Traumatic stress disorder (PTSD) (Post traumatic stress disorder)

ICD-10F43.1	Post-traumatic stress disorder
DSM-5-TRF43.10	Posttraumatic Stress Disorder

1. Definition and nosology

Post-traumatic Stress Disorder (PTSD; ICD-11: 6B40; DSM-5-TR: F43.10) — a disorder developing after direct or witnessed exposure to actual or threatened death, serious injury, or sexual violence, characterized by three main symptom domains: Re-experiencing (intrusions), Avoidance, persistent sense of threat (ICD-11) / Cognitive-emotional changes and hyperarousal (DSM-5-TR).

2. History

• “Shell shock” (World War I), “combat fatigue” (World War II).
• DSM-III (1980) — “Posttraumatic Stress Disorder” — based on Vietnam veteran studies.
• DSM-5 (2013) — separated from anxiety disorders and moved to the “Trauma- and Stressor-Related Disorders” category; Criterion A narrowed (only specific trauma types).
• ICD-11 (2019) — a more compact diagnostic concept; Complex PTSD (6B41) officially recognized as a distinct category.

3. Epidemiology

• Lifetime prevalence: 3.9% (WHO World Mental Health), in the US ~6.8%.
• Sex: twice as common in females (due to risk of sexual violence exposure).
• Risk by trauma type: sexual violence ~50% PTSD, physical assault ~25%, accident ~10%, natural disaster ~5%.
• Comorbidity: MDD ~50%, GAD, panic, substance use, BPD, complex PTSD.
• Suicide risk is significantly elevated.

4. Etiology and pathogenesis

• Heritability 30–40%.
• Neurobiological — amygdala hyperreactivity, impaired prefrontal-amygdala regulation, hippocampal volume reduction, HPA axis dysregulation (paradoxically low cortisol).
• Trauma characteristics — severity, duration, perpetrated by others (intentional), occurrence in childhood.
• Risk factors — previous trauma, previous psychiatric history, lack of social support, female gender, peritraumatic dissociation.
• Protective — social support, post-traumatic meaning seeking.

5. Clinical features

Three main domains (ICD-11)

• Re-experiencing — intrusive memories, flashbacks, nightmares; acute distress and somatic reactions with triggers.
• Avoidance — avoidance of thoughts, feelings, reminders, situations related to trauma.
• Persistent sense of threat (hyperarousal) — hypervigilance, easily startled, sleep disturbance, irritability.

DSM-5-TR additional domain — cognitive-mood changes

• Negative beliefs (about self, others, the world).
• Anhedonia, social isolation.
• Numbing of feelings, persistent negative mood.

Duration

Symptoms ≥ 1 month; the onset may be delayed after the trauma (delayed onset > 6 months).

6. Diagnosis

6.1 Unified diagnostic criteria

A. Exposure to traumatic event (personal, witnessing, information about death/injury of close ones, repeated exposure to traumatic information in occupational context).

B. Re-experiencing (intrusive memories, flashbacks, nightmares).

C. Avoidance of trauma reminders.

D. ICD-11: persistent sense of threat; DSM-5-TR: cognitive-mood alterations + hyperarousal.

E. Duration ≥ 1 month.

F. Significant distress or functional impairment.

G. Exclusion of substance or medical condition.

6.2 Differences between sources

• DSM-5-TR: 4 symptom domains (intrusions, avoidance, cognitive-mood, hyperarousal); dissociative subtype qualifier (depersonalization/derealization); delayed onset.
• ICD-11 (6B40): 3 symptom domains (more compact); complex PTSD as a separate category (6B41).
• NICE NG116 (2018, Post-traumatic stress disorder): Diagnosis: structured clinical interview (CAPS-5).
• VA/DoD 2023: CAPS-5 is the gold standard for diagnosis; PCL-5 screening in primary medical care.

6.3 Diagnostic algorithm

1. Clinical interview + trauma history.
2. CAPS-5 (Clinician-Administered PTSD Scale) — gold standard structured interview.
3. PCL-5 (PTSD Checklist) — self-assessment screening, 20 items.
4. Comorbidity (MDD, GAD, substance, BPD, complex PTSD).
5. Suicide risk (C-SSRS).
6. Exclude medical conditions and traumatic brain injury (TBI).

6.4 Differential diagnosis

7. Examination and assessment

• CAPS-5 — gold standard.
• PCL-5 (20 items) — screening.
• PHQ-9, GAD-7, C-SSRS — comorbidity.
• Trauma history (LEC-5 — Life Events Checklist).

8. Treatment

8.1 General principles (VA/DoD 2023 · APA 2025 · NICE NG116 Consensus)

1. First-line: trauma-focused psychotherapy — individual format:
   • Prolonged Exposure (PE, Foa E.B.) — in vivo and imaginal exposure to traumatic memory.
   • Cognitive Processing Therapy (CPT, Resick P.A.) — cognitive restructuring; 12 sessions.
   • EMDR (Eye Movement Desensitization and Reprocessing, Shapiro F.) — bilateral stimulation + traumatic memory processing.
   • Trauma-Focused CBT (TF-CBT, Cohen J.) — in children and adolescents.
2. First-line pharmacotherapy: SSRI (sertraline and paroxetine — FDA approval for PTSD), SNRI (venlafaxine).
3. Second-line: mirtazapine, nefazodone (risk of hepatotoxicity — use with caution).
4. For nightmares — prazosin (α1 antagonist) — evidence base is controversial (Raskind 2003 positive, 2018 PACT trial neutral); individual response.
5. Adjunct — atypical antipsychotic (in refractory cases); benzodiazepines are contraindicated long-term (worsens PTSD course).
6. ECT — in refractory severe comorbid depression.
7. Treatment duration — psychotherapy 12–16 sessions; pharmacotherapy ≥ 12 months after remission.

8.2 Treatment methods

1. Prolonged Exposure (PE) — Foa (Foa E.B.) — Imaginal exposure to traumatic memory (repeated, sequential description) + in vivo exposure (to avoided situations). 10–15 sessions. Evidence: Foa E.B. et al. RCTs; the strongest evidence in meta-analyses.
2. Cognitive Processing Therapy (CPT) — Resick (Resick P.A.) — Cognitive restructuring — “stuck points” about trauma (safety, trust, power, self-esteem, intimacy). 12 sessions. Resick P.A. et al. RCTs.
3. Eye Movement Desensitization and Reprocessing (EMDR) — Shapiro (Shapiro F.) — Reprocessing traumatic memory with bilateral stimulation (eye movement, auditory, or tactile). 8-phase protocol. Evidence: Bisson J.I. et al. Cochrane 2013 — comparable effect to CBT.
4. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) — Cohen J.A., Mannarino A.P. — for children and adolescents aged 3–18 years; PRACTICE protocol (Psychoeducation, Relaxation, Affective modulation, Cognitive coping, Trauma narrative, In vivo, Conjoint sessions, Enhancing safety).
5. Clinician-Administered PTSD Scale (CAPS-5) — 30-item structured interview; gold standard.
6. PTSD Checklist (PCL-5 — Posttraumatic Stress Disorder Checklist) — 20-item self-assessment; screening and monitoring.

8.3 Differences between sources

• VA/DoD 2023 Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder: trauma-focused psychotherapy first-line (strong recommendation); pharmacotherapy as a first-line alternative; evidence for combination is insufficient (for or against); benzodiazepines contraindicated.
• APA 2025 PTSD Guideline (American Psychological Association; supersedes the 2017 edition): CPT, PE and trauma-focused CBT are first-line (strong recommendation); cognitive therapy, EMDR and narrative exposure therapy are second-line (conditional recommendation). VA/DoD 2023 and ISTSS 2018 place EMDR in the top tier alongside CPT and PE.
• NICE NG116 (2018): Trauma-focused CBT or EMDR; SSRIs second-line.
• ISTSS 2018: international recommendations.
• Critical Incident Stress Debriefing (CISD) — Cochrane (Rose S. et al. 2002) and NICE do not explicitly recommend; some studies show an increased PTSD risk.

9. Prognosis

• Trauma-focused psychotherapy yields significant improvement in most patients.
• Chronicity without early intervention.
• Comorbid MDD, substance use poor prognosis markers.

10. Myths and misconceptions

Myth 1: “PTSD only occurs in war veterans”

Evidence: PTSD can develop following any traumatic event — sexual violence (~50% prevalence), physical assault, accidents, natural disasters, medical procedures. Prevalence among veterans is high, but it is also widespread in the general population.

Myth 2: “CISD (Critical Incident Stress Debriefing) prevents PTSD after trauma”

Evidence: Cochrane (Rose S. et al. 2002) — CISD does not reduce PTSD risk, and in some studies increases it. NICE and VA/DoD do not explicitly recommend. Early intervention should be “watchful waiting”, with trauma-focused CBT only for symptomatic patients.

Myth 3: “The patient should not talk about trauma, ‘disclosure’ is harmful”

Evidence: Evidence-based trauma-focused therapies (PE, CPT, EMDR) work specifically with traumatic memory; effective in appropriate structured form. Avoidance strengthens PTSD.

Myth 4: “Benzodiazepines are a good treatment for PTSD”

Evidence: VA/DoD 2023, APA, NICE — Benzodiazepines contraindicated; worsen PTSD course, impair cognitive processing, high addiction potential.

Myth 5: “Forgetting traumatic memories is the main goal”

Evidence: The goal is not forgetting but living with the memory — emotional reaction decreases, but memory remains. The patient can talk about trauma without distress.

Myth 6: “Cannabis or cannabidiol (CBD) cures PTSD”

Evidence: VA/DoD — Cannabis not recommended; preliminary research exists, but insufficient for clinical guidance; THC may worsen PTSD course.

Myth 7: “MDMA-based therapy is an official treatment”

Evidence: MDMA-assisted psychotherapy is in the research phase; FDA 2024 approval request denied (further research required); not standard clinical practice.

Myth 8: “EMDR has weak evidence — just a placebo effect”

Evidence: Bisson J.I. Cochrane 2013, VA/DoD 2023 and ISTSS 2018 — EMDR is strongly recommended, with efficacy comparable to CPT and PE. The exception is the American Psychological Association (APA) guideline (2017, updated 2025), which places EMDR in the second line with a conditional recommendation, while CPT, PE and trauma-focused CBT receive a strong first-line recommendation.

11. Sources

1. WHO. ICD-11. 6B40 Post traumatic stress disorder. 2024.
2. APA. DSM-5-TR. 2022.
3. Department of Veterans Affairs / Department of Defense. Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. 2023.
4. American Psychological Association (APA). APA Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults. 2025 (supersedes the 2017 edition). https://www.apa.org/about/policy/guideline-ptsd-in-adults.pdf
5. NICE NG116. Post-traumatic stress disorder. 2018.
6. Bisson J.I., Roberts N.P., Andrew M. et al. Psychological therapies for chronic post-traumatic stress disorder (PTSD) in adults. Cochrane Database Syst Rev 2013;(12):CD003388.
7. Foa E.B., Hembree E.A., Rothbaum B.O. Prolonged Exposure Therapy for PTSD. Oxford Univ Press; 2007.
8. Resick P.A., Monson C.M., Chard K.M. Cognitive Processing Therapy for PTSD: A Comprehensive Manual. Guilford Press; 2017.
9. Rose S., Bisson J., Churchill R., Wessely S. Psychological debriefing for preventing post-traumatic stress disorder. Cochrane Database Syst Rev 2002;(2):CD000560.
10. Shapiro F. Eye Movement Desensitization and Reprocessing (EMDR) Therapy: Basic Principles, Protocols, and Procedures. 3rd ed. New York: Guilford Press, 2018.
11. Cohen J.A., Mannarino A.P., Deblinger E. Treating Trauma and Traumatic Grief in Children and Adolescents. 2nd ed. New York: Guilford Press, 2017.
12. Raskind M.A., Peskind E.R., Chow B. et al. Trial of prazosin for post-traumatic stress disorder in military veterans. N Engl J Med 2018;378(6):507–517.