Post-traumatic stress disorder

Clinical picture (children and adolescents)

• About 15.9% of trauma-exposed children and adolescents develop PTSD; the rate is higher after interpersonal trauma and in girls (32.9% in girls after interpersonal trauma, 8.4% in boys after non-interpersonal trauma) (Alisic et al., 2014; 43 samples, 3,563 people). A
• In young children, re-experiencing may appear as traumatic play, frightening dreams and behavioral regression; adolescents show a picture similar to adults, sometimes with self-harm and substance use. B
• Dissociative subtype: a sense of detachment from oneself or one's surroundings. B
• Common co-occurring conditions: depression, other anxiety disorders, ADHD-like attention problems, sleep disorders. A

Circuits and networks

• Amygdala: threat appraisal; in PTSD, an exaggerated response to threat cues. B
• Medial & Frontopolar Prefrontal Cortex (ventromedial PFC): recall of fear extinction and braking of the amygdala; its activity is reduced in PTSD. B
• Hippocampus: telling contexts apart ("this place is safe"); smaller in PTSD (Logue et al., 2018). A
• Anterior Cingulate Cortex and Insula: salience and bodily arousal. B
• Periaqueductal Gray, Hypothalamus & Pituitary, Locus Coeruleus: defense responses (flight, fight, freeze), the stress axis and noradrenergic arousal. B
• Networks: increased activity in the Salience network (salience) network and reduced connectivity within the Default mode network (DMN) have been reported. C

Neurotransmitter systems

• Noradrenaline (noradrenaline): hyperarousal and startle; the locus coeruleus. B
• Stress axis (CRF, cortisol): regulation of the HPA axis is altered. B
• Serotonin (serotonin): SSRIs are effective in adults; the evidence in children is weak. B

Imaging and neurobiological findings

• ENIGMA-PGC (1,868 people, 794 with PTSD, 16 cohorts): in current PTSD the hippocampus is smaller than in trauma-exposed controls (d = −0.17); the amygdala difference (d = −0.11) is not significant after correction for multiple comparisons (Logue et al., 2018). A
• These are group-level differences; imaging cannot diagnose an individual. A

Developmental course

• Trauma during development can affect the maturation of prefrontal regulatory pathways and the stress axis; early intervention matters. B
• Most trauma-exposed children do not develop PTSD; a supportive caregiver is protective. B

Treatment and the systems it targets

• Trauma-focused cognitive behavioral therapy (TF-CBT) is first line in children and adolescents; an individual participant data meta-analysis found it effective regardless of age, sex and trauma type (de Haan et al., 2024). A
• Medication: in 131 children and adolescents, 10 weeks of sertraline did not beat placebo (Robb et al., 2010); SSRIs are not first choice in children but can be used for co-occurring depression and anxiety. B
• Exposure aims to strengthen fear extinction learning (vmPFC → amygdala). B

Link to the book (The Green Walnut on the Couch)

• In the book (translated from the Turkish original):
  • FEAR system, clinical: "phobias, generalized anxiety, PTSD, behavioral inhibition".
  • PAG, clinical: "PTSD and dissociation, selective mutism, exhaustion in depression, the EMDR hypothesis".
  • Hippocampus, where it appears in the book: "chronic stress leading to a loss of contextualization (the “everywhere is dangerous” feeling in PTSD; Chapters 10 and 18)".
  • Amygdala, where it appears in the book: "post-traumatic hippocampus-amygdala imbalance (Chapter 18)".
  • Amygdala-hippocampus pathway: "contextual generalization in PTSD (Chapter 18)".
  • Polyvagal hierarchy: "post-traumatic dissociation and the window of tolerance (Chapter 18)".

In the atlas

Regions

Core structures in bold.

Networks

Neurotransmitter pathways

Panksepp systems

References

1. Alisic E et al. (2014). Rates of post-traumatic stress disorder in trauma-exposed children and adolescents: meta-analysis. British Journal of Psychiatry, 204(5), 335–340. Search PubMed
2. Logue MW et al. (2018). Smaller hippocampal volume in posttraumatic stress disorder: a multisite ENIGMA-PGC study. Biological Psychiatry, 83(3), 244–253. Search PubMed
3. Robb AS et al. (2010). Sertraline treatment of children and adolescents with posttraumatic stress disorder: a double-blind, placebo-controlled trial. Journal of Child and Adolescent Psychopharmacology, 20(6), 463–471. Search PubMed
4. de Haan A et al. (2024). Efficacy and moderators of efficacy of cognitive behavioural therapies with a trauma focus in children and adolescents: an individual participant data meta-analysis of randomised trials. The Lancet Child & Adolescent Health, 8(1), 28–39. DOI: 10.1016/S2352-4642(23)00253-5.