To cite this article: Auxéméry Y. Post-traumatic psychiatric disorders: PTSD is not the only diagnosis. Presse Med.

(2018), https://
doi.org/10.1016/j.lpm.2017.12.006

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Update
Post-traumatic psychiatric disorders: PTSD is
not the only diagnosis

Yann Auxéméry

Available online: Hôpital d'Instruction des Armées Percy, service médical de psychologie clinique
appliquée à l'aéronautique [Medico-Psychological Service Applied to Aeronautics,
Main Aeromedical Centre], 101, avenue Henri Barbusse, 92140 Clamart, France

Yann.auxemery@hotmail.fr

Key points
Traumatic events and their consequences are often hidden or minimised by patients for reasons
linked to the post-traumatic stress disorder itself (inexpressibility, shame, depressive thoughts,
fear of stigmatisation, etc.).
Although post-traumatic stress disorder (PTSD) remains the most widely known disorder, chronic
post-traumatic psychiatric disorders are many and varied.
After a trauma, the practitioner has to check for the different clinical forms of post-traumatic
psychological consequences: PTSD is not the only diagnosis.
Based on our own clinical experience compared to the international literature, we think necessary
to build a didactic classification describing chronic post-traumatic symptoms and syndromes.
Post traumatic depressions and bereavement lead to high risk of suicidal crisis and self-harm
behaviours.
Re-experiencing are felt with anxiety, hyper arousal increases anxious reactivity, and avoidance
strategies increase anticipatory anxiety, indicating post-traumatic anxiety disorders (agoraphobia,
specific phobia, obsessive compulsive disorder, separation anxiety, social phobia).
Characterising an often-severe clinical picture, the co-occurrence of post-traumatic and chronic
psychotic symptoms is not unusual (post-traumatic schizophrenia, post-traumatic depression with
mood-congruent psychotic features, non-schizophrenic post-traumatic psychotic disorder, and
bipolar reaction to trauma).
A physical injury occurring at the same time as a traumatic exposure increases the risk of
developing post-traumatic stress disorder later which, in turn, afflicts the subjective perception
of the physical health (development of somatoform and psychosomatic disorders, comorbidity
with a post-concussion syndrome).
The trauma may cause a rupture in the biography of a person, also in his/her internal physiological
functioning as in his/her social activities (impacts of instinctive functions and behaviours,
personality changes, and adjustment difficulties on professional and personal life).
Although a nomenclature is necessary for semiological descriptions, a thorough analysis of the
patient's general psychological functioning must also be conducted.

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1

https://doi.org/10.1016/j.lpm.2017.12.006
© 2018 Elsevier Masson SAS. All rights reserved.

LPM-3517
 To cite this article: Auxéméry Y. Post-traumatic psychiatric disorders: PTSD is not the only diagnosis. Presse Med. (2018), https://
doi.org/10.1016/j.lpm.2017.12.006

Y. Auxéméry
Update

Points essentiels
Les troubles psychiques post-traumatiques : l'état de stress post-traumatique n'est pas
le seul diagnostic

Du fait de l'expression clinique même de ces troubles (indicibilité, sentiment de honte, cognitions
dépressives, crainte de stigmatisation . . .), la confrontation à un événement traumatique,
comme ses conséquences médico-psychologiques, sont souvent tues ou minimisées par les
patients.
Alors que le trouble de stress post-traumatique (TSPT) reste le diagnostic le plus connu, sans doute
parce qu'il est le plus fréquemment posé, les troubles psychiques post-traumatiques chroniques
sont en réalité divers et variés par leurs expressions cliniques.
Après un trauma, le praticien se doit de rechercher les différentes formes cliniques constituant les
troubles psychiques post-traumatiques : le TSPT n'est pas le seul diagnostic.
D'après notre expérience clinique confrontée aux données de la littérature internationale, il nous
ait apparu nécessaire de décrire les symptômes et syndromes post-traumatiques chroniques
grâce à la présentation d'une classification construite sur un mode didactique.
Les dépressions et deuils post-traumatiques sont à risque élevé de crise suicidaire et de compor-
tements auto-agressifs.
Les reviviscences sont souvent éprouvées dans l'angoisse, l'hyperactivité neurovégétative majore
la réactivité anxieuse tandis que les stratégies d'évitement pérennisent l'anxiété anticipatoire,
impliquant la présence fréquente de troubles anxieux post-traumatiques (agoraphobie, phobies
spécifiques, troubles obsessionnels et compulsifs, anxiété de séparation, anxiété sociale).
Longtemps négligés dans la littérature, les symptômes psychotiques post-traumatiques chron-
iques sont pourtant fréquents (schizophrénie post-traumatique, dépression post-traumatique
avec caractéristiques psychotiques congruentes à l'humeur, réactions bipolaires, trouble psycho-
tique post-traumatique non schizophrénique).
Une blessure physique contemporaine d'une exposition traumatique augmente le risque de
développer un syndrome de répétition ultérieur qui, réciproquement, grève la perception sub-
jective de la santé physique, alors même que cette dernière est objectivement impactée
(développement de troubles somatoformes et psychosomatiques, comorbidité avec un syndrome
post-commotionnel).
Le vécu traumatique peut entraîner une rupture dans la trajectoire d'un sujet, autant pour son
fonctionnement psychophysiologique individuel que dans ses liens sociaux (modifications des
fonctions instinctuelles et des conduites, mise en tension des traits de personnalité, désadapta-
tions dans les espaces professionnels et privés).
Une nomenclature reste indispensable aux descriptions séméiologiques, mais, dans tous les cas,
une analyse globale de la situation psychique singulière du patient est également nécessaire.

Introduction Through a short nosography, we suggest clinical descriptions for

Post-traumatic psychiatric disorders have existed since antiq-
uity [1,2] and are still described in modern classifications
[3,4]. Psychotraumatology has become a full-scale speciality
with neurobiological, psychological, and societo-anthropo-
logical scopes. Although "post-traumatic stress disorder''
(PTSD) remains the most widely known disorder, chronic
post-traumatic psychiatric disorders are many and varied.
Psychotherapeutic and pharmacological options must be
adapted to each clinical entity, and the expert assessment
of psychological damage requires a clear description of post-
traumatic symptoms.
2
existing post-traumatic symptoms and syndromes, based on our
own clinical experience and the international literature. After
providing clinical descriptions of psychological trauma, the
immediate clinical response, and the cardinal chronic symp-
toms, we describe post-traumatic psychotic, mood, and anxiety
disorders. We then give an overview of the somatoform expres-
sions, and psychosomatic and somatic sequelae (including brain
injury consequences if associated), before describing the impact
of trauma on instinctive functions, conduct disorders, personality
changes, and adjustment difficulties on professional and per-
sonal life.

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 To cite this article: Auxéméry Y. Post-traumatic psychiatric disorders: PTSD is not the only diagnosis. Presse Med. (2018), https://
doi.org/10.1016/j.lpm.2017.12.006
Post-traumatic psychiatric disorders: PTSD is not the only diagnosis
Traumatic event, immediate clinical
response, latency period, cardinal
symptoms and other post-traumatic
symptoms
From the traumatic event to the latency period
Although one person can face several traumas throughout his/
her life, we focus here on the clinical consequences of a single
psychological trauma in adulthood (repeated assaults and child
traumas are clinically specific). A potentially traumatic event is
defined as a sudden and direct confrontation with death or its
equivalents (such as serious injury, assault, or witnessing a
cataclysmic event) [4–6]. The DSM-5 also defines the possibility
of "indirect exposure'', caused by the announcement, from afar,
of the death or serious injury of relatives or closed friends [4,7].
The term "remote trauma'' can be used to describe specific
circumstances, such as those witnessed by surveillance camera
operators or drone pilots [8]. A traumatic event, as such, is
defined by an immediate subjective feeling of traumatic and
peritraumatic distress, characterised by the negative emotions of
fear, helplessness, revulsion and/or horror [3,4]. Resulting from
the traumatic event, traumatic and peritraumatic dissociation
manifests as a reduction in consciousness, changes in tempor-
ospatial perception (such as the slowing of time, perception of a
long silence), derealisation (feeling as if the surroundings are
unreal, altered sensory perceptions), depersonalisation (out-of-
body experience, sensation of body fragmentation), automatic
motor behaviours (adaptive or otherwise), and partial or com-
plete dissociative amnesia [9,10]. Other immediate clinical signs
are characterised by restlessness, panickly flight, or shock and
stupor. After a few minutes, anxiety often predominates, but a
confused state and psychotic disturbances are also possible.
Although flashbacks are frequent in the hours and days following
the trauma, they usually disappear for a latency period lasting
several days to several weeks [11,12]. Clinically characterised by
mild symptoms, this period terminates with the return of flash-
backs, triggered by implicit environmental perceptions or con-
scious thoughts evoking the trauma. Less commonly, a stressor
linked to a happy event, apparently far removed from the initial
traumatic circumstances, may also be the trigger. A chronic
symptomatology can then wax and wane between periods of
partial remission and active post-traumatic symptoms [13–16].
Chronic cardinal symptoms: re-experiencing, hyper-
arousal, avoidance, dissociation
The pathognomonic sign of PTSD is re-experiencing the trau-
matic scene with the same distress, perceptions, emotions and
dissociation that were originally experienced. Internal feelings
of anxiety and negative thoughts are also recalled. These epi-
sodes can occur during sleep – as traumatic nightmares, and
during waking periods – as flashbacks. Other manifestations are
possible: intrusive memories perceived as distinct from the
original event; mental ruminations about the event; delusions
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PSYCHIATRY
Update
of re-experiencing the event by recognising elements of it in the
environment; elementary motor phenomena replicating the
motor response from the time of the event; and repetitive
behaviours (fugue, crying, self-harm or aggression) [4,17].
Resulting from the fear of a new trauma, or from flashbacks
during a reduction in awareness, the two other cardinal symp-
toms are autonomic hyperactivity (hypervigilance, irritability,
startle response, restlessness) and, cognitive and behavioural
strategies for avoiding stimuli that might re-awaken the trau-
matic memory (places, activities, persons, objects, internal per-
ceptions). Another major symptom, dissociation, is found in the
peritraumatic and post-traumatic continuity [18]: traumatised
people tend to manifest dissociative phenomena (traumatic
amnesia, dissociative fugue, depersonalisation, derealisation,
nonepileptic psychogenic seizures) [4,19]. Finally, negative
thoughts or feelings that began or worsened after the trauma
have been included in the DSM-5 definition of PTSD.
Links between PTSD and other chronic post-
traumatic symptoms
Although PTSD remains the most widely known pathological
state, many other post-traumatic symptoms are associated with
re-experiencing. Varying degrees of the following should be
considered: mood disorders (especially depressive), pathologi-
cal bereavement, anxiety disorders (primarily agoraphobia and
obsessive compulsive disorders), psychotic disorders, psychoac-
tive substance misuse (particularly alcohol and drug misuse),
somatoform expressions, psychosomatic and somatic symp-
toms (including brain injury sequelae if associated), disturban-
ces in instinctive behaviours, conduct disorders, personality
changes, and adjustment difficulties on professional and per-
sonal life. These disorders, or symptoms of them, have some-
times been called "nonspecific'' because they are also found in
psychiatric disorders other than PTSD. However, hyper-arousal,
avoidance strategies, and other many symptoms, maintain a
strong clinical connection to the traumatic circumstances that
gave rise to them, meaning they are not only "comorbidities'' or
"complications'' [13,14], but authentic post-traumatic clinical
entities. Cardinal and other post-traumatic symptoms do not
necessarily occur together, but may fluctuate qualitatively and
quantitatively between periods of remission and relapse. Re-
experiencing can fade or even disappear over time, whereas
other clinical manifestations can appear or worsen. Without
treatment, the post-traumatic disorder may become disabling
as symptoms accumulate, with negative somatic impacts and
bad social consequences.
Post-traumatic clinical forms of disorders
elsewhere described
Without attempting to redefine every disorder listed in the
literature, we present definitions and examples of post-trau-
matic clinical forms.
3
 To cite this article: Auxéméry Y. Post-traumatic psychiatric disorders: PTSD is not the only diagnosis. Presse Med. (2018), https://
doi.org/10.1016/j.lpm.2017.12.006
Y. Auxéméry
Update
Post-traumatic depression, bereavement, and
suicidal risk
Depressive symptoms are newly-addressed in the DSM-5 as a
PTSD criterion: negative thoughts or feelings about oneself or
the world, decreased interest in activities, feelings of isolation,
and difficulty experiencing positive affect.
Post-traumatic depression
Morbid ruminations, often fatalistic, are focused on the causes
and consequences of the trauma, and are dominated by feelings
of shame, abandonment and guilt [20,21]. Culpability is partic-
ularly felt by survivors who had to run away from danger or who
blame themselves for their responsibility during the trauma.
Links to the world and to others are often marred by pessimistic
reflections: the impossibility of controlling one's own destiny,
the lack of meaning in life, etc. A loss of confidence in human
nature persists, with the impression that others cannot under-
stand traumatic suffering. A withdrawal into oneself and
restricted social activities is common [22,23].
Post-traumatic bereavement
Post-traumatic bereavement arises when the traumatic event
relates to the loss of relatives or closed friends (discovering the
corpse of a relative who has committed suicide, watching family
members dying, soldier seeing his/her partner killing in action)
[24–26]. Flashbacks keep the deceased close to the bereaved,
making it more difficult to progress through the stages of
bereavement. Blocking is frequent during the depressive stage.
Suicidal risk
Post-traumatic depression and bereavement lead to a high risk
of self-harm and suicide [27–29].
Post-traumatic phobic and anxiety disorders
Intense anxiety is often present during, and immediately after
the traumatic event. Later, re-experiencing episodes are conco-
mitant with anxiety, the hyper-arousal intensifies anxious reac-
tivity, and avoidance strategies increase anticipatory anxiety.
Moreover, generalised post-traumatic anxiety is often associ-
ated with panic attacks [30].
Agoraphobia
Agoraphobia is more frequent when the traumatic event occurs
in a public place such as a market or on public transport – places
in which an individual could also experience specific phobias
[31].
Specific phobias
Specific phobias linked to perceptions of a traumatic event are
common (darkness, sharp objects, entering a lift, seeing some-
one with a similar physical appearance to an attacker, etc.)
[32,33].
Obsessive compulsive disorder
Obsessive compulsive disorder may be closely related to the
traumatic event (locking doors after an intrusion into the home,
4
checking the gas after a fire, and repeated washing after an
assault, etc.) [34].
Separation anxiety
The fear of losing someone close during a trauma often gen-
erates separation anxiety [35].
Social phobia
Social phobia is also common, arising from a fear of having to
recall the trauma and/or its consequences at the request of
others [33,36,37].
Post-traumatic psychotic and bipolar disorders
Characteristic of an often-severe clinical picture, the co-occur-
rence of chronic post-traumatic and chronic psychotic symptoms
is common [38]. Several authors have described the trauma as
an important element revealing a pre-existing vulnerability
[39,40]. Especially, interacting with several genes belonging
to several different biological pathways, childhood traumatic
events are risk factors for developing bipolar disorders, in addi-
tion to a more severe clinical presentation over time [39,40].
From another angle, schizophrenic patients report more trauma
and abuse than the general population and the prevalence of
PTSD in patients with a severe mental disorder is between 30%
and 40% [41,42]. Although the accuracy of trauma reports is
difficult to precisely evaluate in patients suffering from distor-
tions of though and memory difficulties, trauma exposure in
patients with schizophrenia tends to be underreported [43].
Nevertheless, it appears difficult in many cases to differentiate
clinically between psychotic hallucinations and intrusive
memories.
Non-schizophrenic post-traumatic psychotic disorder
The post traumatic stress disorder with secondary psychotic
symptoms (PTSD-SP) is a PTSD complicated by additional psy-
chotic features that are not related to another nosographic
framework than PTSD itself. That is to say that PTSD-SP is a
severe form of PTSD that is marked by severe pathological
perceptions and dissociative symptoms [44–46]. Hallucinatory
and delirious phenomena can arise, based on themes related to
the trauma and its consequences [47,48]. In the absence of
disorganised thoughts and ambivalence, these symptoms do
not belong to the schizophrenia spectrum. However, paranoid
reactions are possible [49].
Post-traumatic depression with mood-congruent psychotic
features
A feeling of incurability dominates this clinical entity in which
the subject blames him/herself for the traumatic event and its
consequences [20,50,51]. Symptoms of identity denial are
sometimes found: confined to intense depersonalisation, the
subject feels he/she is "no longer him/herself'' and that his/her
mind "no longer functions''. Psychotic visions of ruin may coin-
cide with re-experiencing scenes of destruction.
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 To cite this article: Auxéméry Y. Post-traumatic psychiatric disorders: PTSD is not the only diagnosis. Presse Med. (2018), https://
doi.org/10.1016/j.lpm.2017.12.006
Post-traumatic psychiatric disorders: PTSD is not the only diagnosis
Bipolar reaction to trauma
An attack of mania can be triggered by a traumatic confrontation
that can reveal or sensitize underlying bipolarity [20,39,40,52].
Post-traumatic schizophrenia
Latent schizophrenia may be triggered by several elements of
the psychological trauma: fragmentation anxiety after witness-
ing amputation, anxiety of being devoured after witnessing
anthropophagy, and annihilation anxiety after witnessing total
destruction [23,53]. Delusions often integrate, into its paralo-
gical system, traumatic circumstances and/or its consequences.
Somatoform, psychosomatic and somatic
consequences of psychological trauma
A physical injury occurring at the same time as a traumatic
exposure increases the risk of developing PTSD; this, in turn,
affects the subjective perception of physical health [54,55].
Physical lesions from a traumatic event may have major con-
sequences comprising functional deficits, aesthetic sequelae,
pains and dysaesthesia [56].
Somatoform expressions
Post-traumatic pain syndrome
When a psychological trauma is combined with a physical injury,
this physical pain is a reminder of the tragedy, equivalent to
physically re-experiencing the event. These bodily perceptions
may also trigger other re-experiencing (proprioception in case of
assault; visual and olfactory reminders of the initial injury) [57].
Post-traumatic conversion
There is a concordance between the physiological function
affected by the trauma and the location of the post-traumatic
conversion (blindness when facing an approaching object,
aphonia after being unable to avert the traumatic event, paral-
ysis after a fall) [58–60]. Fixing the immediate post-traumatic
behavioural reaction, the conversion could sometimes be con-
sidered equivalent to re-experiencing the event.
Post-traumatic somatisations
Anxious somatisations manifest in several areas (cardiac, neu-
rological, rheumatological, and gastrointestinal, etc.) [61]. Per-
ceptions of anxiety, often felt periodically since the trauma, may
return with re-experiencing episodes, or may become
continuous.
Post-traumatic psychosomatic and somatic consequences
Psychosomatic disorders may result from the stress sustained in
PTSD, leading to cutaneous (psoriasis, eczema, hair whitening,
hair loss), digestive (gastritis, inflammatory bowel disease),
cardiovascular (arterial hypertension, atheromatosis), endocrine
and auto-immune diseases (diabetes, dysthyroidism) [61–63].
The traumatised person may also suffer physical damage due to
risky post-traumatic behaviours (misuse of psychoactive sub-
stances, self-harm, dangerous driving, and sexual promiscuity).
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PSYCHIATRY
Update
Comorbidity between PTSD and post-concussion syndrome
Several psychological and neuropsychiatric symptoms have
been described after varying degrees of cranial trauma [64–
69]. The combination of psychological trauma and mild trau-
matic brain injury increases the risk of post-concussion syn-
drome [68]. Appearing a few days or weeks after the
trauma, post-concussion syndrome is characterised by a lack
of consistency between the multiple subjective complaints from
the patient, and, confirmation based on clinical examinations or
routine explorations (neurobiological markers start to be used
for research). Post-concussion syndrome may consist of general
symptoms (fatigue, sleep problems), somatic symptoms (head-
aches, dizziness), cognitive symptoms (memory and concentra-
tion problems), and affective symptoms (irritability, emotional
lability, depression, apathy, anxiety) [70,71].
Impact of trauma on cognitions, behaviours,
personality, and adjustment capacities
Trauma may disrupt a person's physiology as well as his/her
social functioning.
Cognitive difficulties
Cognitive difficulties frequently involve impairments to atten-
tion, memorising (especially verbal and working memories) and
executive functions (decreasing flexibility and inhibition).
Effects on instinctive behaviours
Parasomnias
Non-recurring nightmares, terrors, panic attacks and sleepwalk-
ing are frequent [72,73].
Eating disorders
Alterations in eating behaviour such as anorexia, bulimia, snack-
ing, and hyperphagia are possible [74,75].
Sexual dysfunction
A decline in sexual desire often occurs, in addition to sexual pain
[76,77].
Conduct disorders
Problematic use of psychoactive substances, behavioural
addictions
The use of licit or illicit psychoactive substances is frequent,
notably to reduce anxiety and to increase sleep. Tobacco and
alcohol addictions are frequent, but dependences on other
drugs, primarily benzodiazepines and opioids, are often comor-
bid in cases of polydrug use [78–80]. Repetitive behaviours such
as compulsions or addictions are possible (addiction to games
mimicking the trauma, risk-taking behaviours, and self-injury).
Self-harming and aggressive behaviours
Traumatised individuals often endanger themselves with sui-
cidal equivalents or other confrontations with death, such as
aggressive behaviours towards themselves or others, dangerous
driving, risky sexual behaviours, or drugs taking [27–29].
5
 To cite this article: Auxéméry Y. Post-traumatic psychiatric disorders: PTSD is not the only diagnosis. Presse Med. (2018), https://
doi.org/10.1016/j.lpm.2017.12.006

Y. Auxéméry
Update

Post-traumatic personality changes Conclusion

Traumatic events, exposure to prolonged distressing situations,
and physical injuries (amputations, the presence of foreign
bodies such as bullets or shrapnel, and various other sequelae)
are all likely to cause personality changes [17,81,82]. These
manifestations reflect a split from the previous way of life,
whatever form it may have taken [83,84]. Whatever the type
of response caused by activating defence mechanisms, people
suffering from re-experiencing episodes and other post-trau-
matic symptoms regularly isolate themselves from others.
Professional and personal adjustment difficulties
When an individual has been injured during his/her job (a bus
driver attacked, a bank cashier robbed, or a soldier wounded in
action), the motivation for pursuing his/her profession is tested
and, it may be difficult to go back to his/her former activities
[85,86]. More generally, returning to "normal life'' is often
complex. Hobbies may be impossible to continue, and, familial
problems such as the break-up of relationships, parenting diffi-
culties, and financial problems are frequent [87].
Traumatic events and their consequences are often hidden or
minimised by patients for reasons linked to the disorder itself
(inexpressibility, shame, depressive thoughts, fear of stigmati-
sation, etc.). Rather than simply recognising the best-known
symptoms, the practitioner must check for the different post-
traumatic psychic disorders. In the present work, we have
described the landscape of post-traumatic disorders using a
logical and didactic classification. However, although a nomen-
clature is useful for semeiological descriptions and expert
assessments, a thorough analysis of the patient's general psy-
chological functioning must also be conducted [88,89].
Disclosure of interest: the author declares that he has no competing
interest.
The positions expressed in this article are only the views of the author and
should not be considered as the official point of view of the French Army
Health Service.

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