Woman crossing street with large manipulator looming above tethering her to PTSD symptoms

Understanding the clinical course
of PTSD

The presentation and clinical course of PTSD are variable among individuals, highlighting the heterogeneity of the disorder. Symptoms, duration, and severity can all vary for each individual.

PTSD is the development of characteristic symptoms after exposure to one or more traumatic events. Characteristic symptoms are described by the American Psychiatric Association’s DSM-5 diagnostic criteria as the 4 core symptom clusters of PTSD and may occur soon after exposure to a traumatic event or may be delayed.^1-3*

Intrusion 
(re-experiencing)^2,3

Persistent avoidance^2,3

Negative changes in cognitions and mood^2,3

Alterations in arousal and reactivity^2,3

Please see the DSM-5 Diagnostic Criteria for the full criteria.

~25% of individuals who develop PTSD experience delayed onset of symptoms^1,2,4*

*While symptoms may present anytime after the trauma, delayed onset is defined as only meeting diagnostic criteria ≥6 months after the index event.
†Representative symptoms.

‡Based on a retrospective study in which 273 psychiatrists who had diagnosed and treated ≥1 civilian adult patient with PTSD were provided patient-level information for 687 patients diagnosed from 2016-2020.⁵

According to the American Psychiatric Association, PTSD symptom recurrence and intensification may occur in response to reminders of the original trauma, ongoing life stressors, or newly experienced traumatic events²

PTSD is commonly a chronic condition^6§

1/3 of patients may recover by 1-year follow-up

1/3 of patients were still symptomatic 10 years after the exposure to the trauma

§Based on the 1990 to 1992 National Comorbidity Survey of 5,877 people that included both treated and untreated patients.

An Expert’s Insights

Join Dr. Javanbakht as he shares how training is critical to diagnosing PTSD

Consider the PTSD symptoms within the symptom clusters as seen in the DSM-5

Diagnosis of PTSD can be challenging due to the variable onset of symptoms and the inherent heterogeneity in presentation.⁷ And patients often seek care for physical symptoms without mentioning psychiatric symptoms or trauma histories.⁸

Download a PTSD symptom sheet for a quick reference on the representative symptoms associated with each cluster.

Intrusion (re-experiencing)^2,3

Recurrent intrusive memories
Traumatic nightmares
Flashbacks

Persistent avoidance of stimuli^2,3

Avoiding trauma-related thoughts and feelings and/or objects, people, or places associated with the trauma

Negative alterations in cognitions and mood^2,3

Distorted beliefs about  oneself or the world
Persistent shame or guilt
Emotional numbing
Feelings of alienation
Inability to recall key details of the trauma

Marked alterations in arousal and reactivity^2,3

Irritability
Hypervigilance
Reckless behavior
Sleep disturbance
Difficulty in concentrating

Diagnosis of PTSD requires the identification of 1 or more traumatic events^2,9

The DSM-5 provides the diagnostic criteria to make a diagnosis of PTSD. View the DSM-5 Criteria for complete diagnostic information.

The traumatic event is defined as an index trauma, which serves as the basis for assessment for severity of PTSD.^2,9,10 Instruments used across clinical and research settings for PTSD include:

Clinician-Administered PTSD Scale 5 (CAPS-5)

The CAPS-5 is a structured interview designed to make a categorical PTSD diagnosis, as well as to provide a measure of PTSD symptom frequency and severity based on the 4 symptom clusters. PTSD symptom items are rated on a 5-point scale of severity ranging from 0 (Absent) to 4 (Extreme/‌incapacitating).¹¹ The full interview takes between 45 and 60 minutes.

PTSD Checklist for DSM-5
(PCL-5)

The PTSD Checklist for DSM-5 (PCL-5) is a 20-item self-report measure of the DSM-5 symptoms of PTSD with a variety of purposes, including monitoring of symptom changes during and/or following treatment, screening for PTSD, and making a provisional PTSD diagnosis.¹²

These are 2 commonly used PTSD assessment instruments. The VA, APA, and APoA also provide additional tools and descriptions of the available assessment instruments.

Behind the numbers
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Journey into the pathophysiology

Explore the science

1.
Bryant RA, et al. A multisite analysis of the fluctuating course of posttraumatic stress disorder. JAMA Psychiatry. 2013;70:839-846.
2.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. DSM-5™. American Psychiatric Publishing; 2013.
3.
Lancaster CL, et al. Posttraumatic stress disorder: overview of evidence-based assessment and treatment. J Clin Med. 2016;5:E105.
4.
Smid GE, et al. Delayed posttraumatic stress disorder: systematic review, meta-analysis, and meta-regression analysis of prospective studies. J Clin Psychiatry. 2009;70:1572-1582.
5.
Davis LL, et al. Patient journey of civilian adults treated for post-traumatic stress disorder – a chart review study. Poster presented at the Annual Meeting of the American Society of Clinical Psychopharmacology (ASCP), May 30-June 2, 2023.
6.
Kessler RC, et al. Posttraumatic stress disorder in the national comorbidity survey. Arch Gen Psychiatry. 1995;52:1048-1060.
7.
Committee on the Assessment of Ongoing Efforts in the Treatment of Posttraumatic Stress Disorder; Board on the Health of Select Populations; Institute of Medicine. Diagnosis, Course, and Prevalence of PTSD. In: Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. National Academies Press, Washington DC; 2014. Accessed March 2023. https://www.ncbi.nlm.nih.gov/books/NBK224874/?report=reader#_NBK224874_pubdet_
8.
Greene T, et al. Prevalence, detection and correlates of PTSD in the primary care setting: a systematic review. J Clin Psychol Med Settings. 2016;23:160-180.
9.
Mann SK, Marwaha R. Posttraumatic stress disorder. In: StatPearls. Treasure Island (FL): StatPearls Publishing; Updated January 30, 2023.
10.
Priebe K, et al. Defining the index trauma in post-traumatic stress disorder patients with multiple trauma exposure: impact on severity scores and treatment effects of using worst single incident versus multiple traumatic events. Eur J Psychotraumatol. 2018;9:1486124.
11.
Weathers FW, et al. The clinician-administered PTSD scale for DSM-5 (CAPS-5): development and initial psychometric evaluation in military veterans. Psychol Assess. 2018;30:383-395.
12.
US Department of Veterans Affairs. PTSD: National Center for PTSD. PTSD Checklist for DSM-5 (PCL-5). 2023. Accessed December 4, 2023. https://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp

Understanding the clinical course
of PTSD