In the aftermath of a traumatizing experience, it is normal to experience some signs and symptoms of PTSD. To meet the threshold of a disorder, the symptoms must persist for longer than one month and be severe enough to interfere with daily life. Symptoms must also not be attributable to the physiological effects of medications, the use or misuse of substances, or other illnesses, such as a seizure condition.

Most people who experience a traumatic event will recover. But for those whose symptoms persist, PTSD can impair every aspect of life, from personal relationships to educational and professional pursuits.

2.1 Criteria for Diagnosis of PTSD

The criteria for PTSD appear in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). A new category was recently added: Trauma-and Stressor-Related Disorders, which involves exposure to a traumatic or stressful event and includes reactive attachment disorder, acute stress disorder, adjustment disorders, and post-traumatic stress disorders. All of the conditions included in this classification require exposure to a traumatic or stressful event as a diagnostic criterion.

To be diagnosed with PTSD, DSM-5 criteria require that:

1. The person was exposed to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, in the following way(s):
   • Direct exposure
   • Witnessing the trauma
   • Learning that a relative or close friend was exposed to a trauma
   • Indirect exposure to aversive details of the trauma, usually in the course of professional duties (e.g., first responders, medics)
2. Symptoms last for more than 1 month.
3. Symptoms create distress or functional impairment.
4. Symptoms are not due to medication, substance use, or other illness.

In addition to meeting criteria for the PTSD diagnosis, an individual who experiences high levels of the following in reaction to a trauma-related stimuli may have the diagnosis further differentiated:

• Depersonalization: Experience of being an outside observer of or detached from oneself (e.g., feeling as if “this is not happening to me” or one were in a dream)
• Derealization: Experience of unreality, distance, or distortion (e.g., “things are not real”)
• Delayed specification: Full diagnostic criteria are not met until at least six months after the trauma(s), although onset of symptoms may occur immediately

2.2 Clinical Presentation of PTSD

In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), symptoms of PTSD are grouped into four categories:

1. Intrusion Symptoms (formerly called re-experiencing symptoms)
   • Intrusive thoughts, nightmares, flashbacks
   • Emotional distress after exposure to traumatic reminders
   • Physical reactivity to traumatic reminders
2. Avoidance Symptoms (avoiding trauma-related stimuli)
   • Trauma-related thoughts or feelings
   • Trauma-related reminders
3. Negative Alterations in Cognition and Mood (negative thoughts or feelings that began or worsened after the trauma)
   • Inability to recall key features of the trauma
   • Overly negative thoughts and assumptions about oneself or the world
   • Exaggerated blame of self or others for causing the trauma
   • Negative or flat affect, decreased interest in activities
   • Feelings of isolation
   • Difficulty experiencing positive affect
4. Alterations in Arousal and Reactivity (trauma-related arousal and reactivity and reactivity that began or worsened after the trauma)
   • Irritability or aggression
   • Risk or destructive behaviors
   • Hyper-vigilance, heightened startle reaction
   • Difficulty concentrating, difficulty sleeping

Anxiety and obsessive-compulsive behaviors and negative emotions like anger, shame or humiliation, sadness and guilt may also persist. Other symptoms can include dysphoria, dissociative states, thoughts of suicide, panic attacks, and somatic complaints like trembling, headaches, dizziness, shortness of breath or bodily heat. Women and girls who have been diagnosed with PTSD are especially prone to somatic symptoms and high levels of negative emotions.

The significance of symptoms varies across cultures. Members of some cultural groups may be more affected by the traumas experienced by loved ones than traumas they have experienced themselves. PTSD can also develop upon the destruction of sacred sites and the inability to perform funeral rites for lost relatives (WHO, 2024).

2.3 Further Effects of PTSD

Because of funding from the Veterans Administration (VA), many PTSD studies have included military veterans. But PTSD is widespread in other fields and workplaces as well. During the COVID-19 pandemic, 22% of U.S. adults reported symptoms of PTSD. A 2021 survey by CDC found that this figure jumped to 36.8% of respondents in the public health field. Almost half of the frontline workers in personal care and service jobs reported symptoms of posttraumatic stress (Bryant-Genevier et al., 2021).

PTSD is now recognized as a complex diagnosis with links to neural disturbances, inflammation conditions, emotional resilience, and difficulty regulating mood and attention (Evans et al., 2022). It can inhibit learning, interfere with executive function and concentration, and even prolong grief. People who survive a trauma but lose a loved one are at risk of developing PTSD as well as complicated grief, or grief that is so unbearable it interferes with daily life and causes feelings of isolation from others. This suggests that targeting the PTSD symptoms for treatment may also diminish symptoms of complicated grief (Glad et al., 2021).

It is estimated that over 40% of adults with PTSD experience feelings of stigma associated with what is often perceived as a mental illness. Many have said the name of the disorder can discourage them from seeking treatment. In a survey of over 1,000 subjects, two-thirds agreed that changing the name from PTSD to post traumatic stress injury (PTSI) would reduce the stigma associated with having a disorder and increase the likelihood that they would seek medical help (Lipov, 2023).

There may be an association between asthma and PTSD, both of which afflict more women than men. A recent study in Atlanta involving more than 500 women with both conditions showed that the women with asthma had a higher risk of more severe PTSD and depression than those without asthma. Female military veterans with PTSD are more than one and a half times more likely to have asthma than those without PTSD (Lin et al., 2023).

Although traumatic experiences often lead to post traumatic stress, researchers are looking into factors that predict post-traumatic growth (PTG), or the positive psychological changes that some people experience after a trauma. PTG is described as a positive change that people experience after a traumatic event, to the point of developing beyond their previous level of psychological functioning in certain areas of their lives (Campodonico et al., 2021). There is a possibility that PTSD and post-traumatic growth co-exist; that every now and then, the cognitive process activated by trauma results in a positive outlook of the self, others, and the world (Bhushan et al., 2022).

2.4 Risk Factors

A diagnosis of PTSD is usually related to a specific traumatic event. Chronic stress related to poverty, racial discrimination, and historical trauma can increase the likelihood of PTSD in populations that have been exposed to these stressors.

Previous trauma, especially if it is severe, can also contribute to PTSD. A family history of anxiety or depression, as well as an individual’s temperament, may increase the likelihood of developing the condition. Other risk factors include physical injury during the traumatic event, the misuse of alcohol or other drugs, and the lack of a strong social support network.

Though it is not known exactly how poverty contributes to the development of PTSD, one study of people who visited a hospital emergency department after a traumatic event indicated that neighborhood poverty was significantly associated with baseline PTSD symptoms, even six months after the traumatizing event (Ravi et al., 2023a).

Racial discrimination combined with poverty is associated with high levels of PTSD, with one study indicating that more frequent experiences of racial discrimination and higher rates of neighborhood poverty both predicted higher PTSD symptoms. The effect of neighborhood poverty on PTSD symptoms was less present for those who reported fewer experiences of racial discrimination (Ravi et al., 2023b).

There has been a great deal of interest recently in the effects of historical trauma, with data suggesting that the descendants of traumatized groups and individuals may experience PTSD as a result of their forebears’ experiences. American Indian and Alaskan Native groups have suffered an accumulation of negative impacts from long-standing policies of neglect, translocation, and extermination over the last several centuries (Ehlers et al., 2022).

People in American Indian and Alaskan Native communities may also experience a high level of direct trauma, making it difficult to determine exactly which factors contribute to an individual’s PTSD. In a study of PTSD, suicide, and historical loss among American Indians, 94% of the respondents reported that they had experienced life-threatening trauma, with a third of those qualifying for a diagnosis of PTSD. PTSD and historical trauma are also associated with suicide and suicide attempts in this American Indian community (Ehlers, et al., 2022).

Pre-existing attitudes may contribute to the likelihood of developing PTSD, including adherence to traditional masculinity. Research indicates that beliefs about the importance of adhering to masculine norms are strongly associated with the severity of PTSD symptoms. Treatments that include discussing emotions like fear and shame are antithetical to masculine norms about control, rationality and fortitude. Researcher indicates that veterans who seek to maintain the appearance of powerful masculinity may be less inclined to seek help or follow through with a therapeutic program (Neilson et al, 2020).

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