History and exam
Key diagnostic factors
common
exposure and response to trauma
The person was exposed to actual or threatened death, serious injury, or sexual violence.[1]
Exposure was through one or more of the following means: (1) directly experiencing the traumatic event; (2) witnessing the event in person as it occurred to others; (3) learning that a close relative or close friend was exposed to trauma - if the event involved actual or threatened death, it must have been violent or accidental; and/or (4) repeated or extreme direct exposure to aversive details of the event(s), usually in the course of professional duties. This does not include indirect non-professional exposure through electronic media, television, films, or pictures.[1]
intrusion symptoms
Refers to involuntary re-experiencing of aspects of the traumatic event in a vivid and distressing way (e.g., flashbacks, intrusive images and sensory impressions, dreams/nightmares, emotional and physiological reactivity to internal and external cues).
Such re-experiencing arouses intense distress and/or physiological reactions.
These symptoms must persist for more than 1 month and cause functional impairment for a diagnosis to be made.
avoidance symptoms
Refers to persistent effortful avoidance of reminders of the trauma.
Patients typically avoid people, situations, or circumstances resembling or associated with the event. This may extend to more general avoidance of potential reminders, such as newspapers, television programmes, or films.
Patients often try to push memories of the event out of their mind and avoid thinking or talking about it in detail, particularly about its worst moments. However, many ruminate excessively about questions that prevent them from coming to terms with the event.
These symptoms must persist for more than 1 month and cause functional impairment for a diagnosis to be made.
negative alterations in cognitions and mood
Refers to alterations in beliefs and mood that either began or worsened after the traumatic event.
These changes include a diminished ability to experience positive feelings and feelings of closeness to others, persistent negative/distorted beliefs, distorted ideas of blame, loss of interest in significant activities, and inability to recall key aspects of the traumatic event.
These symptoms must persist for more than 1 month and cause functional impairment for a diagnosis to be made.
alterations in arousal and reactivity
Include hypervigilance for threat, exaggerated startle response, irritability, angry outbursts, self-destructive or reckless behaviours, difficulty concentrating, and sleep problems.
These symptoms must persist for more than 1 month and cause functional impairment for a diagnosis to be made.
Other diagnostic factors
common
depression
Frequently comorbid.
alcohol or substance misuse
Many people misuse both alcohol and a range of drugs in an attempt to cope with their symptoms.
anxiety
Frequently comorbid.
Risk factors
strong
serious accident
experience or witness of violence or domestic violence
natural disaster
terrorist attack
torture
combat exposure
traumatic brain injury
Classified as a peri-traumatic risk factor. Mild traumatic brain injury (i.e., concussion) that occurred among soldiers deployed in Iraq was strongly associated with post-traumatic stress disorder 3-4 months after the soldiers returned home.[37]
sudden death of loved one
sexual abuse or assault
Classified as a peri-traumatic risk factor. Sexual abuse is associated with a lifetime diagnosis of post-traumatic stress disorder (PTSD).[38] Of those exposed to rape, 10% to 45% develop symptoms of PTSD.[36][39] Of those exposed to sexual abuse in childhood, approximately 40% develop symptoms.[40] Those victimised by an attacker are at a higher rate of retraumatisation.
Childhood abuse increases the risk of adult victimisation and development of PTSD.[4][40]
victimisation by attacker
Classified as a peri-traumatic risk factor. Those victimised by an attacker are at a higher rate of retraumatisation.
Childhood abuse increases the risk of adult victimisation and development of post-traumatic stress disorder.[4]
previous trauma
Classified as a pre-traumatic risk factor. Those previously traumatised are at a higher rate of retraumatisation.
Childhood abuse increases the risk of adult victimisation and development of post-traumatic stress disorder.[4]
multiple major life stressors
Classified as a pre- and post-traumatic risk factor. Those affected are at greater risk than those exposed to a single stressor.[41]
A sizeable percentage of patients, particularly crime victims, have experienced more than one type of event. Many victims experience events that occur repeatedly over time (e.g., physical abuse by parents, sexual assault by relative, or domestic violence). Chronicity of exposure to stressors is associated with greater risk and a more complex clinical picture.[42]
low social support
Classified as a pre- and post-traumatic risk factor. Individuals with low levels of social support are typically at greater risk of post-traumatic stress disorder (PTSD) after traumatic events than those with higher levels of support.[16][17][43]
In meta-analyses, social support has emerged as one of the strongest predictors of PTSD status.[16][17]
history of mental disorder
Classified as a pre-traumatic risk factor. Those affected are at increased risk of both trauma and post-traumatic stress disorder (PTSD) symptoms. Children with behavioural disorders that develop before the age of 15 years (e.g., conduct disorder developing into adult antisocial personality disorder) also have an increased risk.[44]
Also, PTSD increases the risk of mental disorders (i.e., affective disorders, anxiety disorders, and substance misuse). Approximately one or more psychiatric disorders are present in 88.3% of men and 79% of women with PTSD.[33]
history of drug and alcohol use
Classified as a pre-traumatic risk factor. Affected people are one-and-a-half times more likely to endure trauma, thereby increasing risk.[33]
weak
female sex
Classified as a pre-traumatic risk factor. Women have approximately twice the risk of post-traumatic stress disorder (PTSD) compared with men.[35] It is unclear whether this reflects increased vulnerability to PTSD, or a greater exposure to potentially traumatic experiences.[45] Women are much more likely than men to experience sexual assault; US data indicate that around 25% of women compared with approximately 4% of men experience completed or attempted rape in their lifetime.[46] The majority of survivors of sexual assault experience acute traumatic stress symptoms, with 74.6% meeting diagnostic criteria for PTSD at 1 month and 41.5% at 1 year.[47] One in three women experience a traumatic childbirth, with 3% to 6% of all women giving birth developing postpartum PTSD; however, this is often not recognised or misdiagnosed as postnatal depression.[48]
The prevalence of PTSD is similar among men and women exposed to events such as accidents, natural disasters, or the death of a loved one.[49]
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