Post-Traumatic Stress Disorder (PTSD)

Complex PTSD

Complex PTSD (C-PTSD) develops in response to prolonged or recurring trauma. C-PTSD is more likely when the trauma was experienced at a young age, when the individual had little or no hope of escaping the trauma, and when it was caused by someone they trusted, such as a parent or caregiver.

Experiences that may trigger C-PTSD include

• Child abuse (especially physical or sexual), neglect, or abandonment
• Being the victim of or witnessing prolonged domestic violence
• Kidnapping and being held hostage
• Torture
• Slavery and human trafficking, including being forced or manipulated into sex work
• Solitary confinement of prisoners
• Concentration camp experiences
• Genocide
• War

Symptoms of C-PTSD include those of PTSD but also difficulty controlling emotions, anger, distrust, hopelessness, emptiness, feelings of worthlessness, and difficulties with relationships and friendships. Some symptoms of C-PTSD align with those of borderline personality disorder and some people may be misdiagnosed with BPD.^[1][3]

Dissociative subtype

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) includes a dissociative subtype of PTSD. When exposed to reminders of the trauma, people with dissociative PTSD people don’t experience hyperarousal symptoms such as accelerated heart rate and sweating typical of people with PTSD. Instead, they present with dissociative symptoms, especially depersonalization and derealization.

• Depersonalization: the sense of being detached from the self and mental processes or outside of the body. People may feel they are observing themselves from distance or watching a movie of themselves.
• Derealization: a sense of being disconnected from the surrounding world, with everything feeling unreal, artificial, dream-like, foggy, and visually distorted.

It’s thought that this dissociation is a strategy to limit hyperarousal in PTSD. It’s associated with greater severity of PTSD, early life trauma, and more comorbid mental health conditions and is more prevalent in men.^[4][5]

Delayed-onset PTSD

In most people with PTSD, the symptoms emerge within three months of the traumatic experience. But in some people, the symptoms develop more than six months later, and sometimes even years later, leading them to be diagnosed with delayed-onset PTSD.

Intrusion symptoms

The traumatic event is persistently or recurrently re-experienced in one or more of the following ways:

• Flashbacks: reliving the traumatic event as if it were happening again
• Nightmares
• Unwanted upsetting memories
• Emotional distress after being exposed to reminders of the event
• Physical reactions to reminders, such as a racing heart and sweating

Avoidance symptoms

• Staying away from places, events, or objects that are reminders of the event
• Avoiding thinking or talking about the event

Arousal and reactivity symptoms

These symptoms begin or worsen after the trauma and are often present continuously, making it difficult to complete daily activities, sleep, and relax. They’re thought to be a result of an increased fight or flight response following trauma.

• Hypervigilance
• Feeling tense or on edge
• Heightened startle response
• Risky or destructive behavior
• Irritability, aggression, or angry outbursts
• Difficulty concentrating
• Difficulty sleeping

Mood and cognition symptoms

These include negative thoughts and emotions that began or worsened after the trauma:

• Inability to recall key events of the trauma
• Negative appraisal of the world and the future, hopelessness
• Difficulty experiencing positive emotions
• Emotional numbness
• Lack of interest in activities previously enjoyed
• Feeling detached from other people
• Exaggerated guilt or blame of others for causing the event^[6][7]

Symptoms of complex PTSD

Symptoms of C-PTSD include symptoms of PTSD and also:

• Negative self-concept, including feeling they are worthless, damaged, or evil; guilt; and sometimes having no sense of self
• Interpersonal difficulties, including avoiding relationships or finding them difficult, never feeling close to another person, feeling that no one can understand what happened to them
• Interpersonal sensitivity, including difficulty controlling emotions, angry outbursts, feeling distrustful of other people and having their feelings easily hurt
• Dissociative symptoms, including depersonalization and derealization
• Physical symptoms, such as headaches, dizziness, chest pains, and stomach aches
• Suicidal feelings and self-harm^[8]

Risk factors

Most people who experience a traumatic event won’t develop PTSD. 

Higher susceptibility to PTSD has been linked to:

• Genetics, which may account for 5% to 20% of the variation in PTSD risk following a traumatic event^[11]
• Childhood experiences, including trauma and family stressors, especially maternal distress and loss of a parent^[12]
• A history of mental health disorders such as depression, panic disorder, and OCD

Pathophysiology

During frightening or life-threatening events, the amygdala in the brain signals the body to release the stress hormones adrenaline, norepinephrine, and cortisol, putting us into fight or flight mode. In people with PTSD, this stress response is overactive and creates a neurological pattern in the brain. Even after the danger has passed, a hyperactive amygdala keeps firing, and the prefrontal cortex, which usually pumps the brakes on this fear response, is underactive. That’s why people with PTSD experience overwhelming fear reactions to small reminders of the trauma, have exaggerated fear reactions to harmless situations, and avoid situations that might trigger these responses.^[13]

Long-term exposure to these stress hormones, especially cortisol, can damage the brain’s hippocampus, the part responsible for storing and retrieving memories. This leads to the memory problems of PTSD, including the loss of some memories of the traumatic event and the frequent recurrence of other memories through flashbacks and nightmares. Additionally, people with small hippocampi might be more susceptible to developing PTSD.^[14]

Psychotherapy

Trauma-focused psychotherapy is the main treatment for PTSD, with many different modalities used and researched, especially cognitive-behavioral and behavioral therapies.

The American Psychiatric Association recommends as first-line treatments prolonged exposure therapy (PE), cognitive processing therapy, cognitive behavioral therapy (CBT), and cognitive therapy (CT).^[15] The Department of Veterans Affairs (VA) recommends PE, CPT, and Eye Movement Desensitisation and Reprocessing (EMDR).^[16]

In exposure therapy, the patient is brought into contact with reminders of the traumatic event to desensitize them and weaken the link between the triggers and trauma memories and the intense arousal states of PTSD. The exposure can be:

• imaginal: for example, the patient recounts the traumatic memory to the therapist multiple times
• in vivo: in real life. For instance, riding in a car if the trauma was a road traffic accident.
• interoceptive: in which a triggering feeling is generated physically. For example, running in place to elevate the heart rate.
• Virtual reality (VRET): use of a computer-generated visual environment. This method is particularly useful for combat veterans because they’re unable to be exposed in vivo to the traumatic event.

Prolonged exposure (PE) therapy combines exposure therapy and other psychotherapy elements in a structured way, in eight to fifteen weekly, 90-minute appointments. As many as 73% of participants may see clinically significant improvement.^[17]

Cognitive behavioral therapy (CBT), the patient learns to identify, challenge, and replace negative patterns of thought and behavior and develop coping mechanisms. Unhelpful thought patterns that may be challenged in PTSD include negative thinking, catastrophizing, and overgeneralizing bad outcomes.^[18]

Cognitive processing therapy is a type of CBT that teaches patients to challenge and modify unhelpful beliefs about the trauma and reach a new understanding of the traumatic event to reduce its negative impact on their life.^[19]

In eye movement desensitization and reprocessing (EMDR) the patient recalls the traumatic experience while experiencing bilateral stimulation (usually side-to-side eye movements or hand-tapping). It’s based on the theory that PTSD emerges because a distressing event wasn’t adequately processed by the brain and aims to change the way memories of it are stored.^[20]

Medication

Antidepressants, especially SSRIs and SNRIs, are the most commonly prescribed medication for PTSD. However, the effects are small and a meta-study suggests that a combination of psychotherapy and medication is no more effective than psychotherapy alone.^[21][22]

Recently there's been interest in the use of the party drug MDMA (ecstasy) to treat PTSD. A randomized controlled trial (RCT) found that one dose of MDMA, paired with psychotherapy, improved symptoms in 88% of participants without adverse effects.^[23] It's expected that the FDA will approve the drug for PTSD as early as 2023.^[24]