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Chapter 7: Posttraumatic
Stress Disorder
Patricia A. Resick
Candice M. Monson
Shireen L. Rizvi
Trauma and
Stressor-related Disorders
 Posttraumatic Stress Disorder (PTSD)
 A disorder of nonrecovery (or stalled recovery) after a traumatic
event- must now specify if experienced, witnessed, or experienced
indirectly.
 Requires presence of specified numbers of symptoms in each of 4 broad
categories which includes a total of 20 possible symptoms
 Acute Stress Disorder (ASD)- 9 of 14 symptoms
-Subjective reaction of horror criteria eliminated for both disorders
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Symptoms
Epidemiology
Biological, cognitive, emotional, and behavioral components
Comorbidity factors
Assessment
Treatment
DSM-5 Diagnostic Criteria
of PTSD
A. The individual must have experienced or witnessed a traumatic event*,
learned about a traumatic event happening to a loved one, or been repeatedly
exposed to details of traumatic events (not just media exposure).
* An event is considered traumatic if it involved (1) actual or threatened death, (2)
serious injury, or threat to physical integrity (e.g., motor-vehicle accident, rape, threat
with a weapon, natural disaster), or (3) sexual violence
NOTE: All of the symptoms of PTSD must have started or worsened after the
traumatic event
B. The individual must exhibit at least one of the following intrusion symptoms:
~ persistent and distressing memories of the trauma
~ recurrent distressing nightmares about the traumatic event
~ dissociative reactions (e.g., flashbacks)
~ intense psychological or physiological responses when exposed to
cues
(internal or external) that resemble the trauma
DSM-5 Diagnostic Criteria
of PTSD
C. The individual must exhibit at least one of the following avoidance symptoms*:
~ effortful avoidance of internal cues
~ efforts to avoid external reminders of the trauma, like places, people,
or situations.
*These symptoms reflect strategies that individuals use in order to reduce coming
into contact with events, places, thoughts, or emotions that remind them of the
traumatic event.
D. The individual must exhibit at least two of the following mood and cognitive
symptoms:
~ numbing, amnesia, or inability to have positive feelings
~ strong negative emotions such as guilt, anger, or fear
~ distorted self-blame or erroneous blame of others who did not cause or
intend the event
~ negative beliefs about self, others, and the world as a consequence of
the traumatic event, or feelings of detachment/estragement from others
~ anhedonia or lack of participation related to significant activities
DSM-5 Diagnostic Criteria
of PTSD (cont)
E. The individual must exhibit at least two of the following physiological arousal
and reactivity symptoms:
~ sleep difficulties
~ impairment in concentration
~ exaggerated startle response
~ hypervigilance
~ irritable or aggressive behavior
~ reckless or self-destructive behavior
F. All of these symptoms must be concurrently present for at least 1 month
G. Symptoms must:
a. be perceived as distressing
OR
b. cause functional impairment
DSM-5 PTSD Subtypes/Specifers
PTSD: Preschool subtype
• For children younger than 6 years old
•
Accounts for differences in PTSD presentation in young children
PTSD with prominent dissociative symptoms
• For individuals who meet full criteria but also experience
persistent or frequent experiences of depersonalization or
derealization
• Thought to be qualitatively different than PTSD without
dissociation
PTSD specifier- with delayed expression (full criteria not met until 6+
months
Prevalence of PTSD
 About 7% of the population will have had PTSD at some point in their
lifetime
 Increased prevalence rates (up to 20% to 30%) in specific trauma-
exposed groups (e.g., in victims of sexual abuse or rape, natural
disasters, war veterans)
 Most people exhibit PTSD symptoms immediately following trauma
exposure (delayed onset PTSD is very rare)
 Less “personal” events that have a wider range of severity (e.g., natural
disasters, accidents) are associated with lower rates of PTSD than more
personally directed events (e.g., rape, molestation, assault, combat)
 There is also a dose-response relationship such that the more traumatic
events one experiences, the more likely one will develop PTSD symptoms
Gender Differences
Men
Women
 More likely to report experiencing
 More likely to report rape,
a physical attack, being threatened
with a weapon, being in an
accident, or witnessing a trauma
 Have more overall exposure to
molestation, neglect, or physical
abuse
 Are nearly 3 times as likely to
have a lifetime diagnosis of PTSD
(9.7% to 3.6%)
trauma (60.7% of men vs. 51.2% of
women have experienced at least
one trauma in their lifetime)
***
* However, recent studies of veterans deployed to Iraq or Afghanistan
reported no gender differences in overall number of traumatic events
during deployment or gender differences in rates of PTSD
* Rape is the single event most likely to result in PTSD among both men
and women
Psychobiology and PTSD
 Selected neurobiological systems implicated in PTSD:
 Noradrenergic System
• Increased noradrenergic activity in people with PTSD
• Heightened norepinephrine reactivity to pharmacological and behavioral
challenge
• Low baseline levels of neuropeptide Y (NPY): released with norepinephrine;
associated with anxiolysis (anti-anxiety) and cognitive-enhancement
 Hypothalamic-Pituitary-Adrenal (HPA) Axis
• HPA dysregulation is consistently associated with trauma exposure and PTSD
(e.g., Vietnam vets have enhanced CRF release)
 Gamma-Amino Butyric Acid (GABA)
• GABA is the brain’s primary inhibitory neurotransmitter
• Reduced GABA action and baseline levels in patients with PTSD
 Disinhibition of the amygdala via higher monoamine levels and
subsequently disrupted PFC dysfunction
Cognition, Memory, and PTSD
Disruptions in cognition and memory are at the core of PTSD:
 Problems remembering and forgetting traumatic events (e.g., someone with
PTSD may have trouble intentionally accessing his or her memory of the event
but have involuntary intrusions of parts of it)
 Maladaptive cognitions (e.g., “Because one person assaulted me, that means
no one can be trusted”)
 Flashbacks, intrusive memories, amnesia, and fragmented memory
 Altered beliefs about the self, the world, and others (e.g., self as
incompetent; world as dangerous)
 Disorganized narratives about the trauma with more sensory details and
negative emotional content
 Cognitive avoidance strategies (e.g., thought suppression)
Behavior, Emotion, and PTSD
Behavioral Factors

Avoidance behaviors are key in PTSD

As in classical fear conditioning, the
traumatic event becomes associated
with other stimuli (e.g., certain sounds or
smells), which then elicit conditioned
emotional responses.

Avoidance of the conditioned stimuli
reduces anxiety in the short term.

Following traumatic events, a pathological
fear structure develops that is composed
of feared stimuli, responses, and meaning
elements (Cahill & Foa, 2007)
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When the fear structure is triggered,
cognitive, behavioral, and arousal anxiety
result
Emotional Factors
 Traumatic events also become
associated with emotional stimuli
(e.g., unpleasant emotions like fear,
guilt, and shame)
 Fear and anxiety play a large role in
PTSD
 But other emotions have also been
implicated as central in PTSD: anger,
shame, guilt, hopelessness,
sadness, and humiliation
Comorbidity and PTSD
High rates of comorbidity:
 Major depressive disorder found in 50% or
more of PTSD cases
 Generalized anxiety disorder and alcohol
abuse/dependence are also common
comorbidities
 Rates of comorbidity range between 50% to
80% in military veterans
Personality and PTSD
Evidence for three subtypes of PTSD:
Internalizing Subtype
Externalizing Subtype
* Tends to direct distress
inwardly through shame, selfdeprecating beliefs, anxiety,
avoidance, depression, and
withdrawal
* Tends to outwardly express
distress through antagonistic
interactions with others, blaming
others, and coping through acting
out
* High rates of comorbid major
depression, panic disorder,
schizoid and avoidant
personality disorder features
* Tendency toward anger,
aggression, impulsivity
* Personality profile defined by
high negative emotionality and
low positive emotionality
* High rates of substance-related
disorders and cluster B personality
disorder features
* Hypersensitivity to negative
evaluation
* Emotionally labile, overactive,
fearless
* Feels chronically betrayed and
mistreated by others
“Simple” Subtype
* (Low on both internalizing
and externalizing)
Environmental Factors and PTSD
Social Support and
Additional Life
Stress
Conservation of
Resources Theory
Intimate Relationships
•
Dysfunction in intimate
relationships is associated
with vulnerability to PTSD

Traumatic stress 
sudden, rapid loss of
resources that are most
valued (e.g., trust in self
and others, social support,
perception of control,
sense of well-being)

People with abundant
personal, social, and
financial resources will
recover more quickly

People with depleted
resources or people
already facing additional
life stressors are most at
risk
 Lack of social support
is a major risk factor for
PTSD among people
exposed to trauma
•
 Additional life
stressors also a major risk
factor for PTSD (e.g.,
family adjustment problems
and problems with work or
housing)
•
•
Individuals with PTSD are
more likely to experience
divorce, relationship
discord, domestic
violence
Avoidance and numbing
symptoms are implicated in
relationship satisfaction
Hyperarousal symptoms
are associated with
violence
Assessment
 Assessment for PTSD must be careful and sensitive, determining:
 Whether a life event meets the seriousness requirement of a traumatic stressor
 The presence and severity of the 20 associated symptoms
 Diagnostic interviews
 More time-consuming
 Most widely used: Clinician-Administered PTSD Scale (CAPS) (Blake et al., 1995)
 Self-Report Measures
 Rely on participant’s judgment about what constitutes a traumatic event
 Some are limited to certain populations (e.g., Mississippi Scale for Combat-Related PTSD)
 Can be used as a screening tool in conjunction with a diagnostic interview
 For example PTSD Symptom Scale–Self-Report (PSS-SR)
 Physiological Assessment
 Physiological reactivity to trauma cues is one of the criteria for PTSD
 A comprehensive assessment of PTSD should include psychophysiological testing (e.g., heart rate
and blood pressure response to combat-related sounds)
 However, psychotropic drugs and antisocial characteristics can alter physiological responses
 Measures for the updated DSM-5 criteria have been developed and are
currently being tested
Psychosocial Treatments
 There have now been over 75 randomized controlled trials of
psychotherapy for PTSD*
 We have treatments that work with the majority of people with
PTSD (40% to 80% fully remit)
 Approximately 50% of individuals in intention-to-treat samples
do not have a remission in their PTSD diagnosis as a result of
treatment
*As of May, 2013
Psychosocial Treatments
 Cognitive behavior therapy (CBT) has the largest body of research
supporting its efficacy in treating PTSD
 Most of these therapies propose that for therapy to work, the person must be able
to activate the trauma memory, block the negative reinforcement that occurs with
escape and avoidance behavior, and disconfirm erroneous beliefs through extinction
of anxiety
 Prolonged exposure (PE) - includes both imaginal and in vivo exposure techniques
 Cognitive processing therapy (CPT) - a predominantly cognitive therapy for PTSD
that includes some behavioral elements
 Stress Inoculation Therapy (SIT) - one of the few cognitive behavior therapies that
does not include any trauma-specific interventions
 Generally, little evidence for any one (or any single element) of these therapies being
more efficacious than any other
 However, PE out-performs SIT at follow-up (Foa, Rothbaum, Riggs, & Murdock, 1991)
Psychosocial Treatments
Interventions with limited empirical evidence for treating PTSD
 Eye Movement Desensitization and Reprocessing (EMDR)
• No evidence supporting the specific efficacy of eye movements
• Evidence that the active ingredients of EMDR are actually cognitive-behavioral in nature
 Brief eclectic psychotherapy (BEP) - Combines cognitive-behavioral and psychodynamic
approaches and includes:
• (1) psychoeducation about PTSD, (2) imaginal exposure, (3) writing tasks and memorabilia
aimed at uncovering difficult feelings, (4) meaning and integration, and (5) farewell ritual
• Has been shown to be efficacious with police officers and outpatients with a range of trauma
 Narrative exposure therapy (NET)
• Patients provide a detailed chronological report of their own biographies, with a special focus on
traumatic experiences.
• Report is recorded in written form and read during sessions with the goal of developing a
coherent narrative of the traumatic event and the habituation of emotional responses to
reminders of the traumatic event
 Cognitive-behavioral conjoint therapy for PTSD (CBCT)
• 15-session, manualized therapy that also addresses interpersonal functioning
• Evidence for improved: 1) relationship functioning and 2) psychological functioning in partners
*As of May, 2013
Psychopharmacological
Treatments
 Currently, only sertraline and paroxetine (SSRIs) have received indication
from the FDA for the treatment of PTSD.
 Other antidepressants:
 Two controlled trials support the efficacy of venlafaxine, a serotonin norepinephrine reuptake
inhibitor (SNRI), in the treatment of PTSD
 Antiadrenergics (Drugs Acting on the Epinephrine and Norepinephrine Systems)
 Prazosin reveals improvements in trauma-related nightmares and other PTSD symptoms
 A single randomized controlled trial (RCT) of guanfacine found no superiority over placebo in
veterans with PTSD
 Mood stabilizers and Atypical Antipsychotics
 Limited support; decreased reexperiencing and avoidance symptoms of PTSD with lamotrigine
(Hertzberg et al., 1999); Risperidone superior to placebo (Padala et al., 2006)
 Augmentation With Partial NMDA Agonist
 D-cycloserine (DCS) improved anxiety symptoms in PTSD when used as augmentation to other
PTSD medications (Heresco-Levy et al., 2002).
 GABA-ergic Agonists (Antianxiety Medication)
 No evidence for efficacy
PTSD Treatments
 Discontinuation of medication is associated with
relapse of PTSD symptoms
 In psychotherapy trials, long-term follow-up with
PTSD patients suggests maintenance of gains
across different types of therapy
 Results from research favor psychotherapy
over medications for treating PTSD, but many
medications can provide some relief for some
symptoms
Summary and Future Directions
 Most people experience traumatic events in their lives that are serious.
Nevertheless, with time, the majority of people go on to recover.
 The more traumas that people experience, the more likely they are to have
symptoms. A strong dose-response relationship.
 PTSD treatment may be complicated by substance abuse, chronic pain, severe
depression, and personality disorders.
 PTSD is maintained over time by avoidance and numbing. People often refuse
to seek treatment even when they know it is available, and show high dropout
rates (20% to 40%).
 Most of the research and treatment focus has been on fear and anxiety to the
exclusion of other important emotions, such as anger, sadness, shame, or
horror.
 Current theories of PTSD are concerned with memory, emotions, and cognition.
More research is needed in these areas.
 Future research needed in the underlying biology of PTSD (e.g., brain
structures, neurotransmitters, and hormones), which will help us understand the
interaction of biology, individual differences, and environment in PTSD