Number of people exposed to traumatic events is on rise day by day. Despite of this increased rate of exposure, little is known about the disease, treatments available for preventing/relieving PTSD symptoms. As research is a continuous process and huge body of evidence is being added to the existing literature, it is very important to update ourselves. All the conclusions made by various researchers are the result of experiments performed in their set up which is different from ours. The applicability of those conclusions in our kind of population has to be evaluated and build our own body of evidence.

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INTRODUCTION
“Post Traumatic Stress Disorder” is a common, typical
chronic anxiety disorder usually develops in few people
after seeing or involving or living in event/ situation which
result in serious harm or death. [1] It is quite natural to feel
frightened or afraid, when a person is in danger. Our body
provide “Fight and Flight” response to avoid the danger
triggered by the fear. It is a healthy reaction meant to
protect from the serious harm or danger. [2] Any deviation
or damage of the above process will develop as PTSD. As a
result the individual may feel stressed or afraid even when
she/he is no longer in dangerous event. A person with
PTSD may have impairment in daily functioning, frequent
suicidal behavior and high rates of co-morbidity. The
incidence of PTSD may be due to multitude of factors such
as domestic violence, terrorism or war. Its incidence is
likely to increase in case of military populations in
particular because of ongoing, large-scale military
operations in the past decade. The rise in events like
international terrorism, natural disasters such as tsunami,
earth quakes and hurricanes will likely enhance the
prevalence of PTSD. [3]
SYMPTOMS OF PTSD
The core phenomenon of PTSD is the presence of traumatic
memories, which drive the hyperarousal, numbing and
avoidance. Somatic symptoms are the important triggers
for the ongoing memories of the traumatic events and
hence they are important aspect of clinical presentation. [5]
The symptoms of PTSD after heart attack are as follows:
associated with worse sleep quality, shorter sleep duration
and more sleep disturbances, use of sleeping medications
and daytime dysfunction due to poor sleep the night
before. [6]
EPIDEMIOLOGY OF PTSD
Prevalence of the exposure to traumatic events is
underestimated frequently and it requires direct
systematic enquiry while assessing patients. PTSD may
1Department of Pharm D, PRRM College of Pharmacy, Kadapa- 516001,
Andhra Pradesh, India.
E-mail: amarpdtr@gmail.com
*Corresponding author
2Department of Psychiatry, Rajiv Institute of Medical Sciences, Kadapa-
516001, Andhra Pradesh, India.
occur at any age, for anyone. It has a life time prevalence of
8 to 10%. In one of the study, the prevalence of PTSD
among adolescent boys was found to be 3.7% and among
girls it was 6.3%. [7] As per DSM-IV criteria, the projected
life time risk for occurrence of PTSD at the age of 75 years
is 8.7%. [8] PTSD includes survivors of physical and sexual
assault or abuse, war veterans, survivors of accidents,
disasters and many other serious events. Everyone with
PTSD may not go through a dangerous event. Some people
may get when loved ones experiences dangerous event or
is harmed. The sudden and unexpected deaths of friend or
family member may come under this. [1]
RISK FACTORS AND REASONS
Not everyone who involved in a dangerous event gets PTSD
but most of the people will get PTSD. Many factors
influence a person to get PTSD. The risk factors and
reseillance factors are common among all the factors. Risk
factors induce the PTSD in a person whereas reseillance
factors helps to reduce the risk of PTSD. The risk factors
include living through threatening events and traumas,
history of mental illness, getting hurt, seeing the people
hurt or killed, helpless, extreme fear, loss of social
support, loss of loved one/home/job. The reseillance
factors include seeking out support from the
family/friends, being able to act and respond effectively
instead of feeling fear. [9] By considering re-experiencing
symptoms, a pilot study on monozygotic twins showed
that PTSD patients have altered extinction of novel
conditioned fear stimuli. In a research article published in
journal psychological medicine, the researchers from new
Michigan state university had declared that people who
worry most of the time are at high risk for developing
PTSD. [10] The ongoing researches help to understand the
involvement of gene in creating fear memories. Few
examples are;
1. The lack of GRP (gastrin-releasing peptide) involves in
creation of everlasting or long lasting memories of fear
because GRP controls the fear response when its action
was checked in mice. Usually GRP releases in the brain
when a person face any danger or during emotional
events. [11]
2. Another research in mice showed that the protein called
“stathmin”, needed to form fearful memories. If the level
of stathmin made very less, then a protective response
to danger is automatically produced.
Post Traumatic Stress Disorder: An Updated Review
Amareswara Reddy G1*, Venkata Ramudu R2, Alekhya P1, Divyaja M1
Abstract: Every year millions of children and adults are exposed to at least one traumatic event such as war, motor vehicle
accidents, natural/human-made disasters, sexual assault, domestic violence or community violence, etc and the number is going
to rise day by day. Lot of literature has been published during the past decade and is still going on. The main objective of the
present review is to make physicians, other health care professionals and students understand the disorder – including signs
and symptoms, epidemiology, risk factors, diagnosis, various types of therapy, education to patient and family members etc,
with results of latest publications included in every category. Medline, medscape, science daily, various journal and textbook
articles have been searched with special focus on the works published in recent days. This review provides an overview of PTSD
stuffed with essential updates which are mandatory for every health care professional to know.
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3. Researchers have also found that a gene called ‘5-
HTTLPR’, which controls the serotonin levels in brain,
act as a fuel to the fear response. [12]
4. Dr. Ya-Ping Tang has found that timely attraction of a
specific neurotransmitter system in the brain at the
time of exposure to trauma is a good strategy in
preventing the PTSD pathogenesis. He has found that
CCKR-2 gene functions as a co-factor in the brain
together with trauma insult in the development of
PTSD. If once this experiment is validated in human
subjects, this findings help in aiming potential therapies
to cure or prevent PTSD. [13]
The combination of the following risk factors that affect
the early growth of the brain could be used to predict the
persons who will get PTSD. [1]
1. Individual genetic differences.
2. Environmental factors such as childhood trauma or
injury to the head or past history of mental illness.
3. Personality and cognitive factors such as optimism,
challenging tendency (either positive or negative).
4. Social factors such as availability and use of social
support.
In a study conducted at Utah, the researchers compared
physiological and emotional responses between two
Table 1: Symptoms of PTSD [4]
Re-experiencing symptoms The event is re-experienced by the person through flash-backs, night mares and frightening
thoughts.
Avoidance symptoms It includes staying away from places/events, emotional numbness, strong guilt, depression or
worry.
Hyper arousal symptoms It includes feeling tense or ‘on edge’, difficulty in sleeping, being easily startled and angry out
bursts. Among all the above symptoms, hyper arousal symptoms are stable; make it hard to do
daily activities such as eating, sleeping etc
Table 2: Diagnosis of PTSD [18]
Criteria Components
Criteria 1 It has four components.
x Directly experiencing the traumatic event(s)
x Witnessing, in person, the event(s) as it occurred to others
x Learning that the traumatic event(s) occurred to a close family member or friend
x Experiencing repeated or extreme exposure to aversive details of the traumatic event(s); this does not
apply to exposure through media such as television, movies, or pictures
Criteria 2 It involves the persistent re-experiencing of the event in 1 of several ways
x Thoughts or perception
x Images
x Dreams
x Illusions or hallucinations
x Dissociative flashback episodes
x Intense psychological distress or reactivity to cues that symbolize some aspect of the event
Unlike adults, children re-experience the event through repetitive play rather than through perception.
Criteria 3 The third criterion involves avoidance of stimuli that are associated with the trauma and numbing of general
responsiveness, as determined by the presence of 1 or both of the following:
x Avoidance of thoughts, feelings, or conversations associated with the event
x Avoidance of people, places, or activities that may trigger recollections of the event
Criteria 4 The fourth criterion is 2 or more of the following symptoms of negative alterations in cognitions and mood
associated with the traumatic event(s):
x Inability to remember an important aspect of the event(s)
x Persistent and exaggerated negative beliefs about oneself, others, or the world
x Persistent, distorted cognitions about the cause or consequences of the event(s)
x Persistent negative emotional state
x Markedly diminished interest or participation in significant activities
x Feelings of detachment or estrangement from others
x Persistent inability to experience positive emotions
Criteria 5 The fifth criterion is marked alterations in arousal and reactivity, as evidenced by 2 or more of the following:
x Irritable behavior and angry outbursts
x Reckless or self-destructive behavior
x Hyper-vigilance
x Exaggerated startle response
x Concentration problems
x Sleep disturbance
Criteria 6 The duration of symptoms is more than 1 month
Criteria 7 The disturbance causes clinically significant distress or impairment in functioning
Criteria 8 The disturbance is not attributable to the physiological effects of a substance or other medical condition
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groups: the military veterans and their partners. Among
these two groups veterans were diagnosed with PTSD and
their partners in the control group are not affected. They
are allowed to engage in a “disagreement task” which is
completely set in a clinically monitored environment.
Stunningly, the results showed that the partners of
veterans are at similar, if not greater, health risk. Great
emotional and physiological distress was seen in partners
of veterans diagnosed with PTSD. [14] More percentage of
adolescents aged 13 to 17 had been mostly exposed to at
least one of the traumatic event in their lifespan, including
interpersonal violence (such as rape, physical abuse or
witnessing domestic violence), injuries, natural disasters
and death of a close friend or family member and least with
3 or more events. In one of the study conducted by Herbert
Irving comprehensive cancer center (HICCC), the
researchers have found that among newly diagnosed
women with breast cancer, one in four (nearly 23%)
showed symptoms of PTSD, with high risk seen among
Asian and black women. [15] PTSD symptoms are also seen
in every one in three patients who stayed in ICU and
survived. They experience their flashbacks they had in the
hospital as hallucinations and delusions which actually had
not occurred. [16] If the mothers are suffering with PTSD or
with co-morbid PTSD and depression, then their children
are experienced with more traumatic events than their
mothers and the severity score of PTSD is more, then the
risk of child experiencing mental violent behavior and the
traumatic events number also increases. [17]
DIAGNOSIS OF PTSD
Recently, fifth edition of Diagnostic and Statistical Manual
of Mental Disorders (DSM-5) has suggested 8 criteria for
the diagnosis of PTSD. Previously PTSD was include in the
chapter called “Anxiety disorders”, but in the recent fifth
edition of diagnostic and statistical manual of mental
disorders, it is included in a chapter titled “Trauma and
stressor related disorders”. Along with minor revisions, the
six diagnostic criteria which were in DSM-IV are maintained
and in addition to them two criteria have been added.
TREATMENT
Very little is known regarding the effectiveness of
treatments in relieving and preventing symptoms of PTSD.
Even though many treatments are offered for the purpose
of preventing PTSD, many of them lack enough scientific
evidence. There is an immediate necessity to conduct
sound research studies in order to equalize the great
uncertainty while providing best care to the affected
patients. [19] PTSD can be treated by psychotherapy and
pharmacotherapy. Till date psychotherapy remains as gold
standard for treating PTSD while pharmacotherapy is
used to alleviate the symptoms associated with it. By
getting some sort of comfort through medicines, the
patient can easily face tough conditions or other
psychotherapies. [20]
Psychotherapy
“Psychotherapy” is an important ‘talk’ therapy. Talking to the
patient is a big support from the friends, family or
neighbors. Talking therapy lasts from 6-12 weeks or
sometimes it will be more. The psychotherapy alone is not
that much useful but it helps to some extent to treat PTSD.
There are many types of psychotherapy; among that
“cognitive behavioral therapy” is one helpful therapy.
Based up on the person’s need, the doctor can combine the
various types of therapies in the psychotherapy. [1]
Researchers from RIT international, the University of North
Carolina School of medicine have reviewed 6,647 abstracts
and found 21 trials and one cohort study which actually
met their inclusion criteria for review. Only few therapies
showed possible benefits for PTSD affected children.
Among them school based psychotherapy interventions
were most promising interventions that included cognitive
behavior therapy (CBT). In this review they did not find any
evidence of effectiveness for pharmacologic interventions.
Even though this review proved that psychotherapy
provides benefit to traumatic exposed children, still far
more research is warranted to make definitive conclusions.
[21]
1. Exposure Therapy
In this therapy, the danger/fear environment is created as
the patient experienced before in a safe way. This helps the
patient to face and controls the fear. By using the mental
imagery, writing and visits to the place (where the event
happened) the condition of the patient is analyzed and the
therapy is provided according to the patient need.
Exposure therapy is not associated with worsening of
symptoms or early dropout from treatment. [22]
2. Cognitive Restructuring
Often the patients with PTSD, remind the events in a bad
way, which actually not happened in that way
(misunderstanding) and they feel very guilt and sad about
the mistakes not actually done by them. So, the therapy
helps the person in making sense of bad memory and the
therapist helps the person to get rid of that guilt feel by
counseling the person in a realistic way.
3. Stress Inoculation Training
This therapy helps to reduce the anxiety, thereby reduces
the PTSD. It includes educating the patient regarding
trauma related symptoms and techniques to manage
anxiety such as assertiveness training, controlled breathing
and relaxation training, covert modeling, role playing and
thought stopping.[22]
People with PTSD should talk about all the options with
the therapist. Based on the goal of the therapy, the different
types of the therapy include;
1. Explain about the trauma and its effects.
2. Use relaxation therapy and anger controlling skills.
3. Provide tips for better sleep, good diet and exercise
habits.
4. Deal with the guilt, shame, sad and other feelings about
event of the patient.
5. Focus on changing the reaction of the patient to the
PTSD symptoms.
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Traumatic events like natural disasters, loss of loved
ones, sexual abuse, terrorist attacks are on rise day by day.
Though the number of individuals affected with PTSD is
increasing day by day, luckily, various research studies
have identified various psychological interventions which
ameliorate the PTSD symptoms. After testing for many
years, use of prolonged exposure therapy and cognitive
behavioral therapy proved to be more effective in solving
the trauma victims’ dysfunctional and distress related
problems. But Foa, the researcher of the study found out
that most of the mental health professionals won’t use such
evidence based therapies (EBT’s) while working with PTSD
patients. [23] Researchers from university of Michigan
health system have found that one group of patients who
underwent 8-week mindfulness therapy witnessed notable
decrease in symptoms compared to other group with
normal treatment. This method mixes the cognitive therapy
practice along with meditative approach of mindfulness
which stresses the awareness of all emotions and thoughts.
Significant betterment was seen in the mindfulness group
(73%) compared to normal treatment group (33%) after 8-
weeks of therapy. [24]
Pharmacotherapy
The diverse presentation of symptoms in PTSD and the
number of neurobiological systems that may be affected
present a challenge in the search for effective
pharmacological agents in treatment. [25] A pilot study
conducted among civilians showed that PTSD patients
who experienced peritraumatic tonic immobility at the
time of traumatic event have poor prognosis. [26] Taking
the medication may make it easier to go through
psychotherapy. The SSRI’s and SNRI’s are considered as
first line pharmacological choices for the treatment of
PTSD. The USFDA has approved 2 anti-depressant drugs
of SSRI class to treat the PTSD in adults. These are
Paroxetine and Sertraline. Paroxetine shows positive
effect over a placebo but NICE (National Collaborating
Centre for Mental health, 2005) guidelines doesn’t
recommend as a first-line treatment. It is recommended
as a second-line treatment. Due to some potential
problems paroxetine should be used cautiously. Sertraline
is widely recommended for PTSD as an effective
treatment. It is indicated for PTSD in females but not in
males in U.K. Positive findings have been obtained with
Sertraline in many studies. Fluoxetine belongs to SSRI
class but the results are less convincing when compared
to other drugs. But Fluoxetine and Citalopram can help
people with PTSD to feel less sad or tense. [27] The
continuation of maintenance treatment for 6-12 months
decrease relapse rates. The most common side effects of
SSRI’s include;
1. Headache (usually goes away within a few days)
2. Nausea (usually goes away within a few days)
3. Drowsiness or insomnia
4. Agitation
5. Sexual problems (common in both men and women)
6. Suicidal tendency
7. Withdrawal from social situations.
The quality of TCA’s and MAOI’s is inferior when
compared to SSRI’s. As the frequent complaint of PTSD
patients of disrupted sleep and as this problem doesn’t gets
completely cured with psychotherapy or SSRI’s sedative
tricyclic agent like Doxepin or Mirtazapine will be helpful.
[28] The efficacy of Amitriptyline was positive when
compared to Imipramine. Phenelzine (MAOI) is only
available drug for PTSD treatment but it is not known to be
efficacious. The other medications include Benzodiazepines
and Anti-psychotics. Benzodiazepines can help people to
sleep and relax but the problems with benzodiazepines are
“drug-dependence” and also have memory problems.
Another disadvantage of benzodiazepines is that they
contribute to emotional numbing of PTSD patient. [29]
Mirtazapine should be taken cautiously. Olanzapine was
not positive as a first- line therapy for PTSD. Among
atypical, more sedating of them will be effective in
alleviating hyper arousal symptoms. [30] Risperidone has
been investigated as an adjunct to other medications for
the therapy for PTSD. It alone is not efficacious. [8] Atypical
Anti-psychotics (Olanzapine, Risperidone) usually
prescribed to the people with other mental disorders like
schizophrenia. People who take anti-psychotics have the
problems such as weight gain and higher chance of getting
heart disease and diabetes. Among all paroxetine seem to
be effective in PTSD therapy. Amitriptylines have
decreased intrusive and increased arousal symptoms when
compared to paroxetine. Anti-adrenergic agents and D-
cycloserine are currently under development. [31]
SECOND LINE THERAPY
The non-SSRI’s such as Venlafaxine, Nefazodone,
Trazodone and Mirtazapine have been evaluated and
considered as second line therapy because of their
promising results and relatively good safety profile. Non-
adrenergic reuptake inhibitors found to be ineffective in
therapy of PTSD. Anti-convulsants such as Carbamazepine
and Valproic acid can be given if any comorbidity of bipolar
disorder exists. [11] Most of the drugs given to a PTSD
patient are addressing a particular symptom. When
hypervigilance and activation symptoms are seen in a
patient, beta blocker like Propranolol, alfa-1-antagonist like
Prazosin, an alfa-2-agonist like Clonidine might be quite
helpful. 10 mg three to four times daily is good starting
dose of Propranolol. Prazosin acts by decreasing CNS
adrenergic activity. Nightmares are other debilitating
complaints among PTSD patients. For this, Topiramate (25-
35 mg) or Clonidine (0.1-0.2 mg) during the bed time will
be particularly useful. While using these drugs, the patients
should be warned about the possibility of orthostasis when
they get up early in the morning [32]. D-Cycloserine, an
antibiotic is another drug proved to be effective in animal
models of conditioned fear. It is a partial agonist at the
NMDA glutamate receptor and we all know glutamate is a
major excitatory neurotransmitter found throughout the
nervous system. In future we may see PTSD patients taking
this medication along with exposure therapy. [33] At
American psychosomatic annual meeting held in 2011,
Douglas Delahanty et al., had presented the results of a
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study in which hydrocortisone was given 20 mg two times
a day for the patients who underwent recent trauma and
admitted in hospital. The patients were observed to have
less PTSD symptoms one and three months after trauma.
[34] After conducting lot of experiments on animals and
humans, the American societies for experimental biology
have suggested that, a neurotransmitter called
neuropeptide Y (NPY) has therapeutic role in PTSD.
Various human studies had indicated that NPY is associated
with flexibility to development of PTSD or it helps
ameliorate recovery from harsh effects of traumatic stress.
Upon systemic administration of NPY, undesirable side
effects were seen. Hence they have given intranasal
infusion of NPY to rats, a non-invasive method to bypass
BBB. Lower rise in plasma stress hormones was seen.
Hence this study provides proof concept of prophylactic
therapy for persons likely to undergo stress conditions
with non-invasive intranasal NPY. [35]
MEDICATION ADHERENCE IN PTSD
Medication compliance is the most important health
behaviors for the prevention of medical complications.
Non-adherence is common in PTSD patients, who are more
likely to report forgetting and deciding to skip their
medications. The prevalence of medication non-adherence
is higher in patients with PTSD and a recent history of
Myocardial infarction when compared to patients with
PTSD alone. PTSD may be putting the patients at elevated
risk for adverse outcomes due to co-morbidities as a result
of non-compliance. So clinicians should assess for
adherence problems in PTSD patients carefully. [36] In a
study conducted among stroke survivors diagnosed with
PTSD, they were found to more likely avoid treatment. The
study showed that around 65% of stroke survivors who
were diagnose with PTSD were failed to adhere to therapy,
when compared with 33% of those who were not affected
by PTSD. Nearly one in three (38%) of stroke survivors
with PTSD had many concerns regarding medicines
prescribed to them. [37]
TREATMENT AFTER MASS TRAUMA
Sometimes large numbers of people are affected by the
same event, this is called “mass trauma” (ex: terrorist
attacks, tsunami, earthquake, cyclones etc). After these
events, most people will affect with PTSD symptoms during
first few weeks. This is a normal as well as expected
response to serious trauma and for most people, symptoms
lessen with time generally. Most of the people can be
helped with basic support such as;
1. Getting them to a safe place
2. Seeing a doctor if injured
3. Getting food and water
4. Contacting loved ones or friends
5. Learning what is being done to help.
People in community may experience ongoing stress
from loss of jobs and schools and trouble paying bills,
finding housing and getting health care, as they try to
rebuild after a mass trauma. [4] This delay in community
recovery may in turn delay the recovery from PTSD. CBT is
very helpful to some people to relieve the severe stress
during the first couple weeks after a mass trauma. [10] The
“psychological first aid” is an approach to make people feel
safe and secure, connect people to health care and
overcome the stress. [1]
EDUCATION TO THE FAMILY MEMBERS
If a member of a family is detected with PTSD, then entire
family may get affected. The family members usually
experiences fear, anger, shock and pain due to their
concern for the affected person. Communication between
the family members and person affected with PTSD may get
affected. Physical/substance abuse, sleep disturbances are
also seen among family members. If such problems become
issues, they have to engage in counseling. For them, stress
Table 3: Steps to Improve the Detection and Treatment, Measures to Help the PTSD Patient
Steps to Improve the Detection and Treatment Measures to Help the PTSD Patient
x Using powerful new research methods
E.g.: brain imaging and the study of genes to find out the
reasons for PTSD and who most at risk is.
x Trying to understand why few people gets PTSD and
others do not. This help health care professional to
predict who might get PTSD and provide early
treatment.
x Focus on the ways of examining pre-trauma, trauma
and post-trauma risk and resilience factors all at
once.
x Looking for treatments that reduce the impact
traumatic memories have on our emotions
x Improving the screening methods for people with
PTSD, given early treatment tracked after a mass
trauma
x Developing new approaches in self-testing and
screening to help people
x Testing ways to help family doctors detect and treat
PTSD or refer people with PTSD to mental health
specialties.
x Get the right diagnosis and treatment
x Encourage him/her to visit the doctor
x Encourage them to stay in / follow the treatment
x Seek different treatment if his/her symptoms don’t get
better after 6 to 8 weeks
x Offer emotional support, understanding, patience and
encouragement
x Learn about PTSD , so that you can understand what the
patient is experiencing
x Talk to the patient and listen carefully
x Listen to the feelings of patient(friend/relative)
x Invite friend/relative out for positive distractions such as
walks, outings and other activities.
x Remind them that, with time and treatment, he/she can
get better
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and anger management therapy is good choice. They have
to be educated to maintain their outside relationships well
and encourage to be involved in pleasurable activities most
of the time.
HELPING OURSELVES
It is very hard/crucial to take the first step to help
ourselves. [2]
1. Talk to the doctor about treatment options
2. Engage in small activity
3. Exercise to relieve stress
4. Set realistic goals
5. Break up large tasks into small ones and set priorities
and do as you can
6. Spend most of time with loved or trusted ones
7. Expect the symptoms to improve gradually, not
immediately
8. Identify and seek out comforting situations, places and
people
CONCLUSION
Number of people exposed to traumatic events is on rise
day by day. Despite of this increased rate of exposure, little
is known about the disease, treatments available for
preventing/relieving PTSD symptoms. As research is a
continuous process and huge body of evidence is being
added to the existing literature, it is very important to
update ourselves. All the conclusions made by various
researchers are the result of experiments performed in
their set up which is different from ours. The applicability
of those conclusions in our kind of population has to be
evaluated and build our own body of evidence.
REFERENCES AND NOTES
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Cite this article as: Amareswara Reddy G, Venkata
Ramudu R, Alekhya P et al. Post Traumatic Stress
Disorder: An Updated Review. Inventi Rapid: Brain,
2014(3):1-7, 2014.
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