Definition
- Post-Traumatic Stress Disorder (PTSD) is a mental health condition that occurs after experiencing or witnessing a traumatic event, leading to persistent re-experiencing, avoidance, hyperarousal, and emotional dysregulation for >1 month.
Can be acute (<3 months), chronic (>3 months), or delayed-onset (>6 months post-trauma
Causes & Risk Factors
Pathophysiology
- Hyperactivity of the Amygdala → Exaggerated Fear Response.
- Dysregulation of the Prefrontal Cortex → Impaired Inhibition of Traumatic Memories.
Hypercortisolism & Overactive Noradrenaline System → Increased Alertness & Hypervigilance.
Common Causes of PTSD
|
Type of Trauma |
Examples |
|
Combat & War Exposure |
Military Combat, Bombings, Terrorist Attacks. |
|
Physical Assault |
Mugging, Domestic Violence, Rape. |
|
Natural Disasters |
Earthquakes, Floods, Fires. |
|
Serious Accidents |
Car Crashes, Workplace Accidents. |
|
Medical Trauma |
ICU Admission, Life-Threatening Illness. |
Risk Factors for PTSD
|
Risk Factor |
Description |
|
Previous Trauma or PTSD |
Higher Risk of Severe Reaction. |
|
Personal or Family History of Anxiety or Depression |
Pre-existing Mental Health Disorders. |
|
Severity of Trauma |
Repeated, Prolonged, or Life-Threatening Events. |
|
Lack of Social Support |
Increases Vulnerability to Psychological Distress. |
|
Dissociative Reactions at the Time of Trauma |
Higher Risk of Persistent PTSD Symptoms. |
🔹 Severe trauma and pre-existing mental health conditions increase the risk of PTSD.
Clinical Features
Core Symptoms of PTSD (DSM-5 Criteria)
|
Category |
Common Symptoms |
|
Re-experiencing Symptoms (Intrusions) |
Flashbacks, Nightmares, Distressing Memories. |
|
Avoidance Symptoms |
Avoiding Trauma-Related Situations, Conversations, or Thoughts. |
|
Hyperarousal Symptoms |
Insomnia, Irritability, Exaggerated Startle Response. |
|
Negative Mood & Cognitive Changes |
Emotional Numbing, Guilt, Shame, Detachment. |
Signs on Examination
|
Feature |
Description |
|
Hypervigilance |
Easily Startled, Always on Edge. |
|
Emotional Dysregulation |
Mood Swings, Outbursts of Anger. |
|
Social Withdrawal |
Avoidance of Social Interactions. |
|
Flashback Episodes |
Patient Appears to ‘Relive’ Trauma. |
🔹 Flashbacks, avoidance, and hyperarousal are hallmark features of PTSD.
Referral Criteria (NICE Guidelines)
Urgent Referral (If Severe Symptoms or Risk to Self/Others)
- Active Suicidal Ideation or Self-Harm.
- Severe Functional Impairment (Unable to Work, Socially Isolated).
- Severe Dissociative Episodes (Feeling Detached from Reality).
Routine Referral (If Symptoms Persist or Affect Functioning)
- PTSD Symptoms Lasting >1 Month.
- Comorbid Severe Depression or Anxiety.
- Significant Sleep Disturbances.
🔹 Early intervention is key to preventing chronic PTSD.
Diagnosis
Clinical Diagnosis (DSM-5/ICD-10 Criteria)
|
Criterion |
Description |
|
Exposure to Trauma |
Directly Experiencing or Witnessing Trauma. |
|
Persistent Re-experiencing (≥1 Symptom) |
Flashbacks, Nightmares, Intrusive Thoughts. |
|
Avoidance Symptoms (≥1 Symptom) |
Avoiding Trauma-Related Situations. |
|
Hyperarousal Symptoms (≥2 Symptoms) |
Insomnia, Irritability, Exaggerated Startle Response. |
|
Negative Mood or Cognitive Changes (≥2 Symptoms) |
Guilt, Shame, Emotional Numbing. |
|
Duration >1 Month |
To Differentiate from Acute Stress Reaction. |
Differential Diagnosis
|
Condition |
Key Differences |
|
Acute Stress Reaction (ASR) |
Symptoms Resolve Within 1 Month. |
|
Generalised Anxiety Disorder (GAD) |
Chronic Worry, No Flashbacks. |
|
Depression |
Persistent Low Mood, No Hyperarousal. |
|
Panic Disorder |
Episodic Panic Attacks, No Avoidance. |
🔹 PTSD is diagnosed clinically; psychological assessment tools (e.g., PTSD Checklist) can support diagnosis.
Management (NICE Guidelines)
Stepwise Approach to PTSD Management
|
Step |
Intervention |
|
Step 1 (Watchful Waiting – If Symptoms <4 Weeks & Mild) |
Psychoeducation, Self-Help. |
|
Step 2 (Trauma-Focused Psychological Therapy – First-Line for PTSD) |
Trauma-Focused Cognitive Behavioural Therapy (TF-CBT) or Eye Movement Desensitisation and Reprocessing (EMDR). |
|
Step 3 (Pharmacological Therapy – If Psychological Therapy Insufficient) |
SSRI (Sertraline First-Line, Paroxetine Alternative). |
|
Step 4 (Specialist Referral – If Severe or Treatment-Resistant) |
Psychiatry, Complex Case Management. |
First-Line Pharmacological Treatment (If Needed)
|
Drug |
Mechanism |
Considerations |
|
Sertraline (SSRI, First-Line) |
Increases Serotonin Levels. |
Start Low, Increase Gradually, Takes 4-6 Weeks to Work. |
|
Paroxetine (Alternative SSRI) |
Same as Sertraline. |
Consider If Sertraline Not Tolerated. |
|
Mirtazapine (Alternative Antidepressant) |
Noradrenergic & Serotonergic Effects. |
Sedative Effect May Help Sleep Disturbance. |
|
Prazosin (For PTSD Nightmares) |
Alpha-1 Blocker, Reduces Nightmares. |
Used If Psychological Therapy & SSRIs Fail. |
🔹 Trauma-focused therapy (CBT or EMDR) is the first-line treatment; medication is considered for severe cases.
Prognosis & Complications
Complications of PTSD
|
Complication |
Features |
|
Depression & Suicidal Ideation |
Common Comorbidity. |
|
Substance Abuse |
Self-Medication with Alcohol or Drugs. |
|
Social Isolation |
Avoidance Behaviour. |
|
Cardiovascular Disease |
Chronic Stress → Hypertension, Heart Disease. |
🔹 Early intervention improves outcomes and reduces complications.
UKMLA Key Points
- Best first-line treatment for PTSD: Trauma-Focused CBT or EMDR.
- Best first-line pharmacological treatment: Sertraline (SSRI).
- When to refer urgently: Suicidal ideation, severe functional impairment.
- Best medication for PTSD-related nightmares: Prazosin.
- Duration of SSRI treatment: At least 12 months, then gradual tapering.