Post-Traumatic Stress Disorder
PTSD develops after exposure to a traumatic event, characterised by re-experiencing, avoidance, negative cognitions, and hyperarousal. Prevalence is approximately 3-4% in the UK.
Key Facts
PTSD develops after exposure to actual or threatened death, serious injury, or sexual violence — directly, witnessed, or learned about Symptoms must persist for >1 month after the traumatic event; onset within 6 months in most cases Four symptom clusters: Re-experiencing (flashbacks, nightmares), avoidance, negative cognitions/mood, hyperarousal First-line treatment: Trauma-focused CBT or EMDR (NICE NG116) Drug treatment is second-line: Venlafaxine 75-150mg or SSRI (sertraline, paroxetine) if psychological therapy declined or not available Single-session debriefing is NOT recommended — no evidence of benefit and may be harmful Complex PTSD (ICD-11): PTSD symptoms plus disturbances in self-organisation (affect dysregulation, negative self-concept, interpersonal difficulties) — typically follows prolonged/repeated trauma Approximately 20-30% of people exposed to trauma develop PTSD; risk factors include female sex, previous trauma, peritraumatic dissociation
Overview
Key Facts
PTSD is a trauma and stress-related disorder that develops following exposure to an exceptionally threatening or horrifying event. It causes significant psychological distress and functional impairment through four core symptom clusters.
Epidemiology
Lifetime prevalence in the UK is approximately 3-4%. Higher in military personnel (~6-17%), emergency service workers, and refugees. Women are approximately twice as likely to develop PTSD as men. Median time to treatment is 12 years.
Aetiology
- Traumatic events: Combat, assault, rape, accidents, natural disasters, terrorism, childhood abuse
- Risk factors: Female sex, prior psychiatric history, childhood adversity, peritraumatic dissociation, lack of social support, repeated trauma
- Protective factors: Social support, resilience, higher education, adaptive coping
Pathophysiology
- Fear conditioning: Amygdala hyperactivation — traumatic cues trigger exaggerated fear response
- Hippocampal dysfunction: Impaired contextualisation of memories — explains flashbacks (memories experienced as current events)
- Prefrontal cortex hypofunction: Failed top-down regulation of amygdala
- HPA axis dysregulation: Paradoxically LOW cortisol in PTSD (unlike depression) — enhanced negative feedback
- Noradrenergic hyperactivity: Locus coeruleus overactivity → hyperarousal, exaggerated startle
- Memory consolidation: Traumatic memories poorly integrated into autobiographical memory — remain "unprocessed" and intrusive
Clinical Presentation
Re-experiencing
- Flashbacks: Vivid, involuntary reliving of the trauma (as if happening now)
- Nightmares: Distressing dreams of the event
- Intrusive memories: Unwanted, distressing recollections
- Psychological/physiological reactivity to trauma reminders
Avoidance
- Avoidance of thoughts, feelings, or conversations about the trauma
- Avoidance of people, places, activities that trigger memories
Negative Cognitions and Mood
- Persistent negative beliefs ("I am broken," "The world is dangerous")
- Distorted blame of self or others for the trauma
- Persistent negative emotional state (fear, horror, anger, guilt, shame)
- Diminished interest in activities, detachment from others
Hyperarousal
- Hypervigilance, exaggerated startle response
- Irritability, anger outbursts
- Difficulty concentrating
- Sleep disturbance
- Reckless or self-destructive behaviour
Red Flags
- Suicidal ideation — PTSD has significant suicide risk (~5-10× general population)
- Substance misuse — very common comorbidity (self-medication)
- Dissociative symptoms — depersonalisation/derealisation variant
- Complex PTSD — requires longer, phased treatment approach
Differential Diagnosis
| Diagnosis | Key Features | Investigation |
|---|---|---|
| Acute stress disorder | Similar symptoms but <1 month after trauma | Clinical assessment |
| Adjustment disorder | Symptoms disproportionate to stressor but don't meet PTSD criteria | Clinical assessment |
| Depression | Low mood, anhedonia without specific re-experiencing | PHQ-9 |
| GAD | Chronic worry about multiple concerns, not trauma-specific | GAD-7 |
| Panic disorder | Recurrent panic attacks, not trauma-triggered | Clinical history |
| Borderline personality disorder | Chronic mood instability, self-harm, identity disturbance | Longitudinal assessment |
| Traumatic brain injury | Cognitive symptoms, trauma history, no re-experiencing | Neuroimaging, neuropsychology |
Diagnosis / Investigation
Bedside
- PCL-5 (PTSD Checklist): 20-item self-report measure aligned with DSM-5
- IES-R (Impact of Event Scale-Revised): Screening tool
- PHQ-9, GAD-7: Comorbid depression and anxiety screening
- AUDIT-C: Alcohol misuse screening
- Risk assessment: Comprehensive — suicide, self-harm, violence
Bloods
- TFTs: Exclude thyroid dysfunction
- FBC, LFTs: Baseline and alcohol-related complications
- Drug screen: If substance misuse suspected
Special Tests
- Structured clinical interview: CAPS-5 (Clinician-Administered PTSD Scale) — gold standard diagnostic tool
- Neuroimaging: Not routine — research shows reduced hippocampal volume, amygdala hyperactivity
Management
Non-pharmacological (NICE NG116)
- Active monitoring: For mild symptoms <4 weeks post-trauma — many improve spontaneously
- Trauma-focused CBT: First-line — 8-12 sessions; includes trauma narrative, cognitive restructuring, in-vivo exposure
- EMDR (Eye Movement Desensitisation and Reprocessing): First-line — 8-12 sessions; bilateral stimulation during trauma memory processing
- NOT recommended: Single-session psychological debriefing
Pharmacological (NICE NG116)
- Second-line (if psychological therapy declined, not available, or not effective):
- Venlafaxine 75-150mg OD
- SSRI: Sertraline 50-200mg OD or paroxetine 20-50mg OD
- Prazosin 1-15mg ON: For PTSD-related nightmares (alpha-1 blocker, off-label)
- Not recommended: Benzodiazepines (may worsen PTSD, impair extinction learning)
- Treatment duration: Continue for ≥12 months; gradual tapering
Referral Criteria
- PTSD symptoms >1 month — psychological therapy referral (IAPT or specialist trauma service)
- Complex PTSD — specialist trauma service
- Treatment-resistant PTSD — secondary care psychiatry
- Significant comorbidity — MDT approach
- Military veterans — Op COURAGE (NHS Veterans' Mental Health service)
Prognosis
- Natural course: ~50% recover within 3 months; ~30% have chronic course
- Trauma-focused CBT: ~60-70% response rate; gains well-maintained
- EMDR: Similar efficacy to trauma-focused CBT
- Chronic PTSD (>1 year): Poorer prognosis; may require longer treatment
- Complex PTSD: Requires phased treatment (stabilisation → trauma processing → reintegration); longer duration
- Comorbidity: ~80% have at least one comorbid condition (depression, anxiety, substance misuse)
- Suicide: PTSD increases suicide risk ~5-10×; comprehensive risk management essential
Other Relevant Information
ICD-11 Complex PTSD
| Core PTSD | Plus Disturbances in Self-Organisation |
|---|---|
| Re-experiencing | Affect dysregulation (emotional reactivity, dissociation) |
| Avoidance | Negative self-concept (worthlessness, shame, guilt) |
| Hyperarousal | Interpersonal difficulties (detachment, distrust) |
PTSD Risk Factors
| Factor | Effect |
|---|---|
| Female sex | 2× risk |
| Prior psychiatric history | Increased risk |
| Peritraumatic dissociation | Strong predictor |
| Lack of social support | Increased risk |
| Severity/duration of trauma | Dose-response relationship |
| Childhood adversity | Increased risk for complex PTSD |