Post Traumatic Stress Disorder (PTSD) is an often underdiagnosed and complex mental illness. This article serves as an overview for the diagnostics, science, and treatment.

PTSD is a mental health condition that some people may develop after experiencing or witnessing a traumatic event. The event may be life threatening or highly stressful, perceived as life threatening and highly stressful, or experienced secondarily to someone else. Traumatic events may include but are certainly not limited to combat, sexual assault, car accidents, natural disasters, or the sudden death of a loved one (1). 

Traumatic or stressful events trigger the “fight or flight” response, which is the activation of the sympathetic nervous system. Triggering events are generally unexpected and out of the impacted individual’s control (2). Catecholamine hormones, such as adrenaline (epinephrine) and noradrenaline (​norepinephrine) are released to increase heart rate, dilate pupils, and increase the respiratory rate. These reactions evolved to help animals and humans defend themselves against danger. As time passes and the event is over, these reactions typically subside and the person returns to baseline. People with PTSD, however, experience fight or flight symptoms long after the event is over, which can lead to higher levels and various forms of anxiety, and increasing depressive and neurovegetative symptoms. PTSD can be very complex, and symptoms may come and go over time, especially in the context of triggers being introduced and removed. 

While PTSD can occur in anyone of any age, ethnicity, or gender, there are risk factors that make it more likely for some people to develop PTSD. These risk factors include exposure to traumatic events, extreme fear, limited support after the event, family history of mental health disorders, and additive stressors after the main traumatic event (3). Women are twice as likely as men to develop PTSD and Latinos, African Americans, and Native Americans are disproportionately impacted by the disorder (4). Resilience factors, like strong support systems and coping strategies, may reduce the chance of a person developing PTSD after a traumatic event. In other words, seeking mental health treatment immediately following a traumatic event will help you mitigate the risk of developing PTSD.

What are the diagnostic criteria?

PTSD is diagnosed in adults, adolescents, and children over the age of 6 using the DSM-5. It falls under the Trauma and Stressor Related Disorders Category. Professionals use the following criteria to diagnose patients:

A. Exposure To A Stressor (One Required)

• Direct exposure

• Witnessing the trauma

• Learning that a relative or close friend was exposed to a trauma

• Indirect exposure to aversive details of the trauma, usually in the course of professional duties (e.g., first responders, medics)

B. Experiencing Intrusion Symptoms (One Required)

• Unwanted upsetting memories

• Nightmares

• Flashbacks

• Emotional distress after exposure to traumatic reminders

• Physical reactivity after exposure to traumatic reminders

C. Avoidance of: (One Required)

• Trauma-related thoughts or feelings

• Trauma-related external reminders

D. Negative Alterations in Mood & Cognition (Two Required)

• Inability to recall key features of the trauma

• Overly negative thoughts and assumptions about oneself or the world

• Exaggerated blame of self or others for causing the trauma

• Negative affect

• Decreased interest in activities

• Feeling isolated

• Difficulty experiencing positive affect

E. Alterations in Reactivity and Arousal

• Irritability or aggression

• Risky or destructive behavior

• Hypervigilance

• Heightened startle reaction

• Difficulty concentrating

• Difficulty sleeping

F. Symptom Duration (Required)

• Experiencing symptoms for longer than one month

G. Functional Significance (Required)

• Symptoms impair daily functions, such as occupation, social situations, causing distress.

H. Exclusion (Required)

• Symptoms are not a cause of medication, substance use, or other illness.

In addition to meeting criteria for diagnosis, an individual experiences high levels of either of the following in reaction to trauma-related stimuli:

1. Depersonalization. An individual is an outside observer or detached from oneself in a dream-like state.

2. Derealization. Experiences a false reality, distortion, or a distance from the presence.

3. Delayed Specification. Full diagnostic criteria are not met until at least six months after the trauma(s), although the onset of symptoms may occur immediately.

What is the science behind PTSD?

The exact biochemical origins of PTSD are unclear, but researchers believe genetics, environment, risk factors, and resilience factors all play a role in the pathology of the disease. A core landmark of the disease is hormonal dysregulation of catecholamines, serotonin, and GABA (5). These hormones are all found in brain circuits that detect, process, and manage stress and fear responses. While there is still much to learn, recent research has unveiled neurochemical, structural, and functional factors of PTSD.

PTSD impacts a variety of brain structures and functions. For example, patients with PTSD have reduced hippocampal volume. The hippocampus is a structure involved in stress response (as well as other cognitive functions) and is susceptible to damage resulting from exposure to chronic stress. Reduced hippocampal volume can lead to increased inability to terminate the stress response, as well as impact the ability to convert short term memories to long term memories, which is thought to be a protective mechanism. It is unclear as to whether reduced hippocampal volume leads to increased susceptibility to PTSD, if PTSD leads to reduced hippocampal volume, or both (5).

The amygdala is an almond shaped structure located near the hippocampus that is involved in emotional processing. While it is unclear as to whether the structure of the amygdala differs in people with PTSD versus people without PTSD, imaging studies have clearly revealed hyperactivity of the amygdala in both traumatic and non-traumatic situations in people with PTSD versus people without PTSD (5). 

The medial prefrontal cortex of the brain inhibits the stress response and is involved in emotional reactivity via it’s connections with the amygdala. Patients with PTSD have been shown to have a reduction in prefrontal cortex volume. This reduction is correlated with PTSD symptom severity. Volume reduction is secondary to PTSD- it is not a risk factor like volume reduction in the hippocampus may be (5).

What are treatment options?

One of the core tenants of PTSD treatment is Trauma Informed Care (TIC). The TIC model emphasizes the need for practitioners to recognize the full impact of trauma on patients, and create trauma- sensitive and/or trauma- responsive services (6). TIC is designed to create a safe space for patients to explore the impact of trauma and develop a path to move forward, while mitigating the risk for re-traumatization. The patient’s strength, resiliency, and abilities are emphasized and used as tools to heal (7). 

Therapy is a common treatment modality for PTSD patients. Cognitive behavioral therapy (CBT) focuses on changing behaviors, thoughts, and feelings as a way to heal from trauma. Prolonged exposure is a form of CBT that works to slowly approach a patient’s memories, feelings, and beliefs about the trauma as a way to overcome the experience and heal. Cognitive processing therapy (CPT) focuses on helping patients modify and challenge beliefs about their trauma in order to fully process their experiences (8). Licensed mental health professionals help patients determine the best path forward based on their experiences, beliefs, and personal goals for healing. 

Many antidepressant, like selective serotonin reuptake inhibitors (SSRIs), are FDA approved for PTSD, but therapy is the primary treatment for PTSD. Your medication provider will be focussed on symptom control to allow for improved participation in therapy. Alpha blockers, like prazosin, clonidine, and gabapentin, may be used for nightmares and other fear center activity during sleep states. Improved sleep can be a game changer, but sometimes social anxiety and panic symptoms can remain overwhelming. Benzodiazepines, like Xanax, Ativan, and Klonopin, are not advised for treatment of PTSD given the high potential for substance abuse in this population. However, other anti-anxiety medications like gabapentin, propranolol, and hydroxyzine may be just as effective for as needed anxiety while minimizing risk to the patient.    

How can Modyfi help?

PTSD is likely underdiagnosed and often overlooked by providers as simply anxiety or depression. If you would like to learn more about PTSD, treatment options, including therapy and medications, we are here to help. Seeking guidance from a professional is a great first step to healing. At Modyfi, we take a holistic approach to care, looking at the whole person to develop an individualized, safe, and sustainable treatment plan. Our team of licensed therapists and medication providers are ready to work with you. When you're ready we are here, or you can schedule an appointment with us today. 

 1 https://medlineplus.gov/posttraumaticstressdisorder.html
2 https://www.ptsd.va.gov/understand/what/ptsd_basics.asp
3 https://www.nimh.nih.gov/health/publications/post-traumatic-stress-disorder-ptsd/ 
4 https://www.psychiatry.org/patients-families/ptsd/what-is-ptsd 
5 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3182008/ 
6 https://www.ncbi.nlm.nih.gov/books/NBK207195/ 
7 https://www.traumainformedcare.chcs.org/what-is-trauma-informed-care/ 
8 https://www.apa.org/ptsd-guideline/treatments