SYMPTOMS, ONSET, AND COURSE

Symptoms

The DSM-5 divides PTSD symptoms into four clusters: intrusion, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity (APA, 2013).

INTRUSION

Intrusion, one of the core symptom clusters of PTSD, can take the form of unwanted and obsessive thoughts, feelings, sensory experiences, or any combination of the three relating to the experienced trauma. These can include:

Involuntary, recurrent, and intrusive memories
Traumatic distressing dreams or nightmares
Dissociative reactions (flashbacks) in which the person feels or acts as if the traumatic event(s) were recurring
Intense or prolonged distress postexposure to internal or external cues symbolizing the event(s)
Marked physiological reactivity postexposure to internal or external cues

AVOIDANCE

Efforts persist to avoid distressing trauma-related stimuli , including:

Trauma-related thoughts or feelings
Trauma-related external reminders, such as persons, places, activities, situations, or objects

NEGATIVE ALTERATIONS IN COGNITION AND MOOD

Such alterations in cognitions and mood begin or worsen after the traumatic event and include:

Inability to recall important feature(s) of the event (dissociative amnesia)
Persistent and often distorted negative beliefs and expectations about self or others
Persistent blaming of self or others for the cause of the traumatic event or the consequences following the event
Persistent negative emotions related to the trauma, such as fear, anger, guilt, shame, or horror
Greatly reduced interest in normal activities
Feeling detached or estranged from others
Persistent inability to experience positive emotions

ALTERATIONS IN AROUSAL AND REACTIVITY

Alterations in arousal and reactivity begin or worsen after the traumatic event and include:

Irritability or aggressive behavior
Self-destructive or reckless behavior
Hypervigilance
Exaggerated startle response
Problems concentrating
Sleep disturbance

Onset and Course

The onset and course of PTSD is unpredictable, and the severity and timing of symptoms are different for each individual. Symptoms may appear immediately but generally present themselves within the first three months following exposure to trauma. There may, however, be a delay of months or even years before criteria are met for the establishment of a PTSD diagnosis.

The course of the illness also varies. Some people recover within 6 months, while others have symptoms that last for months or years. In some people, the condition becomes chronic (NIMH, 2019).

The prognosis of PTSD varies based on a number of factors, including resilience, secondary stresses, the level of support the person has, prior traumatic experiences, ongoing injury, and severity of the stress (Gore, 2018).

CASE

Alex

Alex Moore, age 29, was brought to the emergency department (ED) by his sister. She awoke in the night and found him writing a suicide note at the kitchen table. The smell of alcohol was on his breath, and there were bottles of both pain and sleeping pills beside him. Five weeks earlier, Alex had left his wife in Texas and driven to his sister’s home in California. Three weeks after that he got drunk, wrecked his truck, and became dependent on his sister for transportation. When she confronted him at the kitchen table, he said, “I’m no damn good to anyone. You’ll all be better off without me.” After much pleading, his sister talked Alex into going with her to the local hospital’s ED.

In the ED Alex’s manner was subdued but somewhat hostile, especially when the staff decided to admit him to the hospital as a “danger to self.” His sister gave further history: Alex and his best friend, Loren, joined the Marines together and were stationed in Iraq. They were both trained as medics. Alex and Loren were on patrol one night when a roadside bomb exploded and their vehicle blew up. Loren was engulfed in flames and did not survive, while Alex was thrown free and survived, blaming himself for being unable to save his friend.

Six months later, Alex was discharged from the military and has been functioning poorly ever since. He has not been able to “settle down” or keep a job and has had frequent outbursts of anger, difficulties in his marriage, trouble sleeping, nightmares that he refuses to discuss, difficulty concentrating, and chronic fatigue.

In the hospital Alex was passive, withdrawn, and irritable. He sat stone-faced in group meetings, refusing to participate. He was easily startled by sounds, avoided news programs and movies containing violence, and wandered around the ward checking doors and windows.
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Comorbidities and Consequences

Psychiatric comorbidity is high in patients with PTSD. Data from the National Comorbidity Survey suggests that 16% of patients with PTSD have one coexisting psychiatric disorder, 17% have two disorders, and 50% have three or more. Depressive disorders, anxiety disorders, and substance abuse are two to four times more prevalent in those with PTSD. Approximately 20% have reported use of alcohol or other substances in attempts to self-medicate and relieve tension.

People with PTSD also have increased rates of borderline personality disorder and antisocial personality disorder. These individuals have increased risk of suicide attempts and high levels of traumatic events in childhood.

Traumatic events and PTSD are also associated with physical health problems that include:

Bone and joint diseases
Neurologic, cardiovascular, respiratory, and metabolic diseases
Cardiovascular and pulmonary risk factors, including obesity, dyslipidemia, tobacco use, hypertension, and type 2 diabetes in women
Autoimmune and vascular dementia
Traumatic brain injury (TBI) among both civilians and military personnel
(Sareen, 2020)

PTSD AND TBI

Among American soldiers returning from combat in Iraq and Afghanistan, 11% screened positive for PTSD, but among those with mild TBI, 62% screened positive. Deployment-related TBI by itself is associated with an increased risk for PTSD during the year following injury (Sareen, 2020).