Posttraumatic stress disorder (PTSD) is common, occurring in 6% of individuals.¹ It is often undetected in patients presenting to primary care.^2,3 PTSD can occur in civilian and veteran populations in response to a broad range of traumatic events. PTSD affects people of all ages, and women are twice as likely to receive a diagnosis compared with men.⁴ Symptoms of PTSD typically involve trauma-related intrusive thoughts, avoidant behaviors, negative alterations of cognition or mood, and changes in arousal and reactivity.⁵ Two-thirds of patients with PTSD report moderate to severe symptoms.² PTSD may increase the risk of cardiovascular disease and other medical conditions commonly seen in primary care.⁶

PTSD can be treated in primary care, especially in systems with integrated behavioral health services.⁷ PTSD presents similarly in people with and without military service, but there are differences. The high prevalence of PTSD shows the importance of diagnosis and treatment by family physicians.

Natural History

PTSD may develop at least one month after a qualifying traumatic event, specifically an event that involves the threat of death or harm to physical integrity. Qualifying traumatic events are common across all ages and socioeconomic groups.⁸ The pathophysiology of PTSD appears to involve impairment in traumatic memory consolidation, leading to maladaptive neuropsychological responses.⁹ Patients often report reexperiencing their trauma, which triggers physiologic and psychological responses that present as primary symptoms of the disorder. Although trauma is common, affecting one-half of adults, less than 10% of patients with traumatic experiences develop PTSD.^9–11 People with more exposure to traumatic events are more likely to develop and have persistent PTSD and report severe PTSD symptoms.¹⁰ This association between cumulative trauma and PTSD partially explains why populations at high risk of recurrent trauma carry a higher PTSD disease burden. For example, patients who identify as LGBTQIA (lesbian, gay, bisexual, transgender, queer [or questioning], intersex, asexual) are more likely to experience trauma and develop PTSD compared with their peers.¹²

The Diagnostic and Statistical Manual of Mental Disorders, 5th ed., text revision (DSM-5-TR) lists the diagnostic criteria for PTSD.⁵ However, patients often report symptoms beyond the core symptoms in the diagnostic criteria. Although presenting symptoms of PTSD often involve psychological symptoms such as hyperarousal, reexperiencing traumatic events, and sleep disturbance, patients often report somatic complaints, such as gastrointestinal distress or musculoskeletal problems.⁹ Psychological symptoms of PTSD can be mistaken for anxiety or mood disorders, which are often comorbid with PTSD. This makes diagnosing PTSD challenging and requires physicians to maintain a low threshold for asking about past trauma for a range of symptoms without other psychological or physiologic explanations.

Screening

Because of the considerable overlap between PTSD and other behavioral health disorders, differentiating PTSD from other disorders can be challenging. Routinely inquiring about past trauma in new patients with undifferentiated anxiety or mood symptoms may aid in diagnosing and treating PTSD. Despite the high prevalence of PTSD, there are no standardized recommendations for universal adult screening. It is recommended that all veterans be screened for PTSD annually for five years after separation from service, then once every five years thereafter.¹³ A previous American Family Physician article on care of the military veteran has more information on screening (https://www.aafp.org/pubs/afp/issues/2019/1101/p544.html).

Prevention

Although intervention after trauma is an opportunity to prevent PTSD, there is no consensus on how to prevent PTSD for patients with traumatic exposures. A single session debriefing is not effective at preventing PTSD development.¹⁴ However, early psychological treatments may be helpful. A Cochrane review found low-certainty evidence that multiple early interventions reduced the likelihood of PTSD diagnosis at three to six months after trauma (number needed to treat = 12; 95% CI, 8 to 67), but these interventions may not be effective at one year.¹⁵ Many medications have been proposed to reduce the likelihood of PTSD after trauma, but most show no evidence of benefit. A 2022 Cochrane review found that hydrocortisone, propranolol, and gabapentin do not prevent PTSD development after a traumatic exposure.¹⁶