Post-traumatic stress disorder

Last reviewed: June 2019

Last updated: April 2019

Summary

Disorder that may develop (either immediately or delayed) following exposure to a stressful event or situation of an exceptionally threatening or catastrophic nature.

According to DSM-5, it is characterized by 4 groups of symptoms: intrusion symptoms, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity. These symptoms must impair function for a diagnosis to be made.

More often than not, presentation is comorbid with problems such as depression, anxiety, anger, and substance misuse.

Clinicians should ask whether patients presenting with such symptoms have suffered a traumatic experience.

Assessment should cover physical, psychological, and social needs, and an assessment of risk: this can be facilitated by the use of screening questionnaires and a clinical interview schedule.

Trauma-focused psychological treatments are the most effective treatment. Pharmacotherapy may be used in patients who do not respond to, cannot tolerate, do not want, or do not have access to psychological therapies.

Definition

Post-traumatic stress disorder (PTSD) may develop following exposure to 1 or more traumatic events such as deliberate acts of interpersonal violence, severe accidents, disasters, or military action. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), it is characterized by 4 types of symptoms: intrusions (e.g., flashbacks, intrusive images and sensory impressions, dreams/nightmares); avoidance (e.g., avoiding people, situations, or circumstances resembling or associated with the event); negative alterations in mood and cognition (e.g., feeling alienated from others, constricted affect, diminished interest in significant activities, distorted negative beliefs about oneself or the world, and inability to remember key features of the traumatic event); and alterations in arousal or reactivity (e.g., hypervigilance for threat, exaggerated startle response, irritability, difficulty concentrating, and sleep problems). These symptoms must impair function for a diagnosis to be made. [1] This topic does not cover PTSD in children.

History and exam

Key diagnostic factors

exposure and response to trauma
intrusion symptoms
avoidance symptoms
negative alterations in cognitions and mood
alterations in arousal and reactivity

Full details

Other diagnostic factors

depression
alcohol or substance misuse
anxiety

Full details

Risk factors

serious accident
witness of school violence or domestic violence
natural disaster
terrorist attack
torture
combat exposure
traumatic brain injury
sudden death of loved one
molestation
rape
victimization by attacker
previous trauma
multiple major life stressors
low social support
history of mental disorder
history of drug and alcohol abuse
female sex
younger age

Full details

Diagnostic investigations

1st investigations to order

PTSD Checklist
PTSD Checklist for DSM-5 (PCL-5)
Impact of Event Scale - Revised (IES-R)
Davidson Trauma Scale (DTS)
Trauma Screening Questionnaire (TSQ)
SPAN

Full details

Investigations to consider

Clinician-Administered PTSD Scale (CAPS)
Clinician-Administered PTSD Scale for DSM-5 (CAPS-5)
Structured Clinical Interview for the DSM-IV Axis I Disorders (SCID PTSD Module)
PTSD Symptom Scale-Interview Version (PSS-I)

Full details

Treatment algorithm

ONGOING

not pregnant or breast-feeding

pregnant or breast-feeding

Contributors

Authors VIEW ALL 

Stanley Zammit, MA, BM BCh, MRCPsych, PhD

Professor of Psychiatric Epidemiology

Centre for Academic Mental Health

School of Social and Community Medicine

University of Bristol

Bristol

Clinical Senior Lecturer & Honorary Consultant Psychiatrist

Institute of Psychological Medicine and Clinical Neurosciences

Cardiff University

Cardiff

Disclosures

SZ declares that he has no competing interests.

Mathew Hoskins, MBBCh, MSc, MRCPsych

Consultant Psychiatrist and Clinical Teaching Fellow

Institute of Psychological Medicine and Clinical Neurosciences

School of Medicine

Cardiff University

Cardiff

Wales

Disclosures

MH is an author of references cited in this topic.

Catrin Lewis, BSc, PhD

Research Associate

National Centre for Mental Health

Institute of Psychological Medicine and Clinical Neurosciences

School of Medicine

Cardiff University

Cardiff

Wales

Disclosures

CL declares that she has no competing interests.

Acknowledgements

Dr Stanley Zammit, Dr Mathew Hoskins, and Dr Catrin Lewis would like to gratefully acknowledge Dr Neil P. Roberts, Dr Jonathan I. Bisson, and Dr Steve Wood, previous contributors to this topic.

Peer reviewers VIEW ALL 

Mort Rubinstein, MD

Deputy Associate Chief of Staff

Mental Health

VA New York Harbor Healthcare System

Clinical Associate Professor

New York University School of Medicine

New York

Disclosures

MR declares that he has no competing interests.

Neil Greenberg, MD, MRCPsych

Surgeon Commander

Royal Navy

Defence Professor of Mental Health, Visiting Professor of Psychiatry, and Co-Director

Academic Centre for Defence Mental Health

King's College London

London

Disclosures

NG has been principal investigator on studies with research funding greater than 6 figures USD. NG is a director of a company providing early intervention training for traumatic stress (the company does not provide PTSD treatment services).

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Post-traumatic stress disorder

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

not pregnant or breast-feeding

pregnant or breast-feeding

Contributors

Authors VIEW ALL 

Stanley Zammit, MA, BM BCh, MRCPsych, PhD

Disclosures

Mathew Hoskins, MBBCh, MSc, MRCPsych

Disclosures

Catrin Lewis, BSc, PhD

Disclosures

Acknowledgements

Peer reviewers VIEW ALL 

Mort Rubinstein, MD

Disclosures

Neil Greenberg, MD, MRCPsych

Disclosures

Differentials

Guidelines

Patient leaflets

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