Posttraumatic stress disorder: Epidemiology, pathophysiology, clinical manifestations, and diagnosis

INTRODUCTION

Posttraumatic stress disorder (PTSD) has been described as "the complex somatic, cognitive, affective and behavioral effects of psychological trauma" [1]. PTSD is characterized by intrusive thoughts, nightmares and flashbacks of past traumatic events, avoidance of reminders of trauma, hypervigilance, and sleep disturbance, all of which lead to considerable social, occupational, and interpersonal dysfunction.

The diagnosis of PTSD can be challenging because of the heterogeneity of the presentation and resistance on the part of the patient to discuss past trauma.

The diagnosis of PTSD is made in the subset of people who have experienced trauma who are unable to cope with the consequences of trauma and whose well-being over time is greatly impacted by these consequences. Concerns have been expressed about the potential to "over-medicalize" normal reactions to trauma, on one hand, while failing to recognize and address PTSD, on the other [2].

Pharmacotherapy and psychotherapy of PTSD are discussed separately. The epidemiology, pathophysiology, clinical manifestations, diagnosis, and treatment of PTSD with dissociative features are also discussed separately. The epidemiology, pathophysiology, clinical manifestations, diagnosis, and treatment of acute stress disorder are also discussed separately. (See "Pharmacotherapy for posttraumatic stress disorder" and "Psychotherapy for posttraumatic stress disorder" and "Dissociative aspects of posttraumatic stress disorder: Epidemiology, clinical manifestations, and diagnosis" and "Acute stress disorder: Epidemiology, clinical manifestations, and diagnosis" and "Treatment of acute stress disorder".)

EPIDEMIOLOGY

Many different types of trauma have been found to result in PTSD, including those listed below. Many of these events are common, resulting in a large number of affected individuals.

                

Subscribers log in here

To continue reading this article you must have access through your hospital or your group practice, log in to your personal subscription, or purchase a personal subscription. For more information, click below.
Literature review current through: Apr 2013. | This topic last updated: Nov 30, 2012.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2013 UpToDate, Inc.
References
Top
  1. van der Kolk BA, Pelcovitz D, Roth S, et al. Dissociation, somatization, and affect dysregulation: the complexity of adaptation of trauma. Am J Psychiatry 1996; 153:83.
  2. Stein DJ, Seedat S, Iversen A, Wessely S. Post-traumatic stress disorder: medicine and politics. Lancet 2007; 369:139.
  3. Resnick HS, Kilpatrick DG, Dansky BS, et al. Prevalence of civilian trauma and posttraumatic stress disorder in a representative national sample of women. J Consult Clin Psychol 1993; 61:984.
  4. Kessler RC, Sonnega A, Bromet E, et al. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry 1995; 52:1048.
  5. Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005; 62:617.
  6. Norris FH. Epidemiology of trauma: frequency and impact of different potentially traumatic events on different demographic groups. J Consult Clin Psychol 1992; 60:409.
  7. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005; 62:593.
  8. Stein MB, McQuaid JR, Pedrelli P, et al. Posttraumatic stress disorder in the primary care medical setting. Gen Hosp Psychiatry 2000; 22:261.
  9. Kroll J. Posttraumatic symptoms and the complexity of responses to trauma. JAMA 2003; 290:667.
  10. Vieweg WV, Julius DA, Fernandez A, et al. Posttraumatic stress disorder: clinical features, pathophysiology, and treatment. Am J Med 2006; 119:383.
  11. Liebschutz J, Saitz R, Brower V, et al. PTSD in urban primary care: high prevalence and low physician recognition. J Gen Intern Med 2007; 22:719.
  12. Bisson JI. Post-traumatic stress disorder. BMJ 2007; 334:789.
  13. Campbell DG, Felker BL, Liu CF, et al. Prevalence of depression-PTSD comorbidity: implications for clinical practice guidelines and primary care-based interventions. J Gen Intern Med 2007; 22:711.
  14. Spitzer C, Barnow S, Völzke H, et al. Trauma, posttraumatic stress disorder, and physical illness: findings from the general population. Psychosom Med 2009; 71:1012.
  15. Yehuda R. Post-traumatic stress disorder. N Engl J Med 2002; 346:108.
  16. Beals J, Manson SM, Whitesell NR, et al. Prevalence of DSM-IV disorders and attendant help-seeking in 2 American Indian reservation populations. Arch Gen Psychiatry 2005; 62:99.
  17. G. N. Marshall, T. L. Schell, M. N. Elliott, S. M. Berthold, and C. A. Chun. Mental health of Cambodian refugees 2 decades after resettlement in the United States. JAMA 2005; 294:571.
  18. Chivers-Wilson KA. Sexual assault and posttraumatic stress disorder: a review of the biological, psychological and sociological factors and treatments. Mcgill J Med 2006; 9:111.
  19. Steel Z, Chey T, Silove D, et al. Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis. JAMA 2009; 302:537.
  20. Grieger TA, Cozza SJ, Ursano RJ, et al. Posttraumatic stress disorder and depression in battle-injured soldiers. Am J Psychiatry 2006; 163:1777.
  21. Milliken CS, Auchterlonie JL, Hoge CW. Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. JAMA 2007; 298:2141.
  22. Hoge CW, McGurk D, Thomas JL, et al. Mild traumatic brain injury in U.S. Soldiers returning from Iraq. N Engl J Med 2008; 358:453.
  23. O'Toole BI, Catts SV, Outram S, et al. The physical and mental health of Australian Vietnam veterans 3 decades after the war and its relation to military service, combat, and post-traumatic stress disorder. Am J Epidemiol 2009; 170:318.
  24. Davydow DS, Gifford JM, Desai SV, et al. Posttraumatic stress disorder in general intensive care unit survivors: a systematic review. Gen Hosp Psychiatry 2008; 30:421.
  25. Edmondson D, Richardson S, Falzon L, et al. Posttraumatic stress disorder prevalence and risk of recurrence in acute coronary syndrome patients: a meta-analytic review. PLoS One 2012; 7:e38915.
  26. Walker EA, Katon W, Russo J, et al. Health care costs associated with posttraumatic stress disorder symptoms in women. Arch Gen Psychiatry 2003; 60:369.
  27. Koss MP, Woodruff WJ, Koss PG. Criminal victimization among primary care medical patients: prevalence, incidence, and physician usage. Behav Sci Law 1991; 9:85.
  28. Miller, TR, Cohen, MA, Wiersma, B. Victim costs and consequences: A new look. United States Department of Justice, National Institute of Justice, Research Report, Washington, DC 1996.
  29. Bremner JD, Randall P, Scott TM, et al. MRI-based measurement of hippocampal volume in patients with combat-related posttraumatic stress disorder. Am J Psychiatry 1995; 152:973.
  30. Karl A, Schaefer M, Malta LS, et al. A meta-analysis of structural brain abnormalities in PTSD. Neurosci Biobehav Rev 2006; 30:1004.
  31. Geracioti TD Jr, Baker DG, Ekhator NN, et al. CSF norepinephrine concentrations in posttraumatic stress disorder. Am J Psychiatry 2001; 158:1227.
  32. van der Kolk BA. The psychobiology of posttraumatic stress disorder. J Clin Psychiatry 1997; 58 Suppl 9:16.
  33. Kilpatrick DG, Koenen KC, Ruggiero KJ, et al. The serotonin transporter genotype and social support and moderation of posttraumatic stress disorder and depression in hurricane-exposed adults. Am J Psychiatry 2007; 164:1693.
  34. Broekman BF, Olff M, Boer F. The genetic background to PTSD. Neurosci Biobehav Rev 2007; 31:348.
  35. Binder EB, Bradley RG, Liu W, et al. Association of FKBP5 polymorphisms and childhood abuse with risk of posttraumatic stress disorder symptoms in adults. JAMA 2008; 299:1291.
  36. Breslau N, Chilcoat HD, Kessler RC, Davis GC. Previous exposure to trauma and PTSD effects of subsequent trauma: results from the Detroit Area Survey of Trauma. Am J Psychiatry 1999; 156:902.
  37. Schnyder U, Moergeli H, Klaghofer R, Buddeberg C. Incidence and prediction of posttraumatic stress disorder symptoms in severely injured accident victims. Am J Psychiatry 2001; 158:594.
  38. Halbauer JD, Ashford JW, Zeitzer JM, et al. Neuropsychiatric diagnosis and management of chronic sequelae of war-related mild to moderate traumatic brain injury. J Rehabil Res Dev 2009; 46:757.
  39. Schneiderman AI, Braver ER, Kang HK. Understanding sequelae of injury mechanisms and mild traumatic brain injury incurred during the conflicts in Iraq and Afghanistan: persistent postconcussive symptoms and posttraumatic stress disorder. Am J Epidemiol 2008; 167:1446.
  40. Davidson JR, Hughes D, Blazer DG, George LK. Post-traumatic stress disorder in the community: an epidemiological study. Psychol Med 1991; 21:713.
  41. Smid GE, Mooren TT, van der Mast RC, et al. Delayed posttraumatic stress disorder: systematic review, meta-analysis, and meta-regression analysis of prospective studies. J Clin Psychiatry 2009; 70:1572.
  42. Solomon SD, Davidson JR. Trauma: prevalence, impairment, service use, and cost. J Clin Psychiatry 1997; 58 Suppl 9:5.
  43. Wilcox HC, Storr CL, Breslau N. Posttraumatic stress disorder and suicide attempts in a community sample of urban american young adults. Arch Gen Psychiatry 2009; 66:305.
  44. Bernal M, Haro JM, Bernert S, et al. Risk factors for suicidality in Europe: results from the ESEMED study. J Affect Disord 2007; 101:27.
  45. Taft CT, Watkins LE, Stafford J, et al. Posttraumatic stress disorder and intimate relationship problems: a meta-analysis. J Consult Clin Psychol 2011; 79:22.
  46. Schnurr PP, Hayes AF, Lunney CA, et al. Longitudinal analysis of the relationship between symptoms and quality of life in veterans treated for posttraumatic stress disorder. J Consult Clin Psychol 2006; 74:707.
  47. Monson CM, Fredman SJ, Macdonald A, et al. Effect of cognitive-behavioral couple therapy for PTSD: a randomized controlled trial. JAMA 2012; 308:700.
  48. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed, American Psychiatric Association, Washington, DC 2000.
  49. Hoge CW, Castro CA, Messer SC, et al. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004; 351:13.
  50. Wilson JF. Posttraumatic stress disorder needs to be recognized in primary care. Ann Intern Med 2007; 146:617.
  51. Weathers FW, Juska JA, Keane TM. The PTSD checklist - civilian version. Boston National Center for PTSD. Boston Veterans Affairs Medical Center 1991.
  52. Blanchard EB, Jones-Alexander J, Buckley TC, Forneris CA. Psychometric properties of the PTSD Checklist (PCL). Behav Res Ther 1996; 34:669.
  53. Weathers, FW, Huska, JA, Keane, TM. The PTSD Checklist Civilian Version (PCL-C) Boston, MA: National Center for PTSD (Boston Veterans Affairs Medical Center.1991.
  54. Andrykowski MA, Cordova MJ, Studts JL, Miller TW. Posttraumatic stress disorder after treatment for breast cancer: prevalence of diagnosis and use of the PTSD Checklist-Civilian Version (PCL-C) as a screening instrument. J Consult Clin Psychol 1998; 66:586.
  55. Blake DD, Weathers FW, Nagy LM, et al. The development of a Clinician-Administered PTSD Scale. J Trauma Stress 1995; 8:75.