Posttraumatic stress disorder (PTSD) is a psychiatric disorder that occurs in individuals who have experienced or witnessed a traumatic event, such as a:
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Serious accident
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Sexual assault
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Combat/war experience
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Natural disaster
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Terrorism act
It is a frequent psychiatric comorbidity in individuals with traumatic brain injuries (TBIs), especially in combat-exposed service members and veterans. It has received considerable attention after the conflicts in Iraq (Operation Iraqi Freedom [OIF]) and Afghanistan (Operation Enduring Freedom [OEF]), and together, PTSD and TBI have been termed the signature wounds of these conflicts. PTSD appears to be an important mediator of poor outcomes and negative sequalae after TBI. Diagnosis and treatment of PTSD after TBI can be challenging because of the overlap of core symptoms of these two conditions.
History of posttraumatic stress disorder
Extreme emotional reactions to traumatic events involving bodily harm or death have been noted throughout recorded history. Battle trauma and flashback-like dreams were described by Hippocrates (460–377 BCE). During World War I, the term shell shock was used to describe symptoms believed to be caused by the effects of direct cerebral trauma. However, many soldiers without evidence of head trauma presented with shell shock symptoms, leading to a controversy as to whether symptoms were neurogenic or psychogenic.
Up to as recently as World War II and the Vietnam War, understanding of this phenomenon was lacking, and stigma associated with PTSD continued. Although the most recognized setting for this reaction was in combat, similar reactions were noted among individuals exposed to other types of trauma. This realization lead to the current conceptualization of PTSD as a human response to psychologically overwhelming trauma. PTSD was first officially recognized as a disorder in 1980 in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III). It was classified as an anxiety disorder in DSM-III and DSM-IV and moved to a new category, trauma and stressor related disorders, with the release of DSM-5 in 2013.
Posttraumatic stress disorder prevalence
The lifetime prevalence of PTSD is around 6.8% among adults in the United States. Women’s lifetime risk for PTSD is twice that of men. Although exposure to significant stressors such as motor vehicle accidents, natural disasters, rape, and assault is common in civilian populations—with more than 75% reporting a lifetime exposure—only a small percentage of individuals develop PTSD. Risk factors for the development of PTSD include preexisting psychiatric conditions, poor social support, family history of psychiatric conditions, low IQ, and female gender.
Development of PTSD varies significantly based on the type of traumatic experience and individuals are most likely to develop PTSD after exposure to assaultive violence (including sexual assault) and combat. Prevalence rates of PTSD among Vietnam-era veterans range considerably, because most epidemiological data were collected well after the end of the war. Studies of veterans serving in the conflicts in Afghanistan and Iraq have shown a prevalence of PTSD ranging from 10% to 20% in combat-deployed individuals, more than twice the rate in civilian populations.
Comorbidities of posttraumatic stress disorder and other psychiatric disorders
PTSD is highly comorbid with other psychiatric conditions. Approximately 80% of individuals with PTSD have also been diagnosed with one or more additional psychiatric disorders (lifetime rates). Approximately half of people with PTSD also have major depressive disorder (MDD); 40% of those with PTSD have been diagnosed with generalized anxiety disorder. Over 20% of those with PTSD also have a substance use disorder, developed either as a consequence of PTSD or serving as a risk factor for the development of PTSD. Studies have found that 11% to 39% of bipolar patients also meet criteria for PTSD. PTSD is associated with an increased risk for suicide. Among people who have been diagnosed with PTSD at some point in their lifetime, approximately 27% have attempted suicide.
Prevalence of posttraumatic stress disorder in individuals with traumatic brain injury
Prevalence of PTSD varies depending on the severity of TBI. In a large, multisite prospective study of trauma patients, rates of PTSD at 12 months postinjury were highest for individuals with:
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No TBI (24%)
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Mild TBI (22%)
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Moderate TBI (19%)
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Severe TBI (17%)
It has been argued that rates of PTSD are lower in individuals with moderate to severe TBI because loss of consciousness and/or posttraumatic amnesia interfere with the process of encoding trauma-related memories. In contrast, among those with mild TBI (mTBI), combat-deployed samples have shown an increase in PTSD in service members who experienced mTBI with loss of consciousness (44% with PTSD) versus mTBI with alteration of consciousness (27%) or a nonbrain injury (16%). This finding, which has been replicated in other independent samples, suggests some type of neurochemical or neurobiological change may make an individual with mTBI more susceptible to the subsequent development of PTSD. This finding has also been shown in civilian samples.
Diagnosis of posttraumatic stress disorder
There is no biomarker or laboratory procedure used to diagnose PTSD. A semistructured, clinical interview of specific trauma-related symptoms remains the gold standard. Several self-report measures have been developed and validated for use with individuals who have experienced psychological trauma, although most are best used as screening tools. The diagnostic criteria for posttraumatic stress disorder are detailed in Table 39.1 .
| Criteria | Description of Symptoms |
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| Severe stressor | Person was exposed to death, threatened death, serious injury, actual or threatened sexual assault/violence through direct exposure, witnessing, indirectly (though a close friend or family member) or repeated indirect exposures in the course of professional duties (e.g., first responders) |
| Intrusion symptoms (one symptom required) | Recurrent, involuntary, and intrusive memories related to the stressor, including nightmares, flashbacks, and prolonged distress after exposure to trauma-related stimuli |
| Avoidance behaviors (one symptom required) | Avoidance of situations, external reminders, or thoughts associated with the traumatic experience |
| Negative alterations in cognition and mood (two symptoms required) | Feelings of guilt, persistent/distorted negative beliefs and expectations about oneself and/or the world, inability to recall key features of a traumatic event, persistent distorted blame of self/others for the event or its consequences, feeling emotionally alienated from others, constricted affect (inability to experience positive emotions), or markedly diminished interest in previously enjoyable activities |
| Alterations in arousal and Reactivity (two symptoms required) | Experiencing irritability, aggression, self-destructive behaviors, hypervigilance, exaggerated startle response, sleep disturbance, or problems with concertation |
| Duration | Persistence of symptoms for more than a month (note: delayed onset can occur) |
| Functional impact | Symptoms must be of sufficient severity to cause functional impairment in social and/or occupational functioning |
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