatic stress disorder (PTSD), acute stress disorder is a condition marked by increased stress and anxiety following a traumatic or stressful event. A person can be diagnosed with acute stress disorder if exposed to actual or threatened death, serious injury or sexual violence in one or more of the following ways:

• Directly experiencing the traumatic event(s).
• Witnessing, in person, the event(s) occur to others.
• Learning that a violent or accidental traumatic event(s) occurred to a close family member or close friend.
• Experiencing repeated or extreme exposure to adverse details of the traumatic event (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse).
• Duration of symptoms less than 1 month.

Symptoms of Acute Stress Disorder

A diagnosis of acute stress disorder requires significant distress or impairment in social, occupational, or other important areas of functioning for at least 3 days and up to one month. Symptoms are required in nine or more of the following five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic event(s) occurred.

Intrusion Symptoms

• Recurrent, involuntary and intrusive distressing memories of the traumatic event(s). (In children, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.)
• Recurrent distressing dreams related to the event(s). (In children, there may be frightening dreams without recognizable content).
   Flashbacks in which the individual feels or acts as if the traumatic event(s) are recurring.
• Intense or prolonged psychologic distressed or marked physiological reactions in response to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
• Negative Mood
• Persistent inability to experience positive emotions, such as happiness, satisfaction, or loving feelings.

Dissociative Symptoms

• An altered sense of the reality of one’s surroundings or oneself.
   Inability to remember an important aspect of the traumatic event(s).

Avoidance Symptoms

• Avoidance of distressing memories, thoughts or feelings closely associated with the traumatic event(s).
• Avoidance of people, places, objects and situations that arouse distressing memories, thoughts or feelings closely associated with the traumatic event.

Arousal Symptoms

• Sleep disturbance, such as restlessness or difficulty falling/staying asleep.
• Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects
• Hypervigilance
• Problems with concentration
• Exaggerated startle response

Yes. A diagnosis of “unspecified trauma- or stress-related disorder” is used for patients who have symptoms in response to an identifiable stressor but do not meet the full criteria of any specified trauma- or stressor-related disorder (e.g., acute stress disorder, PTSD, or adjustment disorder). For example, their symptoms may occur more than 3 months after the stressor, or their symptoms may last longer than 6 months. The symptoms cannot meet the criteria for another mental or medical disorder, and cannot be attributed to the physiological effects of a substance.

An adjustment disorder is a depressive or anxious condition resulting from an emotional response to a stressful event. Typically, the stressor involves financial issues, a medical illness, or relationship problem. For a diagnosis of adjustment disorder, symptoms must begin within 3 months of the stressor.
Symptoms of an adjustment disorder include one or both of the following:

•  Marked distress that is out of proportion to the severity or intensity of the stressor, taking into account the context and cultural factors that may affect symptom severity.
• Significant impairment in social, occupation, or other important areas of functioning.
  Once the stressor or its consequences have ended, the symptoms do not persist beyond 6 more months.

Psychotherapy remains the treatment of choice for adjustment disorders. Individual psychotherapy offers patients the opportunity to explore the meaning of the stressor so that earlier traumas can be worked through. After successful therapy, patients sometimes emerge from an adjustment disorder stronger than before. Group therapy can be helpful for patients who share the same types of issues.

Reactive attachment disorder is a condition demonstrated by children between the ages of 9 months and 5 years who show a consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers. The child rarely or minimally either seeks comfort or responds to comfort when distressed.
A diagnosis of reactive attachment disorder is characterized by at least two of the following symptoms:

• Minimal social and emotional responsiveness to others.
• A limited positive demeanor.
• Episodes of unexplained irritability, sadness or fearfulness during nonthreatening interactions with adult caregivers.

In addition, the child has experienced a pattern of insufficient care as evidenced by at least one of the following:

• Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation and affection met by caregiving adults.
• Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care).
• Growing up in unusual settings that severely limit opportunities to form close relationships with adults (e.g., institutions with high child-to-caregiver ratios).
  The pattern of insufficient care is presumed to be responsible for the inhibited or withdrawn behavior toward adult caregivers.

Disinhibited social engagement disorder is a pattern of behavior in which a child approaches and interacts with unfamiliar adults and demonstrates at least two of the following:       

• Little or no shyness in approaching and interacting with unfamiliar adults  
• Overly familiar verbal or physical behavior that is not consistent with cultural and age-appropriate social boundaries.
• Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings.
• Willingness to go off with an unfamiliar adult with minimal or no hesitation.
  The child has experienced a pattern of insufficient care as evidenced by at least one of the following:
• Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation and affection met by caregiving adults.
• Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care).
• Growing up in unusual settings that severely limit opportunities to form close relationships with adults (e.g., institutions with high child-t-caregiver ratios).