Post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is a trauma- and stress-related disorder resulting from direct or indirect exposure to actual or threatened death, serious injury, or sexual or emotional violence and characterized by persistent difficulties that negatively affect an individual's social interactions, capacity to work, or other areas of functioning.

ALSO KNOWN AS: shell shock, combat neurosis, battle fatigue

ANATOMY OR SYSTEM AFFECTED: Psychic-emotional system

CAUSES: Direct or indirect exposure to an actual or threatened traumatic event

SYMPTOMS: May include recurrent, involuntary, and intrusive thoughts and memories of the traumatic event; flashbacks or other prolonged psychological distress; intense psychological distress following exposure to reminders of the traumatic event; avoidance of reminders of the traumatic event; inability to remember important aspects of the traumatic event; recurrent and disturbing dreams or nightmares; difficulty sleeping; irritability or outbursts of anger; aggression; aggressive, reckless, or self-destructive behavior; persistent and distorted sense of blame of self or others; detachment from others or diminished interest in activities; difficulty concentrating; hypervigilance; and exaggerated startle response. Persistent symptoms last for at least one month, cause significant distress or disruption of daily functioning, and are not a result of another medical condition or substance use.

DURATION: Often chronic with acute episodes

TREATMENTS: Individual therapy, group therapy, antianxiety medications, antidepressants

Causes and Symptoms

Post-traumatic stress disorder (PTSD) manifests following either direct or indirect exposure to actual or threatened death, serious injury, or sexual or emotional violence. Events such as natural disasters (earthquakes, mudslides, fires, floods, tsunamis, tornadoes), war, domestic violence, rape, violent crime, accidents, and medical procedures are some incidents that may trigger the development of PTSD. In the 2013 revision of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5), PTSD was included as part of a new chapter on trauma- and stress-related disorders; in previous editions of the DSM, PTSD had been classified as an anxiety disorder. Diagnostic criteria for PTSD did not change in the 2022 text revision of DSM-5 (DSM-5-TR). According to the National Center for PTSD at the US Department of Veteran Affairs in 2023, based on veterans using VA health care, 23 out of every 100, or 23 percent, had PTSD at some point in their lives. It was estimated that PTSD is more common in female veterans because of military sexual trauma.

PTSD involves re-experiencing the trauma, avoidance of things that are reminders of the trauma, and an uncomfortable state of arousal usually connected with readiness to avoid re-experiencing a trauma. Re-experiencing symptoms include flashbacks, recurrent and intrusive thoughts, recurrent distressing dreams and nightmares, feeling as if the event is happening again, intense psychological distress at exposure to any reminders (internal or external) of the event, or intense physical reactivity to any reminders of the event. Avoidance symptoms include staying away from places, events, or objects that are reminders of the traumatic experience; feeling emotionally numb, detached, or estranged; feeling guilt, depression, or anxiety; losing interest in previously enjoyable activities; and having trouble remembering the traumatic event. Increased arousal includes difficulty sleeping; irritability or outbursts of anger; difficulty concentrating; hypervigilance; self-destructive or reckless behavior; or being easily startled. The re-experiencing, avoidance, and arousal start after the traumatic event, last more than one month, and cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The course of the disorder varies, with some individuals not experiencing symptoms for more than six months after the incident trauma, but most individuals experience symptoms within three months of the initial trauma. If the trauma occurs early in life, it may have profound effects on stress response throughout the individual's lifetime.

Persons with PTSD may describe painful guilt feelings about surviving when others did not or about what they had to do to survive. Phobic avoidance of situations or activities that resemble or symbolize the original trauma may interfere with interpersonal relationships and lead to marital conflict, divorce, or job loss.

The likelihood of developing PTSD increases as intensity and physical proximity to the event increase. Recent immigrants from countries where there is considerable social unrest and civil conflict may have elevated rates of PTSD. The disorder may occur at any age. Women are more likely to develop PTSD than men.

Not everyone who experiences a significant trauma will develop PTSD. Individual differences in terms of immediate post-trauma assistance and support, long-term social support, stress response, physical health, and other biological factors may explain a lack of occurrence in some individuals.

Treatment and Therapy

Treatments for PTSD include individual therapy, group therapy, and antianxiety and antidepressant drugs. Combinations of therapies can also be effective. In general, the sooner the victim of PTSD receives treatment, the greater are the chances of recovery. It is important to note, however, that complex techniques such as trauma debriefing and critical incident debriefing should be attempted only by well-trained persons. Discussing traumatic events in a way that is not sensitive to the experience of the victim may retraumatize them, so caution is advised. For untrained persons, the best way to help someone affected by a trauma is to help them get to a qualified treatment professional as quickly as possible. This is especially important because research has suggested that treatment delivered soon after the trauma may reduce the overall negative impacts of the trauma.

Psychotherapy can help the person come to grips with the traumatic event. Different approaches are used, including exposure therapy, anxiety management/relaxation training, cognitive behavioral therapy (CBT), and supportive psychotherapy. Also, hypnosis, journaling (such as thought diaries and grief letters), creative arts and art therapy, and a critical-incident stress debriefing may be used in treating PTSD, either alone or in conjunction with psychotherapy.

Group therapy, in which victims of PTSD can share their experiences and gain support from others, is especially helpful. Groups are typically small (six to eight persons) and are often composed of individuals who have undergone similar experiences. Also, marital and family therapy or parent training may be used in treating PTSD.

In general, the goals of psychotherapy include facilitating one's emotional engagement with the trauma memory, helping to organize a personal trauma narrative, assisting in correcting dysfunctional cognitions that often follow trauma, helping to develop increased trust in others, and decreasing emotional and social isolation. The therapist typically provides empathy, validation, safety, consistency, and sensitivity to cultural and ethnic identity issues.

Antianxiety and antidepressant drugs can relieve the physiological symptoms of PTSD. Selective serotonin reuptake inhibitors (SSRIs) are typically the first-line pharmacological treatment for PTSD. Because of the many biological abnormalities presumed to be associated with PTSD and because of the overlap between symptoms of PTSD and other comorbid disorders, almost every class of psychotropic agent has been administered to PTSD patients. Whether it includes individual or group therapy, drugs, or some combination of these three, the treatment approach must be tailored to the individual PTSD sufferer and his or her unique situation.

Other treatments that may be beneficial include eye movement desensitization and reprocessing (EMDR) and imagery rehearsal therapy. Developed in the late 1980s and 1990s, EMDR has endured controversy to become a widely accepted therapy for PTSD. It combines many aspects of the other therapies described and works to facilitate reprocessing of traumatic information and experience. Guided discussion and therapeutic work may involve specific eye movements while remembering different aspects of the traumatic event. It is suggested that this type of activity creates an orienting response that facilitates trauma processing. The technique requires a high level of skill and sophistication and should be used only by appropriately trained professionals. EMDR has been recommended for trauma victims and remains a topic of great research interest.

It is important to remember that PTSD, like many other mental health disorders, may not occur in isolation. the presence of more than one disorder, or comorbidity, is the rule rather than the exception with PTSD. Anxiety disorders, depression, acute stress disorder, and substance use disorders are the disorders most likely to occur with PTSD. Treatment must address the comorbid conditions when they are present. PTSD can be reliably assessed through semi-structured interview and self-report measures. Treatment typically occurs on an outpatient basis, but it also may occur on an inpatient basis if the symptoms are severe.

Perspective and Prospects

PTSD was observed in World War I after many soldiers had intense anxiety reactions to the horrors they were experiencing. At that time, it was called combat neurosis, shell shock, or battle fatigue. It was formally diagnosed as an anxiety-based personality disorder in the 1960s among Vietnam War veterans, but it is no longer considered a personality disorder and is instead seen as a trauma- or stress-related disorder. It is also now known that traumatic events may include not only war but also violent or sexual assault, kidnapping, terrorist attacks, torture, natural or human-made disasters, severe automobile accidents, complications from surgery or childbirth, or different aspects of a life-threatening illness. Poor social support, especially after a traumatic experience, is a major risk factor for the development of PTSD.

Promising research identifying change to the stress response system in younger persons following trauma as well as gender differences in trauma response are expected to fuel greater understanding of the mechanisms of trauma response. Such knowledge will in turn be useful for developing new medical, biological, and interpersonal therapies for children and adults and for both women and men.

As part of an effort to bring greater awareness to this serious disorder, the US Senate proclaimed in 2010 that June 27th would serve as National PTSD Awareness Day. In addition, the National Center for PTSD declared the entire month of June as PTSD Awareness Month.

Also in 2010, an article published in the Archives of General Psychiatry provided further insight into lingering theories that PTSD could be linked to an increased risk of dementia. Focusing on US veterans, the study concluded that in a sample from this group, those diagnosed with PTSD were two times more likely to develop dementia. Following the publication of this study, researches continued to attempt to determine whether a solid connection exists between PTSD and dementia, with a study in 2016 confirming a link between PTSD and cognitive impairment in a sample of people who had been involved in the rescue and cleanup efforts following the terrorist attacks on September 11, 2001. In addition to exploring this general connection, researchers have also looked into whether medications commonly used to treat people with PTSD could increase the risk of dementia.

Other areas of PTSD research include studies of the biological changes that accompany natural recovery from PTSD symptoms, the intricate connections between memory and processes such as sleep and learning pathways, potential genetic factors, and ways to determine personalized treatments. In the 2020s, targeted research continued to be conducted to discover and validate any biomarkers specific to psychological stress and PTSD that could help in a more routine diagnosis of the disorder at early stages. It was also hoped that if such biomarkers could be more definitively determined, then blood tests or other measurement tools could allow health care professionals to tailor a more effective treatment for individuals. Research conducted by a team from the University of Vermont and reported in late 2019 was considered a significant step in the ability to diagnose PTSD and intervene early on. Their research was seen as more unique in that it collected data from people who had suffered trauma within thirty days of the incident using a smartphone application.

The COVID-19 pandemic that began in 2020 led to elevated instances of PTSD among frontline healthcare workers and those who were hospitalized with the virus. A 2021 study published in the journal Chronic Stress surveyed 3,360 healthcare workers in New York City hospitals and found that 1,005 (39 percent) met the criteria for a PTSD diagnosis resulting from their experiences on the front line of the COVID-19 healthcare crisis. Additionally, a 2021 study published in JAMA Psychiatry examined 381 patients who were hospitalized for COVID-19 and found that 115 of these patients (30.2 percent) were later diagnosed with PTSD resulting from their COVID-19 hospitalization.

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