Posttraumatic Stress Disorder (PTSD)

By John W. Barnhill, MD, New York-Presbyterian Hospital

Posttraumatic stress disorder (PTSD) involves intense, unpleasant, and

dysfunctional reactions beginning after an overwhelming traumatic event. When
terrible things happen, many people are lastingly affected. In some, the effects
are so persistent and severe that they are debilitating and constitute a disorder.
Combat, sexual assault, and natural or man-made disasters are common causes
of PTSD. However, it can result from any experience that feels overwhelming
and life threatening, such as physical violence or an automobile crash.

These events may be experienced directly (such as having a serious injury or

being threatened with death) or indirectly (witnessing others being seriously
injured, killed, or threatened with death; or learning of traumatic events that
occurred to close family members or friends). People may have experienced a
single trauma or, as is common, multiple traumas.

It is not known why the same traumatic event may cause no symptoms in one
person and lifelong PTSD in another. Nor is it known why some people witness
or experience the same trauma many times over years without developing
PTSD, but then develop it following an apparently similar episode.

Posttraumatic stress disorder affects almost 9% of people sometime during their

life, including childhood. About 4% have it during any 12-month period.
Posttraumatic stress disorder lasts for more than 1 month. It may be a
continuation of acute stress disorder or develop separately up to 6 months after
the event. Chronic posttraumatic stress disorder may not disappear but often
becomes less intense over time even without treatment. Nevertheless, some
people remain severely handicapped by the disorder.
Symptoms of PTSD
● Intrusion symptoms. The event repeatedly and uncontrollably invades
people’s thoughts;
● Avoidance of anything that reminds of the event;
● Negative effects on thinking and mood.
People may be unable to remember significant parts of the traumatic event
(called dissociative amnesia). People may feel emotionally numb or
disconnected from other people. Depression is common, and people show less
interest in previously enjoyed activities.
● Changes in alertness and reactions.
People may become less able to control their reactions, resulting in reckless
behavior or angry outbursts.
● Other symptoms. Some people develop ritual activities to help reduce
their anxiety. Many people with PTSD try to relieve their symptoms with
alcohol or recreational drugs and develop a substance use disorder.

Diagnosis of PTSD
Doctors diagnose posttraumatic stress disorder (PTSD) when:
● People have been exposed directly or indirectly to a traumatic event.
● Symptoms have been present for 1 month or longer.
● Symptoms cause significant distress or significantly impair functioning.
● People have some symptoms from each of the categories of symptoms
associated with PTSD (intrusion symptoms, avoidance symptoms,
negative effects on thinking and mood, and changes in alertness and
reactions).
● Doctors also check to see whether symptoms could result from use of a
drug or another disorder.
Treatment of PTSD
Psychotherapy is central to the treatment of posttraumatic stress disorder
(PTSD). Stress management techniques, such as breathing and relaxation, are
important. Exercises that reduce and control anxiety (for example, yoga,
meditation) can relieve symptoms and also prepare people for treatment that
involves stress-inducing exposure to memories of the trauma.

A type of cognitive-behavioral therapy (CBT) called exposure therapy helps to

extinguish the fear left over from the traumatic event. The therapist has people
imagine being in situations associated with prior trauma. For example, they may
be asked to imagine visiting a park where they were assaulted. The therapist
may help people reimagine the traumatic event itself.

Other types of supportive and psychodynamic psychotherapy can also be useful

as long as they do not shift the focus of treatment away from exposure therapy.

Drug therapy
Antidepressants are considered first-line treatment for PTSD, even in people
who do not also have major depression. Selective serotonin reuptake inhibitors
and other antidepressants such as mirtazapine and venlafaxine are most often
recommended.

To treat insomnia and nightmares, doctors sometimes give drugs such as

olanzapine and quetiapine (also used as antipsychotic drugs) or prazosin (also
used to treat high blood pressure). However, these drugs do not treat PTSD
itself.