Posttraumatic Stress Disorder (PTSD)

BASICS

Definition: Psychiatric disorder after experiencing or witnessing traumatic events (death, sexual violence, serious injury, or threat thereof).
Core Symptom Clusters: (≥1 month for diagnosis)
Intrusion: Flashbacks, nightmares, distressing recollections
Avoidance/Numbing: Avoid trauma reminders; emotional detachment
Negative Alterations in Mood/Cognition: Amnesia, negative beliefs, detachment, inability to experience positive emotions
Increased Arousal/Reactivity: Sleep disturbance, irritability, hypervigilance, concentration issues, self-destructive behavior

Biological: Catecholamine hypersensitivity, opioid pathway overactivity, amygdala/hippocampus dysfunction, serotonergic & glutamatergic dysregulation
Learning Theory: Trauma cues → conditioned fear response (“fight-or-flight”)
Cognitive/Psychodynamic: Persistent trauma memories overwhelm defenses, drive repeated recall

Pre-existing: Female sex, young age, psychiatric history, low SES
Peritrauma: Severe trauma, intense emotional response, threat perception
Posttrauma: Injury severity, complications, poor social support, persistent dissociation, further trauma exposure

Trauma-focused CBT and prolonged exposure (delivered within weeks after trauma) best supported for prevention in distressed individuals.

Adults: Depression, substance abuse, panic/social phobias, OCD, dementia, smoking (esp. after assault)
Pediatrics: Oppositional defiant disorder, separation anxiety

A: Trauma exposure (direct, witnessed, learned about close other, or repeated exposure to details)
B: Intrusion (≥1 symptom)
C: Avoidance (≥1)
D: Negative mood/cognition (≥2)
E: Hyperarousal (≥2)
F: Duration >1 month
G: Clinically significant distress/functional impairment
H: Not due to substance or medical illness

Separation fears, regressive behaviors, somatic complaints, school avoidance, nightmares, irritability

Symptoms: Intrusion, avoidance, mood/cognition changes, hyperarousal (>1 month)
Exam: May see agitation, poor hygiene, altered affect, memory/concentration deficits, poor impulse control, somatic injury from trauma
Pediatrics: Heart rate elevation after trauma may predict PTSD

GAD, adjustment disorder, OCD, schizophrenia, depression/mood disorder, substance abuse, dissociative/personality disorders, malingering

SNRIs: Venlafaxine, duloxetine, desvenlafaxine
Mirtazapine: 15–45 mg/day
Antipsychotics: Aripiprazole, risperidone, olanzapine, quetiapine (for intrusive thoughts, hyperarousal)
Alpha-agonists: Clonidine, guanfacine (hyperarousal)
Mood stabilizers: Valproic acid, carbamazepine, topiramate (impulsivity)
Anxiety: Hydroxyzine or (rarely) risperidone PRN (avoid benzodiazepines)

Long-term therapy: May be needed, especially in complex PTSD/childhood sexual abuse.
Monitor for retraumatization, comorbidities.
Parent PTSD is a strong predictor of pediatric PTSD.
Education: National Center for PTSD—https://www.ptsd.va.gov

50% remit in 3 months; others have persistent/life-long impairment.
Better outcomes: Early treatment, good support, avoidance of retraumatization, absence of comorbidities

Increased risk for panic/social/OCD, depression, suicide, homicide, substance abuse
Sexual assault survivors are at especially high risk for severe sequelae