Post Traumatic Stress Disorder (PTSD)

Definitions and Core Concepts

Acute Stress Disorder (ASD) and Post-Traumatic Stress Disorder (PTSD) are trauma- and stressor-related conditions triggered by exposure to actual or threatened death, serious injury, or sexual violence. Exposure can be direct, witnessed, or learned (if involving a close caregiver).

• Acute Stress Disorder: Symptoms last between 3 days and 1 month following the traumatic event.
• Post-Traumatic Stress Disorder: Symptoms persist for more than 1 month and cause clinically significant distress or impairment.

Etiology and Risk Factors

• Traumatic Triggers: Physical or sexual abuse, domestic violence, natural disasters, motor vehicle accidents, severe bullying, or traumatic medical experiences (e.g., prolonged PICU stay, invasive procedures).
• Pre-Trauma Risk Factors: Female gender, lower socioeconomic status, preexisting psychiatric disorders (e.g., anxiety, ADHD), adverse childhood experiences (ACEs), and parental psychopathology.
• Peri-Trauma Factors: Severity, proximity, and duration of the trauma; perceived life threat; lack of immediate caregiver support.
• Post-Trauma Factors: Poor family functioning, lack of social support, and subsequent adverse life events.

Clinical Features

The clinical presentation is categorized into four symptom clusters. Pediatric manifestations often differ from adult presentations.

1. Intrusion Symptoms

• Recurrent, involuntary, and distressing memories.
• Pediatric Manifestation: Traumatic themes expressed through repetitive play.
• Distressing dreams or nightmares. In young children, dreams may lack recognizable content related to the trauma.
• Flashbacks or dissociative reactions (acting as if the event is recurring).

2. Avoidance Symptoms

• Persistent avoidance of internal triggers (memories, thoughts, feelings).
• Avoidance of external reminders (people, places, conversations, activities, objects).

3. Negative Alterations in Cognitions and Mood

• Inability to recall key features of the trauma.
• Persistent negative beliefs about self or the world (e.g., "I am bad," "The world is entirely dangerous").
• Persistent negative emotional state (fear, horror, anger, guilt, shame).
• Markedly diminished interest in significant activities (often appears as social withdrawal in children).
• Inability to experience positive emotions.

4. Alterations in Arousal and Reactivity

• Irritable behavior and angry outbursts, often expressed as extreme temper tantrums.
• Reckless or self-destructive behavior (more common in adolescents).
• Hypervigilance and exaggerated startle response.
• Problems with concentration and significant sleep disturbances.

Special Consideration: Children 6 Years and Younger

• DSM-5 provides a specific subtype for young children emphasizing behavioral indicators (e.g., trauma-specific reenactment in play) and requiring fewer total symptoms for diagnosis, as internal cognitions are difficult to assess.

Diagnosis and Evaluation

• Clinical Assessment: Comprehensive psychosocial history, including private interviews with the adolescent and collateral history from caregivers.
• Screening Tools: Pediatric Symptom Checklist (PSC), Child PTSD Symptom Scale (CPSS), or the UCLA PTSD Reaction Index.
• Differential Diagnosis: Adjustment disorder, major depressive disorder, generalized anxiety disorder, ADHD, and traumatic brain injury.

Management

Management is multimodal, prioritizing psychological safety and trauma-focused therapies.

Non-Pharmacological Interventions (First-Line)

• Trauma-Focused Cognitive Behavioral Therapy (TF-CBT): The gold standard for pediatric PTSD. Involves psychoeducation, relaxation skills, emotion regulation, trauma narrative processing, and joint parent-child sessions.
• Eye Movement Desensitization and Reprocessing (EMDR): Evidence-based alternative utilizing bilateral sensory input while processing traumatic memories.
• Child-Parent Psychotherapy (CPP): Recommended for younger children (infants to preschool age) focusing on the caregiver-child attachment relationship.

Pharmacological Interventions

• Medications are generally reserved for severe, refractory cases or significant comorbid psychiatric conditions. They are not first-line monotherapy.
• SSRIs: Fluoxetine or Sertraline may be used to target core PTSD symptoms and comorbid anxiety/depression (off-label use; careful monitoring for suicidal ideation).
• Alpha-Adrenergic Agonists: Clonidine or Guanfacine to target hyperarousal, hyperactivity, and impulsivity.
• Alpha-1 Antagonists: Prazosin is occasionally used for severe, treatment-resistant trauma-related nightmares and sleep disruption.

Prognosis and Follow-Up

• Early identification and intervention (TF-CBT) significantly improve long-term outcomes and prevent the progression of ASD to PTSD.
• Chronic, untreated PTSD is associated with poor academic performance, substance abuse, high-risk sexual behavior, and adult psychiatric morbidity.
• Regular pediatric follow-up is necessary to monitor treatment adherence, school performance, and family dynamics.