Posttraumatic stress disorder (PTSD) is a psychiatric disorder that may occur after experiencing or witnessing a traumatic event. Common symptoms include intrusive memories, nightmares, avoidance of trauma-related stimuli, negative changes in mood and cognition, and increased arousal and reactivity. Risk factors include prior trauma, lower socioeconomic status, childhood adversity, and female gender. Treatment involves trauma-focused psychotherapy such as cognitive behavioral therapy (CBT) with exposure therapy or cognitive processing therapy. Selective serotonin reuptake inhibitors (SSRIs) or venlafaxine may also be used as a second-line treatment.

1. PTSD
THINESH KUMAR

2. • Posttraumatic stress disorder (PTSD) is a psychiatric disorder that may occur in
people who have experienced or witnessed a traumatic event, series of events or set
of circumstances.
• An individual may experience this as emotionally or physically harmful or life-
threatening and may affect mental, physical, social, and/or spiritual well-being.
• Examples include natural disasters, serious accidents, terrorist acts, war/combat,
rape/sexual assault, historical trauma, intimate partner violence and bullying,

4. RISK FACTORS
• • Prior mental disorders
• • Exposure to prior trauma
• • Lower socioeconomic status
• • Lower education
• • Childhood emotional problems by age 6 yrs.
• • Childhood adversity
• • Economic depravation, family dysfunction, parental separation or
death
• • Lower intelligence
• • Family psychiatric history
• • Younger age at time of trauma exposure (for adults)

5. • • Female gender
• • Proximity to event
• • Intensity of event
• • Personal injury
• • Particularly trauma perpetrated by caregiver
• • For military: being perpetrator, witnessing atrocities, killing
enemy
• • Persons with concussion and TBI run higher risk for
developing PTSD

6. DIAGNOSIS
• A psychological evaluation that includes a discussion of your signs
and symptoms and the event or events that led up to them
• Can be screened using questionnaires such as PCL-5, IESR
• Use the criteria in the Diagnostic and Statistical Manual of Mental
Disorders (DSM-5), published by the American Psychiatric
Association

7. CRITERION A
• Exposure to actual or threatened death, serious injury, or sexual
violence in one (or more) of the following ways:
• 1. Directly experiencing the traumatic event(s);
• 2. Witnessing, in person, the traumatic event(s) as it occurs in others.
• 3. Learning that the traumatic event(s) occurred to a close family
member or close friend (with the actual or threatened death being
either violent or accidental).
• 4. Experiences first-hand repeated or extreme exposure to aversive
details of the traumatic event(s) (e.g., first responders collecting
human remains; police officers repeatedly exposed to details of child
abuse).
• Note: Criterion A4 does not apply to exposure through electronic

8. CRITERION B
• Presence of one or more of the following intrusion symptoms associated with
the traumatic event(s), beginning after the traumatic event(s) occurred:
• 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic
event(s). • Note: In children older than 6, repetitive play may occur in which
themes or aspects of the traumatic event)s) are expressed.
• 2. Recurrent distressing dreams in which the content and/or affect of the dream
are related to the traumatic event(s). Note: In children, there may be frightening
dreams without recognizable content.
• 3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as
if the traumatic event(s) were recurring. (Such reactions may occur on a
continuum, with the most extreme expression being a complete loss of
awareness of present surroundings.) In children, trauma reenactment may occur
in play.
• 4. Intense or prolonged psychological distress at exposure to internal or
external cues that symbolize or resemble an aspect of the traumatic event(s).
• 5. Marked physiological reactions to internal or external cues that symbolize or
resemble the traumatic event(s).

9. CRITERION C
• • Persistent avoidance of stimuli associated with the traumatic
event(s), beginning after the traumatic event(s) occurred, as
evidenced by one or both of the following:
• 1. Avoidance of or efforts to avoid distressing memories, thoughts,
or feelings about or closely associated with the traumatic event(s).
• 2. Avoidance of or efforts to avoid external reminders (people,
places, conversations, activities, objects, situations) that arouse
distressing memories, thoughts or feelings about or closely
associated with the traumatic event(s).

10. CRITERION D
• Negative alterations in cognitions and mood associated with the traumatic
event)s), beginning or worsening after the traumatic event(s) occurred, as
evidenced by two (or more) of the following:
• 1. Inability to remember an important aspect of the traumatic event(s)
(typically due to dissociative amnesia and not to other factors such as head
injury, alcohol, or drugs).
• 2. Persistent and exaggerated negative beliefs or expectations about
oneself, others, or the world (e.g., “I am bad.” “No one can be trusted.” “The
world is completely dangerous.” “My whole nervous system is permanently
ruined.”
• 3. Persistent, distorted cognitions about the cause or consequences of the
traumatic event(s) that lead the individual to blame himself/herself/others.
• 4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or
shame).
• 5. Markedly diminished interest or participation in significant activities.
• 6. Feelings of detachment or estrangement from others.

11. CRITERION E & F
• E. Marked alterations in arousal and reactivity associated with the
traumatic event(s), beginning or worsening after the traumatic
event(s) occurred, as evidenced by two (or more) of the following:
• 1. Irritable behavior and angry outbursts (with little or no
provocation) typically expressed as verbal or physical aggression
toward people or objects.
• 2. Reckless or self-destructive behavior.
• 3. Hypervigilance.
• 4. Exaggerated startle response.
• 5. Problems with concentration.
• 6. Sleep disturbance (e.g., difficulty falling or staying asleep or
restless sleep).

12. CRITERION G & H
• G. The disturbance causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
• H. The disturbance is not attributable to the physiological effects of a substance
(e.g., medication, alcohol) or another medical condition.
• Specify whether: With dissociative symptoms: The individual’s symptoms meet
the criteria for post-traumatic stress disorder, and in addition, in response to
the stressor, the individual experiences persistent or recurrent symptoms of
either of the following:
• 1. Depersonalization: Persistent or recurrent experiences of feeling detached
from, and as if one were an outside observer of, one’s mental processes or body
(e.g., feeling as though one were in a dream; feeling a sense of unreality of self
or body or of time moving slowly)
• 2. Derealization: Persistent or recurrent experiences of unreality of surroundings
(e.g., the world around the individual is experienced as unreal, dreamlike,
distant, or distorted). Note: To use this subtype, the dissociative symptoms must
not be attributable to the physiological effects of a substance (e.g., blackouts) or
another medical condition (e.g., complex partial seizures).
• • Specify if: With delayed expression: If the full diagnostic criteria are not met

13. • Complex PTSD
• Complex PTSD develops in a subset of people with PTSD.
• It is a diagnosis in the ICD-11, which defines it as arising after exposure to
an event or series of events of an extremely threatening or horrific nature,
most commonly prolonged or repetitive events from which escape is difficult
or impossible (for example, torture, slavery, genocide campaigns, prolonged
domestic violence, repeated childhood sexual or physical abuse).
• The disorder is characterised by the core symptoms of PTSD; that is, all
diagnostic requirements for PTSD are met. In addition, complex PTSD is
characterised by:
• severe and pervasive problems in affect regulation
• persistent beliefs about oneself as diminished, defeated or worthless,
accompanied by deep and pervasive feelings of shame, guilt or failure
related to the traumatic event
• persistent difficulties in sustaining relationships and in feeling close to
others.

14. MANAGEMENT

15. ACTIVE MONITORING
• If you have mild symptoms of PTSD, or you've had symptoms for less than 4
weeks, an approach called active monitoring may be recommended.
• Active monitoring involves carefully monitoring your symptoms to see
whether they improve or get worse.
• It's sometimes recommended because 2 in every 3 people who develop
problems after a traumatic experience get better within a few weeks without
treatment.
• If active monitoring is recommended, you should have a follow-up
appointment within 1 month.

16. PSYCHOLOGICALLY-FOCUSED DEBRIEFING
• Do not offer psychologically-focused debriefing for the prevention or
treatment of PTSD
• This includes for Individuals or Group debriefing
• Evidence on psychologically-focused debriefing, either individually or in
groups, showed no benefit for children or adults, and some suggestion of
worse outcomes than having no treatment.
• Providing an ineffective intervention can be regarded as harmful because it
means that people are being denied access to another intervention with
greater evidence of benefits.

17. INITIATING TREATMENT

18. • Prefer to begin treatment for (PTSD) as soon as possible after the
diagnosis is made
• Early treatment of PTSD may prevent chronicity
• Additionally, supportive interventions such as psychoeducation and
case management appear to be helpful in acutely traumatized
individuals
• While the diagnosis of PTSD is made after persistence of symptoms
for at least four weeks following the trauma, most individuals present
for treatment many months, or years, later

19. ESTABLISHING TREATMENT GOALS
• We work with the patient and with permission, involve their chosen
support (eg, family member, partner) to establish treatment goals.
• We review the goals of treatment at each visit through direct
questioning during symptom review.

20. SPECIFIC TREATMENT GOALS
• ●Maintain the safety of the patient and others – We do this through
assessments of suicidality and homicidality at regularly scheduled visits.
• ●Reduce symptoms of distress related to intrusive re-experiencing –
Unwanted intrusive memories of the traumatic event vary widely from
occasional unwanted thoughts to frequent nightmares or flashbacks.
• ●Reduce hyperarousal – These can include symptoms such as insomnia,
anger, irritability, and trouble concentrating and can be very distressing.

21. • ●Reduce avoidant behaviors – Avoidance of stimuli associated with the
traumatic event may lead to behavior changes that affect psychosocial
functioning.
• ●Lessen the risk of relapse of symptoms and diminish anxiety related to fear
of recurrence.
• ●Address related comorbidities that may be present, for example, substance
use disorder (SUD) or mood dysregulation.
• ●Improve adaptive and psychosocial functioning

22. TREATMENT

23. Guideline Institution/Country First-Line Psychological
Recommendation
Australian Guidelines for
the Prevention and
Treatment of Acute Stress
Disorder, Posttraumatic
Stress Disorder, and
Complex Posttraumatic
Stress Disorder (Phoenix
Phoenix Australia—Centre
for Posttraumatic Mental
Health
CPT, CT, Trauma-focused
CBT, EMDR and PE
Effective Treatments for
PTSD: Third Edition (ISTSS)
International Society for
Traumatic Stress Studies
CPT, CT, Trauma-focused
CBT, EMDR and PE
Post Traumatic Stress
Disorder NICE Guidance
(NICE)
National Institute for
Clinical Excellence
UK
Trauma-focused CBT(
including EMDR)
Clinical Practice Guidelines
for the Treatment of PTSD
(APoA)
American Psychological
Association
CPT, CT, Trauma-focused
CBT, and PE
VA/DOD Clinical Practice
Guideline for the
Management of
United States Veterans
Affairs
Ttrauma-focused CBT
(including EMDR)

24. TRAUMA-FOCUSED PSYCHOTHERAPY AS
PREFERRED TREATMENT
• Should be based on a validated manual
• typically be provided over 8 to 12 sessions, but more if clinically
indicated, for example if they have experienced multiple traumas
• be delivered by trained practitioners with ongoing supervision
• include psychoeducation about reactions to trauma, strategies for
managing arousal and flashbacks, and safety planning
• involve elaboration and processing of the trauma memories

25. • involve processing trauma-related emotions, including shame, guilt,
loss and anger
• involve restructuring trauma-related meanings for the individual
• provide help to overcome avoidance
• have a focus on re-establishing adaptive functioning, for example
work and social relationships
• prepare them for the end of treatment
• include planning booster sessions if needed, particularly in relation to
significant dates (for example trauma anniversaries).

26. COGNITIVE BEHAVIOUR THERAPY (CBT)
--It focuses on identifying, understanding, and changing
thinking and behavior patterns of pt.
-CBT is an active treatment involved the patient to engage in and
outside of weekly appointments and learn skills to be applied to
their symptoms.
-The skills learned during therapy sessions are practiced
repeatedly and help support symptom improvement
-CBT treatments traditionally occur over 12 to 16 weeks.

27. COMPONENTS OF CBT USED IN PTSD

28. EXPOSURE THERAPY.
-This type of intervention helps people face and control their fears by exposing them to the trauma
memory they experience in the context of a safe environment
-Exposure can use mental imagery, writing, or visits to places or people that remind them of their trauma
-Virtual reality (creating a virtual environment to resemble the traumatic event) can also be used to
expose the person to the environment that contains the feared situation
-Virtual reality, like other exposure techniques can assist in exposures for treatment for PTSD when the
technology is available
-Regardless of the method of exposure, a person is often gradually exposed to the trauma to help them
become less sensitive over time.

29. COGNITIVE PROCESSING THERAPY (CPT)
• Cognitive Processing Therapy (CPT) is an adaptation of cognitive therapy that aims toward
the recognition and reevaluation of trauma-related thinking.
• The treatment focuses on the way people view themselves, others, and the world after experiencing a
traumatic event.
• Often times inaccurate thinking after a traumatic event "keep you stuck" and thus prevent recovery
from trauma.
• In CPT you look at why the trauma occurred and the impact it has had on your thinking. It can be
especially helpful for people who, to some extent, blame themselves for a traumatic event.
• CPT focuses on learning skills to evaluate whether you thoughts are supported by facts and whether
there are more helpful ways to think about your trauma. There is strong research support showing the
effectiveness for people recovering from many types of traumas.

30. STRESS INOCULATION TRAINING (SIT)
• Stress Inoculation Training (SIT) is another type of CBT that aims to reduce
anxiety by teaching coping skills to deal with stress that may accompany PTSD
• SIT can be used as a standalone treatment or may be used with another types of
CBTs.
• The main goal is to teach people to react differently to their symptoms.
• This is done through teaching different types of coping skills including,, breathing
retraining, muscle relaxation, cognitive restructuring, and assertiveness skills.

31. OTHER PTSD TREATMENTS:
• Eye Movement Desensitization and Reprocessing (EMDR) is a
form of psychotherapy that involves processing upsetting
trauma-related memories, thoughts and feelings. EMDR asks
people to pay attention to either a sound or a back-and-forth
movement while thinking about the trauma memory. This
treatment has been found to be effective for treating PTSD, but
some research has shown that the back-and -forth movement
is not the active treatment component but rather the exposure
alone is.

32. • Present Centered Therapy (PCT)
-is a type of non-trauma focused treatment that centers around current issues rather
than directly processing the trauma
-PCT provides psychoeducation about the impact of trauma on one’s life as well as
teaching problem solving strategies to deal with current life stressors.

33. PHARMACOLOGICAL MANAGEMENT

34. PHARMACOLOGICAL MANAGEMENT
Guideline
Institution/Country First-Line
Pharmacological
Recommendation
Australian Guidelines for the
Prevention and Treatment of Acute
Stress Disorder, Posttraumatic
Stress Disorder, and Complex
Posttraumatic Stress Disorder
(Phoenix)
Phoenix Australia—
Centre for Posttraumatic
Mental Health
Second-line to
psychological
therapies
SSRIs (sertraline,
fluoxetine,
paroxetine),
venlafaxine
Effective Treatments for PTSD:
Third Edition (ISTSS)
International Society for
Traumatic Stress Studies
SSRIs (fluoxetine,
sertraline,
paroxetine),
venlafaxine.
Post Traumatic Stress Disorder
NICE Guidance (NICE)
National Institute for
Clinical Excellence
UK
SSRIs (fluoxetine,
sertraline,
paroxetine),
venlafaxine.
Clinical Practice Guidelines for the
Treatment of PTSD (APoA)
American Psychological
Association
Venlafaxine or
SSRIs only if person
has preference for
drug treatment
VA/DOD Clinical Practice Guideline United States Second-line to

35. SSRI / VENLAFAXINE
• These medicines will only be used if:
• you choose not to have trauma-focused psychological treatment
• psychological treatment would not be effective because there's an
ongoing threat of further trauma (such as domestic violence)
• you have gained little or no benefit from a course of trauma-focused
psychological treatment
• you have an underlying medical condition, such as severe depression,
that significantly affects your ability to benefit from psychological
treatment
• Non availability or lack of expertise to offer psychological treatment

36. ADMINISTRATION
• Serotonin reuptake inhibitors (SSRIs and SNRIs) are typically started at the
low end of their therapeutic range and titrated up gradually until response is
achieved.
• Although there is not clear evidence of a dose-response relationship for
serotonin reuptake inhibitors in PTSD, it is common practice to push the
dose to the very high end of the therapeutic range (to the extent that this is
tolerated by the patient) before concluding that a therapeutic trial has failed.
• Consider a therapeutic trial with a serotonin reuptake inhibitor to be a
minimum of six to eight weeks at maximally tolerated dose within the
therapeutic range, before concluding that the medication has failed.

38. PRAZOSIN
• Two significant distressing symptoms of PTSD, nightmares (intrusion) and sleep
disturbance (alteration in arousal), are often resistant to pharmacological treatment
• Randomised clinical trials provide evidence that the off-label use of prazosin, a
brain-active alpha-1 adrenoceptor antagonist, is effective and safe in the treatment
of nightmares and sleep disturbance associated with PTSD, and contributes to an
improvement in overall clinical status without affecting blood pressure.
• Introducing prazosin into the treatment of a patient with PTSD is guided by the ‘start
low, go slow’ rule.
• The recommended starting dose to minimise the risk of adverse drug reactions
(ADRs) is 1 mg before bed, increasing by 1 mg every 2–3 nights until a clinical
response is obtained. Average doses of prazosin in the treatment of PTSD achieved
daily doses of 19.6 mg for males and 8.7 mg for females

39. Guideline Institution Recommendation for Use of
Prazosin
VA/DOD Clinical Practice
Guideline for the
Management of
Posttraumatic Stress
Disorder and Acute Stress
Disorder (VA)
Department of Veterans
Affairs and Department of
Defense
-United States
Insufficient evidence for or
against its use
A Revision of the 2005
Guidelines from the British
Association for
Psychopharmacology (BAP)
British Association for
Psychopharmacology,UK As adjunct if initial
treatment fails
Canadian Clinical Practice
Guidelines for the
Management of Anxiety,
Posttraumatic Stress and
Obsessive-compulsive
Disorders (ADAC)
Anxiety Disorders
Association of Canada
Level 1 for nightmares

40. ANTIPSYCHOTIC
• Consider antipsychotics such as risperidone, quetiapine in addition to
psychological therapies to manage symptoms for adults with a diagnosis of
PTSD if:
-they have disabling symptoms and behaviours, for example severe
hyperarousal or psychotic symptoms and
-their symptoms have not responded to other drug or psychological
treatments.
Antipsychotic treatment should be started and reviewed regularly by a
specialist
*NICE

41. CARE FOR PEOPLE WITH PTSD AND
COMPLEX NEEDS

42. • PTSD and depression:
-usually treat the PTSD first because the depression will often improve
with successful PTSD treatment
-treat the depression first if it is severe enough to make psychological
treatment of the PTSD difficult, or there is a risk of the person harming
themselves or others. (NICE 2018)
• Substance use disorders
- Treat individuals with PTSD and an active SUD with a hybrid
approach known as COPE (Concurrent Treatment of PTSD and
Substance Use Disorders Using Prolonged Exposure)
- Current substance use does not necessarily require delay of
psychotherapy for PTSD

43. Borderline personality disorder
- treat individuals with co-occurring PTSD and borderline personality
disorder with a modified treatment that combines prolonged exposure
exposure and dialectical behavior therapy
- -This is particularly useful if chronic suicidality and self-harm behaviors
behaviors are prominent

44. • Patients with complex PTSD:
-build in extra time to develop trust with the person, by increasing the
duration or the number of therapy sessions according to the person's
needs
-take into account the safety and stability of the person's personal
circumstances (for example their housing situation) and how this might
affect engagement with and success of treatment
-help the person manage any issues that might be a barrier to engaging
with trauma-focused therapies, such as substance misuse, dissociation,
emotional dysregulation, interpersonal difficulties or negative self-
perception
-work with the person to plan any ongoing support they will need after
the end of treatment, for example to manage any residual PTSD
symptoms or comorbidities. (NICE 2018)

46. • Acute stress disorder
• Acute stress disorder is a DSM-5 diagnosis that applies in the first
month after a traumatic event. It requires the presence of 9 or more
symptoms from any of the 5 categories of intrusion, negative mood,
dissociation, avoidance and arousal. These can be starting or
worsening after the traumatic event.