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Posttraumatic stress disorder (PTSD)
• 89.6% of Americans have been exposed to a traumatic event in their
lifetime
• Such common exposure results in fairly high prevalence rates of
PTSD, which afflicts approximately 6.8% of Americans
• a greater proportion of individuals living in less developed,
nonwestern nations dealing with wars, forced migration, and higher rates of
violence
• nearly 40% of individuals diagnosed with PTSD maintain significant
symptoms a decade after onset

DSM-5 diagnostic criteria for posttraumatic stress disorder

Criterion A: Traumatic event
Exposure to
1. actual or threatened death
2. serious injury
3. sexual violation

in one (or more) of the following ways:

1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the traumatic event(s) occurred to a close family member or
close friend.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic
event(s)

Directly experienced traumatic events

1. Exposure to war (combatant, civilian)
2. Threatened or actual physical assault
3. Threatened or actual sexual violence
4. Being kidnapped
5. Being taken hostage
6. Terrorist attack
7. torture
8. Incarceration as prisoner of war

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9. Natural or human-made disasters
10. Severe motor vehicle accident
Directly experienced traumatic events
Threatened or actual physical assault
1. Physical attack
2. robbery
3. mugging
4. Childhood physical abuse

Directly experienced traumatic events

Threatened or actual sexual violence
1. Forced sexual penetration
2. Alcohol/drug facilitated sexual penetration
3. Abusive sexual contact
4. Noncontact sexual abuse
5. Sexual trafficking
6. Developmentally inappropriate sexual experiences

Medical incidents that qualify as traumatic events

Sudden catastrophic events
1. Waking during sugary
2. Anaphylactic shock

Witnessed events
1. Observing threatened or serious injury
2. Unnatural death
3. Physical or sexual abuse of another person due to violent assault
4. Domestic violence
5. Accident
6. War or disaster
7. Medical catastrophe in one’s child
Indirect exposure
Violent or accidental experiences affecting close relatives or friends
1. Violent personal assault
2. suicide
3. Serious accident

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4. Serious injury

Criterion B: Intrusion
Presence of one (or more) intrusion symptoms
1. associated with the traumatic event(s)
2. beginning after the traumatic event(s) occurred

• e.g.
recurrent, involuntary, and intrusive distressing
1. memories
2. dreams
3. dissociative reactions
4. Psychological distress*
5. Physiological reaction*

*At exposure to internal or external cues that symbolize or resemble an aspect

of traumatic event.

Criterion C: Avoidance
Persistent avoidance of stimuli associated with the traumatic event(s)
beginning after the traumatic event(s) occurred

evidenced by avoidance of or efforts to avoid

1. either distressing memories, thoughts
2. or external* reminders
3. or both.

Criterion D: Negative alterations in cognitions and moods

Two (or more)
1. Dissociative amnesia
2. Negative believe about oneself, others, & the ward
3. Distorted cognition about the cause or consequences of
traumatic events
4. Negative emotion (fear. Horror, anger, shame, guilt)
5. Marked diminished interest in significant activities
6. Feelings of detachment from others
7. Inability of experience positive emotion

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• associated with the traumatic event(s)
• beginning or worsening after the traumatic event(s) occurred

Criterion E: Arousal and reactivity

Two (or more)
1. Verbal or physical aggression towards people or objects
2. Reckless or self-destructive behavior
3. hyper vigilance
4. Exaggerated startle response
5. Problem with concentration
6. Sleep disturbance
• marked alterations in arousal and reactivity
• associated with the traumatic event(s)
• beginning or worsening after the traumatic event(s) occurred

Criterion F: duration
• Duration of disturbance
• > 1 month

Criterion G:Functional significance

The disturbance causes clinically significant distress or impairment in
1. social
2. occupational
3. other important areas of functioning

Criterion H
The disturbance is not attributable to the physiological effects of a substance or
another medical condition
 Specify With delayed expression
 Full criteria are not met until at least 6 ms

The disorder may be specially severe or long-lasting when the stressor is

interpersonal & intentional (e.g. torture, sexual violence)

Associated features supporting the diagnosis

a) Developmental regression
i) loss of language in young children

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b) Auditory pseudo-hallucination
i) Hearing one’s thoughts spoken in one or more different voices
c) Paranoid ideation
d) Difficulties in regulating emotions
i)  Difficulties in maintaining
e) Dissociative symptoms
f) Problematic bereavement
i) When traumatic event produce violent death

Prevalence
a) Risk of developing PTSD after a traumatic event
i) 8-13% for men
ii) 20-30% for women
b) Male : female
i) 1:2
c) Lifetime prevalence estimated as
i) 8%
d) Rate of PTSD high among 
i) veterans
ii) police
iii) firefighters
iv) Emergency medical personnel
e) Highest rate (1/3 > ½)
i) Survivors of rape
ii) Military combat
iii) captivity
iv) Ethnically or politically motivated internment
v) genocide

Aetiology
a) Pretraumatic factors
b) Peritraumatic factors
c) Posttraumatic factors

a) Pretraumatic factors
i) Childhood emotional problem
ii) Prior mental disorder

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b) Peritraumatic factors
i) Severity of trauma
ii) Perceived life threat
iii) Personal injury
iv) Interpersonal violence
v) Military personnel
vi) Being a perpetrator
vii) Witnessing atrocities
viii) Killing the enemy
c) Posttraumatic factors
i) Negative appraisal
ii) Inappropriate coping
iii) Development of acute stress disorder
iv) Exposure to repeated reminder
v) Subsequent adverse life events
vi) Financial lose
Management of PTSD
1) Psych therapy
a) Cognitive-Behavioral Therapy
i) trauma-focused CBT is an effective treatment
ii) CBT techniques focus on having the patient confront rather than avoid his or
her traumatic memories while also confronting distorted cognitions
surrounding the trauma that allow PTSD symptoms to persist.

2) Cognitive-Behavioral Therapy
a) Exposure Therapy
b) Cognitive Processing Therapy
c) Eye Movement Desensitization and Reprocessing

Management of PTSD
Exposure Therapy
a. based on animal models of fear conditioning and extinction,
b. reduce the fear associated with a trauma memory by repeatedly exposing the
patient to that memory and reminders.
c. Theoretically, this repeated exposure habituates the patient to the fear
reminders, thereby reducing anxiety and thus avoidance of the memory and
reminders

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d. In turn, by no longer avoiding the memory, patients can emotionally process
what happened to them and thus correct distorted cognitions regarding the
trauma, with the ultimate goal of learning that their fear is unwarranted and
often also relieving other painful emotions such as shame and guilt.
e. Presentation of trauma-related stimuli can occur through imaginal, in vivo, or
virtual reality exposures while also combining cognitive therapy (CT)
techniques, specifically, Socratic questioning, during emotional processing.
f. PE is a specific program of ET that includes imaginal and in vivo exposure,
processing, education about common responses to trauma, and breathing
relaxation to make the exposure helpful and therapeutic
g. Among the various other treatment modalities, ET is considered the gold
standard and one of the first-line treatments for PTSD.

Cognitive Processing Therapy

CPT focuses on changing maladaptive cognitions or thoughts surrounding the
trauma instead of reducing fear via exposure.
CPT’s three main phases involve:
1) psychoeducation and identification of “stuck points”; identification of
overgeneralized, unhelpful beliefs regarding the trauma;
2) a narrative, written exposure component designed to have patients start to
challenge these beliefs; and
3) further challenging and reshaping of stuck points into healthier thought
patterns.

Cognitive Processing Therapy

 Overall, the goal of this treatment is to change the way the patient thinks
about what happened to him or her.
 Good evidence exists supporting the efficacy of CPT for PTSD treatment.

Eye Movement Desensitization and Reprocessing

EMDR is an eight-phase treatment that involves such cognitive-behavioral
elements as trauma-focused exposure and cognitive therapy but with the added
component of saccadic eye movements or some sort of bilateral stimulation.

Pharmacotherapy
its efficacy may not be as great as that of CBT.Most practice guidelines recommend
antidepressants, usually selective serotonin reuptake inhibitors (SSRIs) and the

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serotonin-norepinephrine reuptake inhibitor (SNRI) venlafaxine as first-line PTSD
treatments.
1) Antidepressants
a) SSRIs
i) sertraline
ii) paroxetine
b) TCAs
i) imipramine
ii) amitriptyline
c) MAOIs
i) phenelzine
d) SNRI
i) venlafaxine
e) noradrenergic and specific serotonergic and tetracyclic antidepressant
i) mirtazapine
f) novel antidepressant
i) nefazodone
g) norepinephrine and dopamine reuptake inhibitor
i) Bupropion
h) serotonin agonist and reuptake inhibitor
i) trazodone
2) Psychotropics
a) Anxiolytics
i) alprazolam
ii) clonazepam
b) anticonvulsants
i) topiramate
ii) valproate
3) Pharmacotherapy Augmentation
a) Atypical Antipsychotics
b) (risperidone and quetiapine)
i) monotherapy
ii) adjunctive therapy
c) Antiadrenergics
i) Prazosin (blocker of the 1 receptors)
ii) amitriptyline

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