Post-Traumatic Stress Disorder (PTSD)
General Psychiatry Article Disclaimer
- DSM-5 criteria or ICD-11 diagnostic requirements are used to structure the Clinical Features and Diagnosis section. The classification system used is selected according to its clarity and suitability for non-specialist learning.
- The criteria are summarised and simplified rather than reproduced in full, while preserving their original diagnostic meaning.
- Where appropriate, a student-friendly pattern-recognition summary is provided to highlight the most clinically and exam-relevant features.
Exam tip (re-psychiatry questions)
- Do not attempt to memorise every DSM-5 or ICD-11 criterion word-for-word. However, it is important to read through the criteria and become familiar with the key symptom clusters, duration thresholds, exclusions, and distinguishing features highlighted in this article.
- Exam questions may not provide every feature required to meet the full diagnostic criteria. Familiarity with the criteria can help one recognise the most likely diagnosis, exclude important alternatives, and narrow the differential diagnosis.
Causes
PTSD develops after exposure to actual or threatened death, serious injury, or sexual violence [Ref]
Exposure may occur through: [Ref]
- Directly experiencing the traumatic event
- Witnessing the event occurring to another person
- Learning that the event occurred to a close family member or close friend
- Repeated or extreme occupational exposure to distressing details of traumatic events (e.g. emergency responders)
NICE noted the following specific examples:
- Serious accidents
- Physical and sexual assault
- Abuse, including childhood or domestic abuse
- Work-related exposure to trauma, including remote exposure
- Trauma related to serious health problems or childbirth experiences (for example, intensive care admission or neonatal death)
- War and conflict
- Torture
Clinical Features and Diagnosis
High-yield pattern recognition for PTSD:
- Onset of stress symptoms after a traumatic event
- Symptoms must be present across all 4 clusters, including
- Intrusion (e.g. re-experiencing, intrusive memories, trauma-related nightmares or flashbacks)
- Avoidance (e.g. avoiding thoughts, conversations, people, places or activities associated with the trauma)
- Negative cognition and mood (e.g. persistent guilt or self-blame, negative beliefs, emotional detachment or loss of interest)
- Arousal and reactivity (e.g. hyperarousal, hypervigilance, exaggerated startle response, irritability, poor sleep or impaired concentration)
- Which lasts for >1 month
- That is causing significant distress or functional impairment
- Not better explained by a different underlying cause
According to the DSM-5 criteria, PTSD can be clinically diagnosed when ALL the following criteria are met: [Ref]
| Diagnostic criteria | Criteria description |
|---|---|
| Exposure to a traumatic event | Exposure to actual or threatened death, serious injury, or sexual violence (see above for examples) |
| Presence of PTSD symptoms | To diagnose PTSD, symptoms across all 4 clusters is necessary:
|
| Duration | Symptoms must persist for >1 month |
| Presence of functional impairment | The symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning |
| Exclusion of other causes | The disturbance must not be attributable to ANY of the following:
|
NICE noted the following specific symptoms that can be seen in PTSD:
- Re-experiencing
- Avoidance
- Hyperarousal (including hypervigilance, anger and irritability)
- Negative alterations in mood and thinking
- Emotional numbing
- Dissociation
- Emotional dysregulation
- Interpersonal difficulties or problems in relationships
- Negative self-perception (including feeling diminished, defeated or worthless)
PTSD vs Acute Stress Reaction
Key differentiating factors between acute stress reaction and PTSD: [Ref1][Ref2]
| Acute stress reaction | PTSD | |
|---|---|---|
| Symptom duration | 3 days to 1 month | >1 month |
| Symptom requirements | ≥9 of 14 symptoms, taken from any combination of intrusion, negative mood, dissociation, avoidance and arousal | Requires a minimum number from each of 4 mandatory symptom clusters |
Also see the Acute Stress Reaction article.
Management
Adults (≥18 y/o)
Standard management:
| Category | Indications | Description |
|---|---|---|
| Psychological therapy | 1st line management for PTSD | Offer individual trauma-focused CBT interventions, including:
Eye movement desensitisation and reprocessing (EMDR) can be considered / offered in non-combat-related trauma in the following scenarios:
Rationale: EMDR is not excluded from use in combat trauma-related PTSD, but its research base and clinical implementation are less extensive compared to civilian / non-combat trauma. Do NOT offer psychologically-focused debriefing |
| Pharmacological management | Only indicated if:
|
If pharmacological management is indicated:
Do not offer benzodiazepines or any other medications to prevent PTSD. |
Children (<18 y/o)
Offer psychological therapy
- 1st line: individual trauma-focused CBT
- Consider group trauma-focused CBT if the event led to large-scale shared trauma
- 2nd line: eye movement desensitisation and reprocessing (EMDR)
- Indicated after >3 months of traumatic event AND if there is a lack of engagement / response to CBT
Do NOT offer psychologically-focused debriefing
Do NOT offer pharmacological management to prevent or treat PTSD in those who are <18 y/o
References