Posttraumatic Stress Disorder

Clinical picture

• Intrusions are involuntary and sensory rather than deliberate recall: flashbacks, nightmares, and cue-triggered distress with autonomic surge.
• Avoidance of reminders progressively narrows life domains, and patients present for insomnia, pain, or substance use rather than for trauma.
• Negative cognitions center on self-blame, permanent damage, and a foreshortened future, accompanied by persistent shame, guilt, and anger.
• Hyperarousal includes hypervigilance, exaggerated startle, irritability or aggression, reckless behavior, and fragmented sleep.
• Depersonalization or derealization mark a dissociative subtype associated with early, repeated interpersonal trauma and worse function.
• Children may show trauma reenactment in play, frightening dreams without recognizable content, and developmental regression rather than verbal report.

Criteria snapshot

• Requires exposure to actual or threatened death, serious injury, or sexual violence, directly, as a witness, by learning of it, or through repeated occupational exposure.
• Symptoms span four clusters: at least one intrusion, one avoidance, two negative alterations in cognition and mood, and two arousal or reactivity symptoms.
• Duration must exceed one month with clinically significant distress or impairment, and symptoms cannot be attributable to substances or medical illness.
• Specify with dissociative symptoms, or with delayed expression when full criteria are not met until at least six months after the event.
• A separate developmental criteria set applies to children age six and younger, requiring fewer symptoms and using behavioral anchors.

Neurobiology

• Amygdala hyperreactivity with reduced ventromedial prefrontal inhibition impairs fear extinction learning and, critically, extinction recall.
• Hippocampal volume reduction correlates with symptom severity and degrades contextual discrimination between genuinely safe and dangerous cues.
• The HPA axis shows low cortisol with enhanced glucocorticoid receptor sensitivity and exaggerated negative feedback, opposite the pattern in depression.
• Noradrenergic hyperactivity originating in the locus coeruleus underlies startle and nightmares and provides the rationale for prazosin.
• Twin heritability is roughly 30-40%, and FKBP5 variants interact with childhood adversity to raise risk after adult trauma exposure.
• Chronic PTSD carries elevated rates of cardiovascular disease, metabolic syndrome, autoimmune illness, and later dementia.

Psychology

• Two-factor learning theory: fear is classically conditioned to trauma cues, then avoidance is negatively reinforced and blocks natural extinction.
• Emotional processing theory holds that a fragmented fear structure must be activated and then met with corrective information to change.
• The cognitive model emphasizes stuck points, distorted appraisals of ongoing danger, self-blame, and beliefs assimilated to preserve prior worldview.
• Peritraumatic dissociation, prior trauma, low social support, and poor post-trauma support predict chronicity more strongly than event severity.
• Moral injury, institutional or caregiver betrayal, and guilt often respond better to cognitive approaches than to exposure-only protocols.

Differential & comorbidity

• Acute stress disorder covers 3 days to 1 month; adjustment disorder covers non-Criterion A stressors or subthreshold responses to trauma.
• Differentiate from panic disorder, OCD intrusions, traumatic brain injury sequelae, and psychotic disorders with true hallucinations.
• Comorbidity is the rule: major depression in about half of patients, alcohol or substance use disorders in 30-50%, and frequent chronic pain.
• Suicide risk is elevated roughly two- to threefold, so assess ideation, means access, and reckless behavior at every clinical contact.
• Screen veterans for TBI, obstructive sleep apnea, and hearing loss, since untreated sleep pathology blunts response to trauma therapy.

Pharmacologic treatment

• Sertraline 50-200 mg/day and paroxetine 20-60 mg/day are FDA-approved, and venlafaxine XR 75-225 mg/day has comparable evidence.
• Allow 8-12 weeks at an adequate dose; effect sizes are modest and VA/DoD guidance prefers trauma-focused psychotherapy first-line.
• Prazosin 1-15 mg at bedtime reduces trauma-related nightmares in many patients; titrate slowly and monitor orthostatic hypotension.
• Avoid benzodiazepines, which impair extinction learning, worsen long-term outcomes, and carry high dependence risk in this population.
• Do not use antipsychotics routinely; adjunctive risperidone showed no benefit over placebo in the large VA cooperative study.

Psychotherapy

• Trauma-focused therapies are first-line: prolonged exposure, cognitive processing therapy, and EMDR, each across 8-16 sessions.
• Cognitive processing therapy addresses stuck points over 12 sessions and can be delivered with or without a written trauma account.
• Prolonged exposure combines in vivo and imaginal exposure with post-exposure processing across 8-15 sessions of 60-90 minutes.
• Written exposure therapy achieves noninferior outcomes in only five sessions and produces markedly lower dropout rates.
• Trauma-focused CBT is the standard for children and adolescents, running 12-16 sessions with structured caregiver participation.

Adjunct options

• Administer the PCL-5 at baseline and every 2-4 weeks; a 10-20 point decrease indicates clinically meaningful improvement.
• Treat sleep directly with CBT-I and imagery rehearsal therapy, since residual insomnia and nightmares predict relapse.
• Concurrent treatment of substance use disorder alongside trauma-focused therapy outperforms requiring abstinence before starting.
• Aerobic exercise, trauma-sensitive yoga, and mindfulness lower hyperarousal but do not substitute for trauma-focused psychotherapy.
• MDMA-assisted therapy is not FDA-approved; the 2024 application drew a complete response letter and further trials are ongoing.

Clinical pearls

• Benzodiazepines block extinction learning; they make PTSD worse, not better.
• Prazosin at bedtime for nightmares; titrate slowly and check orthostatic vitals.
• Trauma-focused psychotherapy beats medication; lead with PE, CPT, or EMDR.