PTSD: Symptoms, Signs and Treatment

Post-traumatic stress disorder (PTSD) is an anxiety disorder that alters the body’s ability to respond to stress and is associated with a wide range of debilitating symptoms. Studies demonstrate biological and psychosocial differences contribute to the risk of developing PTSD. PTSD is characterized by a failure to follow the normative trajectory of recovery after exposure to a traumatic event. It is common among military personnel returning from combat, but also affects victims of assault, domestic abuse, natural disasters or other trauma. During the weeks following a traumatic event, a majority of individuals exhibit normative acute reactions, such as intrusive thoughts or dreams about the event, hyper-alertness, irritability and problems with sleep and memory. For about two-thirds of those individuals, symptoms resolve on their own with time.¹

Complex PTSD differs from regular PTSD in that it results from chronic or long-term exposure to emotional trauma in which the victim has little or no control over the situation and essentially no hope of escape. For example, a child who witnesses a friend’s accidental death may experience some symptoms of PTSD, but a child who grows up in an abusive home may exhibit additional symptoms indicative of complex PTSD.²

A Short History of PTSD

PTSD has likely existed in some form throughout human existence, but was not officially named and recognized until the second half of the 20th century. The first acknowledgement of the negative mental health consequences associated with combat came in the 1800s, when soldiers were diagnosed with “exhaustion” or “soldier’s heart” following battle experience. This was considered to be a physical affliction, since soldiers were not supposed to exhibit any sign of mental weakness and could be executed for any actions perceived as cowardice.³

The term “shell shock” was introduced in World War I in response to symptoms such as panic and sleep problems thought to be a reaction to the explosion of artillery shells. In World War II, the term combat stress reaction (CSR), also known as “battle fatigue,” replaced shell shock. For the first time, there was some degree of acknowledgement that mental illness could result from combat exposure. However, the belief still persisted that these conditions could be treated by simply removing soldiers from battle. If symptoms persisted for months, it was believed soldiers had undiagnosed preexisting conditions.³

In 1952, the American Psychiatric Association (APA) published its first Diagnostic and Statistical Manual of Mental Disorders (DSM-I), which included “gross stress reaction.” In the second edition published in 1968, this diagnosis was eliminated, despite growing evidence that trauma exposure was associated with psychiatric problems. In the third edition published in 1980, PTSD was finally given its contemporary name and classified under anxiety disorders. DSM-5, published in 2013, reclassified PTSD under “trauma- and stressor-related disorders.”³

PTSD Facts and Stats

• According to the U.S. Department of Veterans Affairs’ National Center for PTSD, about six in 10 men and five in 10 women experience at least one trauma in their lifetime.⁴
• Females have a smaller statistical risk of being exposed to trauma. However, nearly 10% of women versus 4% of men develop PTSD.⁴
• About seven or eight out of every 100 people have PTSD at some point in their lives.⁴
• An estimated 7.7 to 8 million people in the U.S. have PTSD in any given year.^4,5
• About 65% of male and 46% of female rape victims develop PTSD.⁵

PTSD Symptoms and Diagnosis

The diagnostic criteria for PTSD include specific qualifying experiences of traumatic events, four sets of symptom clusters and two subtypes. Requirements for a confirmed diagnosis also involve the duration of symptoms, the impact on functioning, and, moreover, cannot be caused by substance use and medical illnesses. The diagnostic criteria are as follows:

Criterion A — Traumatic event: Trauma survivors must have been exposed to actual or threatened death, serious injury or sexual violence. The following types of exposures qualify:

• Direct
• Witnessed
• Indirect: Learning about a relative or close friend who has experienced the event (the indirectly experienced death must be accidental or violent)
• Repeated or extreme indirect exposure to qualifying events, such as those experienced by first responders⁶

Criterion B — Intrusion or re-experiencing: These symptoms define the manner in which a person re-experiences the event, such as:

• Intrusive thoughts or memories
• Nightmares related to the traumatic event
• Flashbacks as if the event is happening again
• Psychological and physical reactivity after exposure to traumatic reminders, such as the event anniversary⁶

Criterion C — Avoidant symptoms: These symptoms describe ways a person may try to avoid any memory of the event, and must include one of the following:

• Avoiding thoughts or feelings connected to the traumatic event
• Avoiding people or situations connected to the traumatic event6

Criterion D — Negative alterations in mood or cognitions: A new criterion, this captures many symptoms long observed by PTSD sufferers and clinicians. This involves a decline in a person’s mood or thought patterns, including:

• Memory problems exclusive to the event
• Negative thoughts or beliefs about one’s self or the world
• Distorted sense of blame of one’s self or others related to the event
• Being stuck in severe emotions related to the trauma (e.g. horror, shame or sadness)
• Severely reduced interest in pre-trauma activities
• Feeling detached, isolated or disconnected from other people⁶

Criterion E — Increased arousal symptoms: These symptoms are used to describe manifestations of the brain “on edge,” wary and watchful of further threats, including:

• Difficulty concentrating
• Irritability, increased temper or anger
• Difficulty falling or staying asleep
• Hypervigilance
• Being easily startled⁶

Criteria F, G and H — These criteria delineate the severity of the symptoms listed above. Symptoms must have a duration of at least one month, seriously affect one’s ability to function and cannot be caused by substance use, medical illness or anything except the event itself.⁶

Subtype — Dissociation: This is now separate from symptom clusters and its presence can be specific. While there are several types of dissociation, only two are included in the DSM-5:

• Depersonalization or feeling disconnected from oneself
• Derealization, which is a sense that one’s surroundings are not real⁶

Additional Symptoms Associated With Complex PTSD

An individual who experiences a prolonged period (months to years) of chronic victimization and total control by another individual may be more likely to experience the following symptoms and behaviors, some of which are included in the PTSD DSM-5 diagnostic criteria.⁷

Emotional regulation: Persistent sadness, suicidal thoughts, explosive anger or inhibited anger.

Consciousness: Forgetting or reliving traumatic events or having episodes in which one feels detached from one’s mental processes or body (dissociation).

Self-perception: Helplessness, shame, guilt, stigma and a sense of being completely different from other human beings.

Distorted perceptions of the perpetrator: Attributing total power to the perpetrator, becoming preoccupied with the relationship to the perpetrator or a preoccupation with getting revenge.

Relationships with others: Isolation, distrust or a repeated search for a rescuer.

Systems of self-meaning: A loss of sustaining faith or a sense of hopelessness and despair.

Treatment for PTSD

Experimental research provides evidence that both biological and psychological interventions delivered relatively soon after trauma exposure have the potential to mitigate or even prevent the development of PTSD.

During exposure-based interventions, the therapist helps the client systematically approach, instead of avoid, safe but feared stimuli (e.g. the memory of the trauma or situations that remind him or her of the traumatic event). In the absence of the feared consequences (such as bodily harm or unending anxiety), the feared consequences are disconfirmed and the automatic fear response to trauma-related stimuli subsides. Cognitive-based therapies help people improve their ability to recognize dysfunctional and irrational thought patterns and develop new ones that support everyday functioning and well-being. Other types of therapy include eye movement desensitization and reprocessing and stress inoculation training. A wide variety of medications for PTSD have been investigated, with selective serotonin reuptake inhibitors (SSRIs) yielding the largest evidence base to date. Relapse may occur after the discontinuation of medications, whereas PTSD symptoms typically remain stable or continue to improve after completion of evidence-based psychotherapy.¹

Undiagnosed, untreated PTSD can lead to self-medication with alcohol, illicit drugs or prescription drugs, and even suicide. Self-medication often exacerbates the symptoms of PTSD and may lead to the development of co-occurring mental disorders. Problems associated with substance use disorders can overshadow PTSD, making it more difficult to diagnose and treat. If you or a loved one experienced trauma and are exhibiting symptoms of PTSD, the sooner you seek help, the greater the likelihood of recovery.

1. Lancaster CL, Teeters JB, Gros DF, Back SE. Posttraumatic Stress Disorder: Overview of Evidence-Based Assessment and Treatment. Lambkin FK, Barrett E, eds. J Clin Med. 2016;5(11):105. doi:10.3390/jcm5110105.
2. Complex Post Traumatic Stress Disorder (C-PTSD). Out of the Fog website. http://outofthefog.website/toolbox-1/2015/11/17/complex-post-traumatic-stress-disorder-c-ptsd Accessed December 11, 2016.
3. History of PTSD in Veterans: Civil War to DSM-5. U.S. Department of Veteran Affairs National Center for PTSD website. http://www.ptsd.va.gov/public/PTSD-overview/basics/history-of-ptsd-vets.asp Updated August 13, 2015. Accessed December 11, 2016.
4. How Common is PTSD? U.S. Department of Veteran Affairs National Center for PTSD website. http://www.ptsd.va.gov/public/PTSD-overview/basics/how-common-is-ptsd.asp Updated October 3, 2016. Accessed December 11, 2016.
5. Facts & Statistics. Anxiety and Depression Association of America website http://www.adaa.org/about-adaa/press-room/facts-statistics  Updated August 2016. Accessed December 11, 2016.
6. Symptoms & Diagnosis of PTSD. Psych Central website. https://psychcentral.com/lib/symptoms-and-diagnosis-of-ptsd/ Updated July 17, 2016. Accessed December 11, 2016.
7. Complex PTSD. U.S. Department of Veteran Affairs National Center for PTSD website. http://www.ptsd.va.gov/professional/PTSD-overview/complex-ptsd.asp Updated February 23, 2016. Accessed December 11, 2016.