Post-Traumatic Stress Disorder (PTSD) is a chronic trauma-related psychiatric disorder that develops following exposure to actual or threatened death, serious injury, or sexual violence. Symptoms persist for more than one month after the traumatic event and are characterized by intrusive memories, avoidance behaviours, negative alterations in cognition and mood, and persistent hyperarousal resulting in significant distress or impairment.

Epidemiology

• PTSD may develop after combat, road traffic injuries, sexual assault, physical assault, torture, natural disasters, or other traumatic events

• Women are affected more frequently than men

• Many patients have coexisting depression, anxiety disorders, or substance use disorders

Risk Factors

• Severe or repeated trauma

• Childhood abuse

• Female sex

• Previous psychiatric illness

• Family history of mental illness

• Lack of social support

• Ongoing life stressors

• Traumatic brain injury

Pathophysiology

PTSD results from persistent dysregulation of fear-processing pathways involving the amygdala, hippocampus, and prefrontal cortex. Altered regulation of serotonin, norepinephrine, and stress hormones contributes to intrusive memories, hyperarousal, impaired extinction of fear responses, and emotional dysregulation.

Clinical Presentation

• Recurrent intrusive memories

• Flashbacks

• Trauma-related nightmares

• Psychological distress on exposure to reminders

• Avoidance of trauma-related situations

• Emotional numbing

• Persistent negative beliefs

• Feelings of guilt or shame

• Hypervigilance

• Exaggerated startle response

• Irritability

• Anger outbursts

• Difficulty concentrating

• Sleep disturbances

Diagnostic Criteria

Diagnosis is clinical and requires:

• Exposure to a traumatic event

• Symptoms lasting longer than 4 weeks

• Intrusion symptoms

• Persistent avoidance behaviours

• Negative alterations in mood or cognition

• Hyperarousal symptoms

• Significant functional impairment

• Symptoms not attributable to substance use or another medical disorder

Differential Diagnosis

• Acute Stress Disorder

• Adjustment disorder

• Major depressive disorder

• Generalized anxiety disorder

• Panic disorder

• Dissociative disorders

• Substance-induced mental disorders

• Traumatic brain injury

Investigations

There is no laboratory test that confirms PTSD.

Assessment should include:

• Detailed psychiatric assessment

• Mental status examination

• Suicide risk assessment

• Screening for depression anxiety and substance misuse

• Physical examination when clinically indicated

• Laboratory investigations guided by clinical findings

Management

Treatment Goals

• Reduce PTSD symptoms

• Improve daily functioning

• Restore quality of life

• Prevent relapse

• Treat comorbid psychiatric disorders

Non-Pharmacological Management

• Provide reassurance and family support

• Trauma-focused cognitive behavioural therapy

• Supportive psychotherapy

• Eye Movement Desensitization and Reprocessing (EMDR) where available

• Stress management techniques

• Sleep hygiene counselling

• Encourage participation in support groups

Pharmacological Management

Amitriptyline 50–150 mg orally at night for 4–8 weeks. In older adults, use 25–75 mg orally at night.

OR

Citalopram 20–40 mg orally once daily for 4–8 weeks.

OR

Fluoxetine 20–40 mg orally once daily in the morning for 4–8 weeks.

An adequate antidepressant trial should continue for 8–12 weeks before considering a change in treatment. Patients who respond should continue maintenance treatment for at least 6–12 months to reduce the risk of relapse. Treatment should be tapered gradually before discontinuation.

Referral Criteria

Refer to the next level of care if:

• Inadequate response after an adequate trial of treatment

• Severe functional impairment

• Suicidal ideation or self-harm risk

• Psychotic symptoms

• Significant comorbid psychiatric disorders

• Diagnostic uncertainty

• Severe substance use disorder

• Requirement for specialist trauma-focused psychotherapy

Complications

• Major depressive disorder

• Substance use disorders

• Chronic insomnia

• Anxiety disorders

• Social isolation

• Occupational impairment

• Suicide

• Poor quality of life

Prevention

• Early psychosocial intervention following trauma

• Strengthening social and family support

• Prompt treatment of acute stress reactions

• Early access to trauma-focused psychotherapy

• Long-term follow-up of high-risk individuals

Prognosis

PTSD may become chronic without treatment. Most patients improve with trauma-focused psychotherapy combined with antidepressant therapy. Early intervention and adherence to treatment improve long-term outcomes.

Patient Education

• PTSD is a treatable medical condition

• Symptoms are a response to trauma rather than personal weakness

• Psychological therapy is an essential component of treatment

• Medicines require several weeks before improvement occurs

• Continue treatment as prescribed even after symptoms improve

• Avoid alcohol and recreational drugs

• Seek urgent medical attention if suicidal thoughts or severe deterioration occur