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 psychological distress
  • Marked physiological reactivity postexposure to internal or external cues

AVOIDANCE

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

  • Avoiding thinking or talking about the event
  • Avoiding external reminders, such as persons, places, activities, situations, or objects
  • Inability to remember important parts of the trauma (dissociative amnesia)
  • Inability to experience positive emotions

NEGATIVE ALTERATIONS IN COGNITION AND MOOD

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

  • Persistent and often distorted blame of self or others
  • Persistent negative emotions related to the trauma, such as fear, anger, guilt, shame, or horror

ALTERATIONS IN AROUSAL AND REACTIVITY

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

  • Angry outbursts, irritability, or aggressive behavior
  • Self-destructive or reckless behavior
  • Hypervigilance
  • Exaggerated startle response
  • Problems concentrating
  • Sleep disturbance

SYMPTOMS IN CHILDREN AND TEENS

Children and teens can have extreme reactions to traumatic events, but symptoms may be different than those seen in adults. In children younger than age 6, symptoms can include:

  • Wetting the bed after having learned to use the toilet
  • Forgetting how to talk or being unable to talk
  • Acting out the scary event during playtime
  • Being unusually clingy with a parent or other adults

Older children and teens usually show symptoms more like those seen in adults. In addition, they may also develop disruptive, disrespectful, or destructive behaviors. They may also feel guilt over not preventing injury or death, or may have thoughts of revenge (NIMH, 2023b).

Onset and Course

Symptoms of PTSD usually begin within three months of the traumatic event, but they can sometimes emerge later. To be diagnosed with PTSD, a person must have all the following for at least one month; they must be severe enough to interfere with daily life, such as relationships or work; and they must not be related to medication, substance use, or other illness:

  • At least one re-experiencing symptom
  • At least one avoidance symptom
  • At least two arousal and reactivity symptoms
  • At least two cognition and mood symptoms

The course of the disorder varies, with some people recovering within 6 months, and others having symptoms that continue to occur for one year or longer (NIMH, 2023b).

CASE

Alex

Alex Moore, age 29, was brought to the emergency department (ED) by his sister. She awoke in the night and found Alex 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 provided a fuller history. She described an episode last summer involving Alex and his close friend from childhood, Loren. The two of them had gone out to a party one night and both had too much to drink. Alex, however, felt he was sober enough to drive, and they headed home. Along a narrow stretch of road that ran along the river, Alex was driving too fast and lost control. The car went over the edge of the road and landed in the water. Alex was able to get out of the vehicle, and he struggled to extricate Loren. Loren had been knocked unconscious in the accident and was unable to help himself. When Alex finally was able to get him free and up onto the riverbank, Loren was already dead.

Six months later, Alex was still struggling to come to terms with his role in Loren’s death. He lost his job due to angry outbursts and was having difficulties with his marriage, trouble sleeping, nightmares, 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 and wandered around the ward checking doors and windows.

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Comorbidities and Consequences

PTSD is commonly accompanied by comorbid psychiatric conditions, including depression, substance use disorders, and somatic symptoms. A person with somatic symptom disorder has a significant focus on physical symptoms to a level that results in major distress and/or problems functioning. The physical symptoms may or may not be associated with a diagnosed medical condition, but individuals believe they are truly ill.

A large U.S. sample demonstrated that almost one quarter of patients with PTSD had a diagnosis of borderline personality disorder (BPD). These individuals also have a high rate of antisocial personality disorder, with increased risk of suicide attempts and high levels of traumatic events in childhood.

Traumatic events and PTSD are also associated with physical health problems. Patients with PTSD have medical comorbidities between 1.5 and 3 times more commonly compared with individuals without PTSD. These include:

  • Bone and joint diseases
  • Cardiovascular diseases related to obesity, dyslipidemia, hypertension, and type 2 diabetes in women
  • Pulmonary diseases related to tobacco use
  • Autoimmune and endocrine diseases
  • Neurologic diseases including Alzheimer’s disease, vascular dementia, and Parkinson’s disease
  • Accelerated aging and early mortality
  • Traumatic brain injury (TBI) sequelae among both civilians and military personnel, which may include memory loss, seizures, fatigue, and paralysis
    (Sareen, 2023; APA, 2023)