Post-traumatic stress disorder
Exam Tips
- For OSCEs: always establish trauma exposure type, then explicitly screen the 4 PTSD domains (intrusion, avoidance, hyperarousal, negative mood/cognition) and duration >1 month with functional impairment.
- Differentiate acute stress disorder (<1 month) from PTSD (>=1 month) and mention that comorbidity with depression/anxiety/substance misuse is common rather than mutually exclusive.
- State first-line treatment as trauma-focused CBT or EMDR; medicines are adjunct/alternative when therapy is not possible or insufficient.
- In children, take a developmentally appropriate history directly from the young person as well as parent/carer, and look for play reenactment, regression, and school/social decline.
- Include safety: ask directly about self-harm/suicidality, substance use, domestic/ongoing threat, and safeguarding concerns.
Definition
Post-traumatic stress disorder (PTSD) is a trauma-related mental disorder that occurs after exposure to actual or threatened death, serious injury, or sexual violence (directly, as a witness, through traumatic loss of a close person, or repeated occupational exposure to traumatic details). It is characterised by persistent re-experiencing, avoidance, hyperarousal, and negative changes in mood/cognition lasting more than 1 month and causing clinically significant distress or functional impairment; a subset develop complex PTSD with additional severe affect dysregulation, persistent negative self-beliefs, and relational disturbance.
Pathophysiology
PTSD reflects maladaptive fear conditioning and impaired extinction: trauma cues become strongly linked to threat responses, so reminders trigger autonomic and emotional reactivity. Neurobiologically, models describe amygdala hyperreactivity (threat salience), reduced top-down control from medial prefrontal/anterior cingulate regions, and hippocampal dysfunction affecting contextual memory, producing intrusive fragmented recollections and overgeneralised danger responses. HPA-axis and noradrenergic dysregulation contribute to hypervigilance, sleep disturbance, and exaggerated startle; repeated trauma and limited social buffering increase risk of persistent symptoms and complex PTSD features. See figure of amygdala-hippocampus-prefrontal fear circuitry in standard psychiatry trauma chapters.
Risk Factors
- Exposure to severe interpersonal trauma (especially rape, sexual assault, physical assault) or prolonged/repetitive trauma
- High perceived threat to life, severe injury, bereavement, or major loss during/after the event
- Occupational exposure: armed forces, emergency services, frontline healthcare staff, journalists, prison staff
- Refugee/asylum-seeker status and conflict-zone exposure
- Female sex overall (pattern varies by trauma type and age)
- Younger age at trauma exposure
- Previous trauma, prior mental illness, and multiple concurrent life stressors
- Low social support/social disadvantage (strong predictor of persistence)
- In children: higher parental distress and poor family support increase risk
Clinical Features
Symptoms
- Intrusive memories, flashbacks, trauma-related nightmares (core symptom cluster)
- Avoidance of reminders, conversations, places, people, or thoughts linked to trauma
- Hyperarousal: poor sleep, irritability/anger, hypervigilance, exaggerated startle, poor concentration
- Negative cognitions/mood: guilt, shame, persistent fear, anhedonia, detachment, hopelessness
- Dissociation (depersonalisation/derealisation) and emotional numbing
- Risk behaviours: reckless/self-destructive behaviour, substance misuse
- Children: trauma reenactment in play, regression, separation anxiety, secondary enuresis, somatic complaints (headache/abdominal pain)
Signs
- Observable distress when discussing trauma or encountering cues
- Marked startle response and scanning/hypervigilant behaviour
- Autonomic arousal during triggers (tachycardia, sweating, tremor)
- Flattened/restricted affect or emotional disengagement
- Functional decline in work/school/relationships
Investigations
Management
Lifestyle Modifications
- Provide psychoeducation on trauma responses and expected recovery trajectories
- Ensure safety planning, crisis contacts, and active suicide-risk management when indicated
- Optimise sleep hygiene, reduce alcohol/recreational drug use, and encourage graded return to routine
- Mobilise social supports (family, peer, veteran/emergency-worker or survivor services)
- Offer/arrange trauma-focused psychological therapy as first-line (trauma-focused CBT or EMDR) via mental health services
Pharmacological Treatment
SSRI (first-line medicine when psychological therapy is declined, unavailable, or ineffective)
- Sertraline 25 mg once daily for 1 week, then 50 mg once daily; titrate by response up to 200 mg/day
- Paroxetine 20 mg once daily; may increase gradually to max 50 mg/day
Start low and review early for activation or suicidality (especially younger adults). Warn about GI upset, insomnia/sexual dysfunction, serotonin syndrome risk with interacting serotonergic drugs, and discontinuation symptoms if stopped abruptly. Paroxetine is generally avoided in pregnancy where possible due to fetal risk concerns; use shared perinatal risk-benefit discussion.
SNRI (specialist or second-line option)
- Venlafaxine modified-release 75 mg once daily, increasing to 150 mg once daily; usual max 225 mg/day
Monitor blood pressure (dose-related hypertension risk), withdrawal effects, and overdose toxicity. Consider interactions and bipolar history before prescribing antidepressants.
Adjunctive/symptom-targeted pharmacology (specialist-led, usually off-label for core PTSD)
- Mirtazapine 15 mg at night, increasing to 30-45 mg at night if needed
- Prazosin 1 mg at night, titrated cautiously (for severe trauma-related nightmares in selected cases)
Avoid routine benzodiazepines for PTSD due to dependence, falls/cognitive adverse effects, and poorer trauma-processing outcomes. Prazosin may cause first-dose and orthostatic hypotension; monitor BP. Use medicines alongside, not instead of, trauma-focused therapy where possible.
Complications
- Comorbid depression, generalized anxiety, panic symptoms, substance use disorders, somatic symptom disorder
- Suicidal ideation, self-harm, and increased suicide risk
- Relationship breakdown, social withdrawal, unemployment, and reduced educational/work performance
- Risky health behaviours (smoking, alcohol misuse, gambling-related harms)
- In children/adolescents: increased behavioural disorders (e. g, oppositional/conduct problems) and possible ADHD overlap
- Higher long-term physical morbidity (cardiometabolic disease, chronic pain, hypertension) and premature mortality
Prognosis
After trauma, many people have acute stress symptoms that settle within weeks; persistence beyond 1 month with functional impairment supports PTSD. Course is variable and may fluctuate with life stressors: untreated illness can persist for years, and full remission is not universal, but meaningful improvement is common with evidence-based trauma-focused therapy and/or appropriately monitored pharmacotherapy, even in longstanding cases. Poorer outcomes are associated with repeated trauma, comorbidity, ongoing threat, and weak social support.
Sources & References
🏥BMJ Best Practice(3)
✅NICE Guidelines(1)
- Post-traumatic stress disorder[overview]