Post-Traumatic Stress Disorder (PTSD)

Etiology, Diagnosis, and Principles of Therapy

For a simpler guide for veterans: PTSD: A Guide to Recovery.

Post-Traumatic Stress Disorder (PTSD) is a delayed or prolonged response to a stressful event or situation (of either short or long duration) of an exceptionally threatening or catastrophic nature. This article examines the history of the diagnostic entity, modern approaches to diagnosis, treatment, and factors influencing the prognosis for rehabilitation.

1. Development of the Concept and Etiology

The phenomenon of PTSD as a formalized diagnostic entity arose from the need to systematize and validate mental disorders that develop in individuals who have experienced extreme stress. Historically, similar conditions were described under various terms: "soldier's heart" (American Civil War), "shell shock" (World War I), "combat fatigue" (World War II). However, these terms often carried a connotation of character weakness and did not reflect the full clinical picture.

A key moment was the study of the consequences of the Vietnam War. The widespread nature of delayed psychological disorders among veterans, which did not fit into existing diagnostic frameworks (such as anxiety or mood disorders), required a revision of classifications.

In 1980, the diagnosis of PTSD was officially included in the American classification of mental disorders (DSM-III). This was a recognition that the cause of the disorder is not an individual's internal predisposition, but the impact of an external traumatic factor that exceeds the adaptive capacities of the psyche. The modern concept extends the etiology of PTSD far beyond combat, including natural disasters, terrorist attacks, sexual and physical violence, severe traffic accidents, and other life-threatening events.

2. Diagnosis

The diagnosis of PTSD is based on a clinical interview and standardized questionnaires. The main diagnostic manuals are the International Classification of Diseases, 11th Revision (ICD-11, code 6B40) and the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5).

According to DSM-5, a diagnosis requires the presence of symptoms from four main clusters, lasting for more than one month and causing clinically significant distress or impairment in social and occupational functioning:

Intrusion Symptoms: Recurrent, involuntary, and intrusive distressing memories (flashbacks), nightmares, intense psychological or physiological distress in response to triggers that resemble the trauma.
Avoidance Symptoms: Deliberate attempts to avoid thoughts, feelings, memories, as well as people, places, and circumstances associated with the traumatic event.
Negative Alterations in Cognitions and Mood: Inability to remember important aspects of the trauma, persistent negative beliefs about oneself and the world, distorted cognitions about the cause or consequences of the trauma, anhedonia (loss of interest in significant activities), feelings of detachment.
Marked Alterations in Arousal and Reactivity: Irritability and angry outbursts, reckless or self-destructive behavior, hypervigilance, exaggerated startle response, problems with concentration, and sleep disturbances.

The diagnosis is confirmed only if the symptomatology cannot be explained by the effects of a substance or another medical condition.

3. Treatment Approaches

The modern standard of care for PTSD involves a comprehensive approach, the main components of which are psychotherapy and, if necessary, pharmacotherapy.

1. Psychotherapy

This is the first-line treatment. The following methods have the strongest evidence base:

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT): Considered the "gold standard." It includes psychoeducation, relaxation and stress management skills training, cognitive restructuring (working with dysfunctional thoughts and beliefs), and exposure therapy (gradual and controlled confrontation with traumatic memories in a safe environment).
Eye Movement Desensitization and Reprocessing (EMDR): A method that uses bilateral stimulation (e.g., eye movements, alternating taps) to facilitate the reprocessing of traumatic memories and reduce their emotional charge.

2. Pharmacotherapy

Used to manage the most severe symptoms (anxiety, depression, insomnia) and to enhance the effectiveness of psychotherapy.

Antidepressants: The first-line medications are selective serotonin reuptake inhibitors (SSRIs), particularly sertraline and paroxetine. They help stabilize mood, reduce anxiety, and symptoms of hyperarousal.
Other Medications: For specific symptoms, such as nightmares, prazosin (an alpha-blocker) may be used. The use of other classes of drugs (e.g., atypical antipsychotics) is considered on an individual basis.

4. Factors Influencing Rehabilitation

The prognosis and success of rehabilitation for PTSD depend on a combination of factors, which can be broadly divided into three groups:

1. Pre-traumatic Factors (before the event):

History of prior mental disorders.
Previous traumatic experiences, especially in childhood.
Low level of education and socioeconomic status.
Genetic predisposition to anxiety and mood disorders.

2. Peri-traumatic Factors (during the event):

Severity and intensity of the trauma: Direct threat to life, severe physical injuries.
Type of trauma: Interpersonal violence (rape, torture, combat) is a more powerful predictor of PTSD than impersonal events (e.g., natural disasters).
Level of dissociation: A feeling of unreality or detachment from one's body at the time of the trauma.

3. Post-traumatic Factors (after the event):

Social support: The presence or absence of support from family, friends, and the community is one of the key prognostic factors.
Timeliness and adequacy of help: Early access to specialized care significantly improves outcomes.
Secondary stressors: Subsequent life difficulties (financial problems, job loss, legal proceedings).
Coping strategies: The use of destructive strategies, such as avoidance or substance abuse, significantly worsens the prognosis. Conversely, active problem-solving strategies promote recovery.