Some of the most important advancements in the diagnosis and treatment of mental health disorders in the last decade have come from an improved understanding of trauma and trauma-related disorders.
Post-traumatic stress disorder (PTSD) is arguably the most well-known trauma-related disorder. Improvements in its diagnosis and treatment have increased understanding of other conditions and changed the mental health landscape.
Growing public awareness of the experiences of traumatized veterans and victims of sexual assault is encouraging more people to open up about trauma-related distress, making PTSD an increasingly common diagnosis and focal point of mental health initiatives.
What Is PTSD?
Post-traumatic stress disorder is a heightened, prolonged stress response that develops into a chronic mental health condition. While most traumatized people experience symptoms of acute stress, not everyone who experiences trauma develops PTSD. The main factor that distinguishes PTSD is its persistence. People who develop the disorder spend long periods, often years, dealing with the aftermath of a traumatic event.
Post-Traumatic Stress Disorder Definition
Among the most extensive updates in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) were those to the definition of PTSD. First, the disorder was re-classified as a “Trauma and Stressor-Related Disorder,” whereas it was previously classified as an anxiety disorder in the DSM-IV. Second, trauma is now more specifically defined as an event belonging to one of the following four categories:
- Death
- Threatened death
- Actual or threatened serious injury
- Actual or threatened sexual violence
In addition, the definition of exposure to trauma was clarified and expanded to include four types of exposure:
- Direct exposure
- Witnessing in person
- Witnessing indirectly, by learning of a close friend or loved one’s trauma
- Repeated or extreme indirect exposure to aversive details of a traumatic event
Other symptom categories were also expanded and clarified. To be diagnosed with PTSD, a person must have one or more symptoms from each of the following categories:
- Intrusive symptoms: flashbacks, nightmares and unwanted memories
- Avoidance symptoms: avoidance of trauma-related thoughts and reminders
- Cognitive and mood symptoms: dissociative amnesia and blunted emotions
- Alterations in arousal and reactivity: hypervigilance and exaggerated startle response
These symptoms must persist for longer than one month and cause significant functional impairment or distress. The updated DSM-5 definition also added a new dissociative subtype of PTSD that features additional dissociative symptoms of depersonalization and derealization.
Related Stress Conditions That Can Lead to PTSD
Normal Stress Response
The normal stress response is the chain of internal events that motivates people to respond to circumstances they need to escape or avoid. People often call this the “fight or flight” response. The amygdala, the part of the brain responsible for emotional arousal, sends stress signals to the hypothalamus, which communicates with the autonomic nervous system. The sympathetic nervous system is activated and releases adrenaline. This causes several changes in the body, including the following:
- Increased heart rate
- Increased blood pressure
- Sharpened senses
- Rapid breathing
Cortisol levels rise to keep the body in this heightened mode until the threat passes. The main subjective effect of the normal stress response is anxiety. Memories of previously threatening situations surge into the brain, which suppresses sleep and the ability to experience pleasure.
Normally, these effects fade soon after the stressful event is over. However, chronic stress can prolong the normal stress response and have significant physical and psychological effects
Acute Stress Disorder
Acute stress disorder (ASD) is a trauma-related disorder listed in the DSM-5. Despite its name, it is triggered by trauma rather than acute stress and has a lot in common with PTSD. Like PTSD, it requires that a person experienced an event that involved actual or threatened death or serious injury and caused them to experience horror, fear or helplessness. To be diagnosed with ASD, a person must also experience at least nine of the following symptoms:
- Recurrent, unwanted memories of the traumatic event
- Frequent distressing dreams related to the traumatic event
- Dissociative reactions in which the person relives the event
- Intense or prolonged distress reactions to trauma-related cues
- Persistent negative mood and inability to experience positive emotions
- Depersonalization, derealization or an otherwise altered sense of reality
- Dissociative amnesia, or the inability to remember details of the trauma
- Attempts to avoid trauma-related memories, thoughts or feelings
- Significant efforts to avoid anything that triggers memories of the trauma
- Irritable behavior, angry outbursts or verbal or physical aggression
- Sleep disturbance and insomnia
- Problems with concentration
- Exaggerated startle response
- Hypervigilance
These symptoms must last at least three days and no longer than a month and must occur within a month of exposure to the traumatic event.
These criteria are slightly less complex than those for PTSD, though the main difference is in the duration and timing of the disorder. ASD is a risk factor for PTSD and can be understood as a precursor to it, though not all people who develop ASD end up having PTSD.
Types of PTSD
Uncomplicated PTSD
Uncomplicated PTSD is simply PTSD with no co-occurring conditions. It has been researched and found to be a normative and primary response to severe trauma even in people with no prior history of mental health problems.
It is common for people with PTSD to have one or more comorbid mental health disorders, which means their risks are higher and their treatment needs are more complex. When people have PTSD and no other conditions, treatment can be focused solely on trauma-related symptoms.
Comorbid PTSD
Comorbid PTSD is extremely common. About 80 percent of people with PTSD experience another mental health disorder in their lifetimes and about 50 percent have a secondary disorder concurrent with PTSD. The most common co-occurring conditions for people with PTSD are major depressive disorder, substance use disorders and anxiety disorders.
These secondary conditions require a more complex and multifaceted approach to PTSD treatment. Co-occurring substance use disorders are a particular concern. Substance abuse increases the general risk of impulsive harm to self or others, which is even further heightened when combined with the symptoms of PTSD.f
Complex PTSD
Complex PTSD occurs when a person is exposed to a series of ongoing traumatic events instead of an isolated traumatic incident. It is currently not a separate diagnosis in the DSM-5 but has been considered as a future addition. Complex PTSD is associated with the following kinds of traumatic situations:
- Prisoner-of-war camps
- Long-term domestic violence
- Human trafficking and forced sex work
- Long-term physical or sexual abuse in childhood
In general, any situation in which a person is repeatedly victimized by others can lead to the development of complex PTSD. In addition to regular PTSD symptoms, complex PTSD may include the following:
- Difficulties with emotional regulation
- Severe and frequent dissociative experiences
- Loss of meaning and prolonged feelings of helplessness or despair
- Social isolation, significant distrust of others or unstable relationships
- Preoccupation with the perpetrators, including fantasies of revenge
Standard PTSD interventions can still be effective, but additional therapeutic work may be necessary to help people with complex PTSD rebuild feelings of control and trust.
Causes of PTSD
PTSD causes and symptoms are more common than people may realize. Exposure to trauma is the main cause of PTSD, and millions of people are exposed to trauma every year.
According to Pew Research, about 7 percent of the United States population are serving or have served in the military and have potentially been exposed to war-related trauma. About 1 in 5 women and 1 in 71 men are sexually assaulted in the United States in their lifetimes. More than 40 percent of children from the ages of 0 to 17 years old are physically assaulted each year.
Post-traumatic stress disorder causes are complex and include other factors besides exposure to trauma. These include temperament, individual stress responses, inherited mental health risks and the overall amount of stress a person has experienced in a lifetime.
Symptoms of PTSD
Post-traumatic stress disorder symptoms fall into one of four main categories: intrusive symptoms, avoidance symptoms, mood and cognitive symptoms and reactivity symptoms.
Intrusive Symptoms
Intrusive symptoms are probably the most well-known PTSD symptoms and are the most frequently dramatized in popular media. These include flashbacks or dissociative reactions in which people feel as if they are reliving traumatic events. Flashbacks are more than memories. They are vivid, overwhelming multi-sensory experiences that provoke a stress response. Intrusive memories and nightmares are other common intrusive symptoms of PTSD.
Avoidance Symptoms
In order to be diagnosed with PTSD, a person must make persistent efforts to avoid intrusive symptoms and other distressing trauma-related experiences. These include efforts to avoid internal and external reminders of trauma as well as associated thoughts or feelings. These symptoms can drive people to seek external means to numb themselves, such as substance abuse and social withdrawal.
Mood and Cognitive Symptoms
People with PTSD often have a comorbid major depressive disorder. Even when they don’t, they typically experience PTSD symptoms that are depressive in nature. These include:
- Constricted affect
- Reduced self-esteem
- Guilt and self-blame
- Loss of interest in activities that were previously enjoyable
In addition to blunted emotions, people with PTSD may feel detached or estranged from others, deal with anhedonia and be unable to remember certain elements of the traumatic event.
Arousal and Reactivity Symptoms
Another well-known symptom of PTSD is an exaggerated startle response. In general, people with PTSD are more reactive to events around them. Their brains are constantly activating the stress response system, driving them into a state of hypervigilance. People with PTSD often become irritable and aggressive, more likely to lash out in response to perceived slights or to become self-destructive or reckless. They may have problems with concentration and sleep.
How Is PTSD Diagnosed?
Like all other mental health conditions, PTSD is diagnosed primarily through one or more clinical interviews in which a mental health professional asks targeted questions to determine whether a person meets the DSM criteria for the disorder. Sometimes screening tools, scales and assessments are used.
PTSD may develop immediately after a traumatic event or have a delayed onset of months or even years. People who start experiencing post-traumatic symptoms at any point after being traumatized should meet with a mental health professional to determine if they have PTSD.
PTSD Statistics & Facts
- Acute stress disorder occurs in 19 percent of people exposed to traumatic events.
- Almost 60 percent of people who are raped experience acute stress disorder, while 13 to 21 percent of people who are in a car accident experience the disorder.
- About 80 percent of people with PTSD have a co-occurring psychiatric disorder in their lifetime.
- Nearly 50 percent of people with PTSD have a co-occurring substance use disorder.
- Major depressive disorder affects 30 to 50 percent of people with PTSD.
- PTSD affects 3.5 percent of the adult population in the United States.
Who Is at Risk For PTSD?
Not everyone who is exposed to trauma develops PTSD. There are several additional PTSD risk factors, which include:
- Prior experience of trauma, including a history of childhood abuse
- Having other mental health conditions prior to trauma exposure
- Having pre-existing or concurrent substance abuse disorders
- Lacking sufficient social support or close relationships
- Having a family history of mental health problems
Having significant additional stressors after the trauma, especially serious stressors like job loss, the death of a loved one, dissolution of a close relationship or physical injury, can increase the risk of PTSD.
Drug or alcohol use and PTSD is common. People who grapple with a trauma disorder and addiction can experience health, social and legal problems that can persist for years. An accredited rehab center, like The Recovery Village, can help people with addiction or co-occurring disorders, like heroin addiction alongside PTSD, better manage their substance use and mental health issues.