Department of Psychiatry

Penn Behavioral Health

Post-Traumatic Stress Disorder


Symptoms

Posttraumatic Stress Disorder (PTSD) is a pathological anxiety disorder resulting after exposure to a traumatic event. Current literature estimates that 8% of the U.S. population meets the criteria for PTSD and while PTSD cases commonly involve combat or assault experiences, there is a wide range of events capable of triggering PTSD symptoms. These events include car accidents, kidnappings, terrorist attacks, natural disasters, and any other traumatic experience where an individual experienced or witnessed an event that involved death or the threat of physical harm.

For example, should a car accident occur, PTSD could result in the drivers, the passengers, or a witness; yet, the development of PTSD in one individual does not imply the development of PTSD in others involved in the incident. How one responds to an event is dependent on a variety of factors that lie outside the traumatic experience itself.

Common Symptoms

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), PTSD is characterized by the following primary symptom areas (applies only for adults and children over age 6):

  • Exposure to a traumatic event: Exposure to actual or threatened death, serious injury, or sexual violence in one or more ways, including:
    • Directly experiencing the event
    • Witnessing the event occur in person
    • Learning that the event happened to a close family member or close friend
    • Experiencing repeated or extreme exposure to distressing details of the event
  • Intrusion or re-experiencing: Recurrent recollections of the event
    • Dreams, intrusive memories, and discernable prolonged distress and physical reactions to cues that resemble the traumatic event
  • Avoidance: Fear and avoidance behavior
    • Avoidance of people, places, thoughts, feelings, or activities closely associated with the traumatic event
  • Changes in Mood and Cognition: Negative alterations in emotions or thoughts
    • Exaggerated negative beliefs and self-blame for the traumatic event, detachment from others, loss of interest, persistent negative emotional state, reduced ability to feel positive emotions
  • Arousal and Hyper-reactivity: Agitation, state of constant wakefulness and alertness
    • Hypervigilance, being easily startled, acting irritable or aggressive, recklessness, sleep disturbances, difficulty concentrating

Take, for example, somebody who witnesses a major car accident on a highway by their home. Over the following week, the individual begins to avoid driving on that highway and over the next month, avoids driving all together - either as a driver or a passenger. He/she may become irritable or angry while watching high-speed car chase scenes or avoid conversations about driving; yet, despite the apparent discomfort, the individual may refuse to discuss his/her fear. Moreover, although the witness is unwilling to discuss the fear or the traumatic event itself, he/she may still be haunted by the memory of the accident with segments of the event on “constant replay” in his/her mind.

Young children do not experience the same reliving of the experience as adults. The progression of PTSD in young children may initially involve dreams about the traumatic event, however, these dreams frequently transform into more generalized nightmares about monsters or different threatening situations where they or another person is in danger. It is more difficult for children to express their sentiments verbally. Therefore, it is necessary for parents or teachers or other adult observers to recognize behavioral changes such as a decreased interest in activity or an altered sense of the future (i.e. the child now believing that he/she will no longer live to become an adult). Other signs of childhood PTSD may occur in the form of repetitive play if the child begins to recreate the incident with toys or may occur through the emergence of physical symptoms such as headaches or stomach aches.

An individual’s PTSD might include symptoms such as feelings of shame, or less commonly, compulsive or aggressive behaviors, or self-destructive behavior. These cases often interfere with an individual’s personal life and thus, they are also associated with certain social patterns. These patterns may include sexual dysfunction, marital conflicts, and job loss. There are also strong feelings of guilt and despair that lead to social withdrawal and substance abuse.

Rare cases of PTSD may involve auditory hallucinations and paranoid ideation. Individuals who experience auditory hallucinations may experience tinnitus, a constant ringing in one’s ears, or they may hear a voice or set of voices that are not physically present. Individuals who are experiencing paranoid ideation are highly guarded and constantly suspicious of being harmed and harassed by those around them. When the trauma involves violent death, symptoms of both complicated grief and PTSD may be present.

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Onset & Course

The development of PTSD is somewhat unpredictable and can occur at any age. The severity and timing of PTSD symptoms differ with each individual; while symptoms usually begin within the first 3 months after the trauma, there can be a delay of months or even years before a person meets criteria to be diagnosed with PTSD.

PTSD typically develops immediately after the trauma. Nonetheless, in some cases symptoms may not emerge until years have passed since the event. Additionally, a traumatic incident may cause mild PTSD symptoms in one individual while chronically debilitating another. Duration of symptoms also varies, with some people recovering from trauma naturally in the first 3 months, and others experiencing symptoms for months or years.

All PTSD sufferers usually experience a range of symptoms after a traumatic episode. These symptoms are maintained through avoidance behavior and treatment must be actively pursued in order for complete recovery. Particular variables surrounding the traumatic event may, however, influence the development of PTSD. Elements that are known to make PTSD more likely are the following:

  • Perceived life threat
  • Personal injury
  • Interpersonal violence, particularly perpetrated by a caregiver
  • Past and present vulnerability, including genetics, childhood trauma, insufficient emotional support, concurrent causes of stress

Example: Childhood abuse and rape
Symptoms of PTSD may emerge later in life. Example: “When I was child, I was abused by my uncle. I was scared by it at first but I eventually came to accept it. He stopped when I was twelve (I have not seen him since). I tried to forget him and blocked the memory from my mind. I had a healthy romantic life throughout high school and college. I dated numerous people and have been involved in two serious relationships. Last year, however, my best friend was raped by a co-worker. I consoled her and she recovered from the experience but since then, I have not been able to stop thinking about my uncle..."

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What causes PTSD?

Why one person gets PTSD and not another is not completely understood. However, a traumatic experience is required for a diagnosis. Trauma events frequently associated with the development of PTSD include the following:

  • Physical, emotional, or sexual abuse
  • Combat experiences
  • Terrorist attacks
  • Natural disasters such as tornados, floods, earthquakes, or fires
  • Life-threatening accidents, such as automobile accidents, airplane crashes, or boating accidents both experienced or witnessed
  • Violent crimes, both experienced or witnessed

Epidemiological information

The prevalence of PTSD differs according to both gender and ethnicity. An estimated 8.7% of the U.S. adult population matches the criteria for PTSD with women more likely to develop symptoms than men. Compared with non-Latino European Americans within the U.S., elevated rates of PTSD have been reported mainly among U.S. Latinos, African Americans, and American Indians. Research also suggests that Asian-Americans have the lowest rates of PTSD within the country. These differences are attributed to a variety of cultural and socioeconomic phenomena.

Lower estimates are seen in Europe and most Asian, Latin American, and African countries, ranging from around 0.5% to 1%. This follows the general finding that developed countries have significantly lower rates of PTSD than the developing world. The prevalence of PTSD in the developing world is, however, reasonable given the harsher political and economic climates.

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More Information

National Institute of Mental Health (NIMH) - An organization with the National Institute of health dedicated to mental health research:
http://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml

Army Behavioral Health - A PTSD informational website provided by the U.S. Army Medical Department for the support of Soldiers and their families:
http://armymedicine.mil/Pages/behavioralhealth.aspx

National Center for PTSD (NCPTSD) - A center established by the U.S. Department of Veteran Affairs to improve the well-being of U.S. veterans through PTSD research and education:
www.ncptsd.va.gov/

 


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