Post-Traumatic Stress Disorder (PTSD) Clinical Overview
I. The "On-Call" Snapshot
Clinical Significance in Malaysia
You will see this. Not just in psychiatric clinics, but in your ED, surgical, and medical wards. Patients post-RTA, victims of domestic violence, or even those with severe medical trauma (e.g., septic shock in ICU) are at high risk. Your job is to recognise it when it presents as "insomnia," "anxiety," or "chronic pain."
High-Yield Definition
PTSD is a trauma- and stressor-related disorder. Per DSM-5, it requires exposure to actual or threatened death, serious injury, or sexual violence, followed by a specific constellation of symptoms (intrusion, avoidance, negative alterations in cognition/mood, and hyperarousal) lasting for more than 1 month and causing significant functional impairment.
Clinical One-Liner
The mind is stuck re-living a trauma it cannot process, forcing the body to remain in a constant state of "fight or flight," which disrupts the patient's entire life.
II. Etiology & Risk Factors
Etiology
The direct cause is exposure to a major traumatic event (Criterion A of DSM-5).
Directly experiencing it.
Witnessing it (in person) as it occurred to others.
Learning it occurred to a close family member or friend (must be violent or accidental).
Repeated or extreme exposure to aversive details (e.g., first responders, police).
Risk Factors
Pre-trauma: Pre-existing mental health conditions (e.g., depression, anxiety), female gender, low socioeconomic status, lack of social support.
Peri-trauma: Severity and duration of the trauma, perceived threat to life.
Post-trauma: Lack of social support, subsequent life stressors, development of acute stress disorder.
III. Quick Pathophysiology
It is a failure of memory consolidation and fear extinction.
Amygdala Hyperactivity: The "fear centre" is over-active, leading to exaggerated threat perception and fear responses (hypervigilance, startle response).
Prefrontal Cortex (PFC) Hypoactivity: The "control centre" that normally dampens the amygdala response is under-active. It fails to provide context and signal that the danger has passed.
Hippocampus: Involved in memory. Dysfunction can lead to the fragmented, intrusive memories (flashbacks) instead of a coherent narrative.
This is all reinforced by an abnormal HPA axis and sustained stress hormone (catecholamine) release.
IV. Classification
Acute Stress Disorder (ASD): Symptoms are present from 3 days to 1 month post-trauma. If it continues past 1 month, the diagnosis converts to PTSD.
PTSD: Symptoms present for > 1 month.
PTSD with Dissociative Symptoms: Patient meets full criteria for PTSD but also experiences persistent depersonalization (feeling detached from self) or derealization (feeling of unreality).
Delayed Onset: Full diagnostic criteria are not met until at least 6 months after the event.
V. Clinical Assessment
🚩 Red Flags & Immediate Actions
Active Suicidal Ideation (SI) with intent/plan:
Action: Ensure 1:1 observation (do not leave patient alone), notify senior/psychiatry team immediately. Secure any means of harm. This is a psychiatric emergency requiring admission.
Reason: High risk of self-harm. PTSD has a high rate of comorbidity with MDD and suicidality.
Homicidal Ideation:
Action: Immediate escalation to specialist, ensure staff/patient safety, ?involve security/police.
Reason: Risk to others.
Severe Dissociation / Psychotic Symptoms:
Action: Urgent psychiatric review. Rule out acute psychosis.
Reason: Inability to engage with reality, poor self-care, potential for unpredictable behaviour.
Inability to perform basic self-care (not eating, drinking, or sleeping):
Action: Consider admission for stabilisation and observation.
Reason: Risk of medical compromise.
History
Your history-taking is the diagnostic tool. You are assessing for the DSM-5 criteria.
Criterion A (The Trauma): "Have you ever experienced an event that made you feel your life was in danger, or that you might be seriously hurt?" (e.g., RTA, assault, natural disaster).
Criterion B (Intrusion Symptoms - 1+ needed):
"Do you have unwanted, distressing memories of the event?"
"Do you have nightmares about it?"
"Do you ever feel like you are re-living the event? (Flashbacks)"
"Do you get very distressed when something reminds you of it?"
Criterion C (Avoidance - 1+ needed):
"Do you try hard to avoid thinking or talking about the event?"
"Do you avoid people, places, or situations that remind you of it?" (e.g., "I stopped driving after the RTA.")
Criterion D (Negative Alterations in Cognition/Mood - 2+ needed):
"Have you had trouble remembering parts of the event?"
"Do you have strong negative beliefs about yourself or the world, like 'I am bad' or 'The world is completely dangerous'?"
"Do you feel a lot of guilt or blame?"
"Are you feeling 'flat' or 'numb'?"
"Have you lost interest in activities you used to enjoy?"
"Do you feel detached or cut off from people?"
Criterion E (Alterations in Arousal/Reactivity - 2+ needed):
"Are you more irritable or having angry outbursts?"
"Are you 'on guard' all the time? (Hypervigilant)"
"Do you get startled very easily?"
"Are you having trouble concentrating?"
"Are you having trouble sleeping?"
Duration & Function:
"When did these symptoms start?"
"How long have they been happening?" (Must be > 1 month).
"How are these symptoms affecting your work? Your family life?"
Physical Examination (OSCE Approach)
The main exam is the Mental State Examination (MSE).
General Inspection: May appear distressed, tearful, or guarded. Alternatively, may appear emotionally "flat" (numb). Often hypervigilant—you will see them scanning the room, sitting near the door, or startling at loud noises.
Vitals: May have baseline tachycardia or hypertension due to chronic hyperarousal.
Speech: May be normal, or show latency (poverty of thought) or pressured (anxiety).
Mood: "Anxious," "low," "irritable," "numb."
Affect: Often restricted, blunted, or incongruent.
Thought:
Process: May be ruminative.
Content: Preoccupation with the trauma. Assess for SI/HI.
Perception: Check for flashbacks (dissociative re-experiencing) or other perceptual disturbances.
Cognition: Assess concentration (often poor), orientation.
Insight & Judgement: Often impaired, especially regarding risk and self-blame.
Clinical Pearl
Always, always screen for comorbidities, especially substance use disorder and depression. Many patients "self-medicate" with alcohol, benzodiazepines, or other substances, which complicates everything.
VI. Diagnostic Workflow
Differential Diagnosis
Acute Stress Disorder (ASD)
Points For: Identical symptoms to PTSD.
Points Against: N/A.
How to Differentiate: Timing. ASD is 3 days to 1 month post-trauma. PTSD is > 1 month.
Major Depressive Disorder (MDD)
Points For: Overlap in negative mood, anhedonia, sleep disturbance, poor concentration.
Points Against: In MDD, symptoms are pervasive and not necessarily linked to a specific trauma memory. PTSD symptoms (flashbacks, avoidance) are trauma-centric.
How to Differentiate: Elicit the core trauma and the link to intrusion/avoidance symptoms. (Note: They are very frequently comorbid).
Generalized Anxiety Disorder (GAD)
Points For: Hypervigilance, anxiety, sleep disturbance.
Points Against: GAD anxiety is "free-floating" and worries about future events (work, health, family). PTSD anxiety is tied past trauma.
How to Differentiate: Ask what they are anxious about.
Substance Use Disorder
Points For: Can cause anxiety, paranoia, insomnia, irritability.
Points Against: Symptoms resolve with sobriety.
How to Differentiate: Urine toxicology, collateral history. Ask when they started using. Was it before or after the trauma?
Investigations Plan
This is a clinical diagnosis. Investigations are to rule out other causes and establish a baseline.
Bedside / Initial (First 15 Mins)
Urine Toxicology Screen (UDS): Especially if patient is agitated or presentation is atypical.
Urine FEME/Pregnancy Test (UPT): For all females of childbearing age before starting psychotropics.
First-Line Labs & Imaging
Labs: FBC, RP, LFT, TFT. Rules out organic causes of anxiety/mood change (e.g., hyperthyroidism, anaemia, electrolyte imbalance).
Screening Tools: PCL-5 (PTSD Checklist for DSM-5). A score of 33-38 is a good cut-off to suggest a provisional diagnosis.
Confirmatory / Gold Standard
CAPS-5 (Clinician-Administered PTSD Scale for DSM-5): A structured clinical interview done by a trained professional (psychiatrist or clinical psychologist). This is the gold standard for diagnosis and severity assessment.
VII. Staging & Severity Assessment
Severity is determined by the CAPS-5 score or PCL-5 score.
Impact is determined by functional impairment: "How much does this interfere with your work, your studies, or your relationships?"
This guides treatment:
Mild: Watchful waiting or psychotherapy.
Moderate to Severe: Psychotherapy + Pharmacotherapy.
VIII. Management Plan
A. Principle of Management
Safety: Ensure safety of patient and others (assess SI/HI).
Symptom Control: Reduce intrusion, hyperarousal, and mood symptoms.
Trauma Processing: Help the patient process the trauma memory.
Functional Recovery: Return to work and social life.
Management should be guided by international guidelines (e.g., UpToDate, NICE) and principles from local CPGs (like the Malaysian CPG for MDD for SSRI use), as there is no specific national CPG for PTSD.
B. Immediate Stabilisation (The ABCDE Plan)
Only relevant in an acute crisis (e.g., severe agitation, active SI, dissociative episode).
A/B/C: Usually intact unless there is self-harm or overdose.
D (Disability/Drugs):
De-escalation: Use calm, non-threatening verbal techniques.
Safety: Ensure a safe environment.
PRN Medication: For severe agitation/anxiety, a short-term, cautious-dose benzodiazepine (e.g., IV/IM Diazepam 2.5-5mg or PO Diazepam 2-5mg) can be used.
WARNING: Benzodiazepines are NOT first-line for chronic PTSD. They blunt emotional processing, interfere with psychotherapy, and have high abuse potential. Use only for acute, severe agitation.
E (Environment): Move to a quiet, safe room.
C. Definitive Treatment (The Ward Round Plan)
This is a combined approach.
Psychoeducation (First-line for ALL):
Explain the diagnosis. Normalise the symptoms as an understandable reaction to an abnormal event. This reduces self-blame.
Psychotherapy (First-line):
Trauma-Focused Cognitive Behavioural Therapy (TF-CBT): This is the gold standard. Refer to a clinical psychologist.
Includes techniques like:
Prolonged Exposure (PE): Gradually and safely re-exposing the patient to the trauma memories (in imagination) and avoided situations (in vivo) to allow processing and habituation.
Cognitive Processing Therapy (CPT): Identifying and challenging "stuck points" (maladaptive beliefs) about the trauma (e.g., "It was my fault").
Pharmacotherapy (First-line for Moderate-Severe):
First-Line SSRIs: (Same as MDD CPG).
Sertraline: Start 25-50mg OD. Titrate up slowly (q1-2 weeks) to target dose (usually 100-200mg).
Paroxetine: Start 10-20mg OD. Titrate up.
Key points: Counsel patient that it takes 4-6 weeks to work, and symptoms may transiently worsen (agitation) in the first 1-2 weeks. Continue for at least 6-12 months after remission.
Second-Line: Venlafaxine (SNRI).
For Nightmares/Sleep:
Prazosin: An alpha-1 blocker. Start 1mg ON, titrate slowly (e.g., 1mg -> 2mg -> 4mg) as tolerated, watch for first-dose hypotension/syncope. Very effective for trauma-related nightmares.
D. Long-Term & Discharge Plan
Follow-up: Regular follow-up (e.g., monthly) in clinic to monitor symptoms (PCL-5), side effects, and adherence.
Referral: Refer to clinical psychologist for TF-CBT. Refer to social worker if there are psychosocial issues (housing, finances).
Lifestyle: Advise on sleep hygiene, exercise, and avoiding alcohol/substances.
Relapse Prevention: Teach patient to identify early warning signs and stressors.
IX. Complications
Immediate: Suicidality, self-harm, breakdown of relationships.
Short-Term: Social withdrawal, occupational dysfunction (losing job), substance use.
Long-Term: Major Depressive Disorder, other anxiety disorders, Substance Use Disorder, chronic pain, somatic symptoms, personality changes.
X. Prognosis
Variable. With treatment, many achieve remission.
Good prognostic factors: Early diagnosis and treatment, strong social support, no pre-existing psychopathology.
Poor prognostic factors: Delayed treatment, comorbid substance use, lack of social support, ongoing trauma.
XI. How to Present to Your Senior
Use the SBAR format.
S (Situation): "Dr, I am in clinic seeing Puan A, a 35-year-old lady with probable new-onset PTSD."
B (Background): "She was involved in a severe RTA 3 months ago. She has no prior psychiatric history. Since the accident, she reports daily intrusive flashbacks, nightmares, and is now avoiding driving and even being a passenger. Her PCL-5 score is 45."
A (Assessment): "Her MSE shows hypervigilance and a restricted affect. She is distressed but not suicidal. My provisional diagnosis is PTSD. I have ruled out organic causes and substance use."
R (Recommendation): "My plan is to:
Provide psychoeducation.
Start Sertraline 50mg OD and counsel on side effects.
Refer to the in-house clinical psychologist for trauma-focused CBT.
Give her an MC for 3 days and a clinic appointment in 2 weeks.
Would you like to review her?"
XII. Summary & Further Reading
Top 3 Takeaways
Diagnose with DSM-5: The diagnosis is clinical and requires all criteria (A, B, C, D, E) for > 1 month.
Treat with 1-2 Punch: The best evidence is for Trauma-Focused CBT + SSRIs (Sertraline/Paroxetine).
Screen for Comorbidities: Always check for Suicide Risk and Substance Use.
Key Resources
UpToDate: "Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, and diagnosis" (and the accompanying "Treatment" article).
Amboss: "Posttraumatic stress disorder"
DSM-5 Criteria: MDCalc or Brainline provides a good checklist. (Source: https://www.mdcalc.com/calc/10211/dsm-5-criteria-posttraumatic-stress-order)
