Post-Traumatic Stress Disorder

Set into motion by the experience of trauma (directly or to others), PTSD may have roots in our biology as well as in experience and individual aspects of perception, cognition, temperament, and resilience. Psychotherapy, like trauma therapy and exposure therapy, and medication, help treat flashbacks, angry outbursts, physical distress, avoidance behaviors, and other signs of the disorder as well as with coping with the experience in a healthy and adaptive manner.

Definition

Post-Traumatic Stress Disorder (PTSD) is a trauma and stress related disorder that may develop after exposure to an event or ordeal in which death, severe physical harm or violence occurred or was threatened. Traumatic events that may trigger PTSD include violent personal assaults, natural or unnatural disasters, accidents, or military combat.

Experiencing a life-threatening event or re-experiencing chronic exposure to abuse or the aftermath of an event can lead to the development of PTSD. People who suffer include military troops who served in wars; rescue workers for catastrophes like the 2001 terrorist attacks on New York City and Washington, D.C.; survivors of the Oklahoma City bombing; survivors of accidents, rape, physical or sexual abuse or other crimes; immigrants fleeing violence in their countries; survivors of earthquakes, floods, and hurricanes; and those who witness traumatic events. Family members of victims can develop the disorder as well through vicarious trauma.

PTSD affects about 8 million American adults, and can occur at any age, including childhood. Women are more likely to develop the disorder than men, and there is some evidence that it may run in families. PTSD is frequently accompanied by depression, substance abuse, or anxiety disorders. When other conditions are appropriately diagnosed and treated, the likelihood of successful treatment increases.

Roughly 30 percent of Vietnam veterans developed PTSD. The disorder also has been detected in as many as 10 percent of Gulf War (Desert Storm) veterans, about 6 percent to 11 percent of veterans of the Afghanistan war, and about 12 percent to 20 percent of veterans of the Iraq war.

For veterans, factors related to combat may further increase risk for PTSD and other mental health problems. These include the veteran's role in the war, the politics around the war, where it's fought, and the type of enemy faced. Another cause of PTSD in the military is military sexual trauma (MST) or sexual harassment or assault that occurs in the military. MST can happen to men and women and can occur during peacetime, training, or war. Among veterans using VA health care, about 23 percent of women reported sexual assault while in the military, 55 percent of women and 38 percent of men have experienced sexual harassment when in the military.

When symptoms develop immediately after exposure and persist for up to a month, the condition may be called acute stress disorder. PTSD is diagnosed when the stress symptoms following exposure have persisted for over a month. Delayed expression of PTSD can occur if symptoms arise six months or more following the onset of trauma.

Symptoms

Many people with PTSD tend to re-experience aspects of the traumatic event especially when they are exposed to events or objects reminiscent of the trauma. Anniversaries of the event, similarities in person, place or circumstance can also trigger symptoms. People with PTSD also experience intrusive memories or flashbacks, emotional numbness, sleep disturbances, anxiety, intense guilt, sadness, irritability, or outbursts of anger, and dissociative experiences. Many people with PTSD may try to avoid situations that remind them of the ordeal. When symptoms last more than one month, a diagnosis of PTSD may be relevant.

Symptoms associated with reliving the traumatic event:

  • Having bad dreams, or distressing memories about the event
  • Behaving or feeling as if the event were actually happening all over again (known as flashbacks)
  • Dissociative reactions or loss of awareness of present surroundings
  • Having a lot of emotional feelings when reminded of the event
  • Having a lot of physical sensations when reminded of the event (heart pounds or misses a beat, sweating, difficulty breathing, feeling faint, feeling a loss of control)

Symptoms related to avoidance of reminders of the traumatic event:

  • Avoiding thoughts, conversations, or feelings about the event
  • Avoiding people, activities, or places associated with the event

Symptoms related to negative changes in thought or mood:

  • Having difficulty remembering an important part of the original trauma
  • Feeling numb or detached from things
  • Lack of interest in social activities
  • Inability to experience positive moods
  • Pessimism about the future

​Arousal and reactivity symptoms:

  • Sleeping Difficulties including trouble falling or staying asleep
  • Irritability and outbursts of anger
  • Difficulty concentrating
  • Feeling easily startled
  • Excess Awareness (hypervigilance)

Other symptoms related to depersonalization (feeling like an observer to one's body and thoughts/feelings) or derealization (experiencing unreality of surroundings) may also exist for some individuals.

Causes

The cause of PTSD is unknown, but psychological, genetic, physical, and social factors are involved. PTSD changes the body's response to stress. It affects the stress hormones and chemicals that carry information between the nerves (neurotransmitters). Prior exposure to trauma in the past may increase the risk of PTSD due to re-experience of trauma. People who have suffered childhood abuse or other previous traumatic experiences are likely to develop the disorder, sometimes months or years after the trauma. Temperamental variables such as externalizing behaviors, or other anxiety issues may also increase risk. Other environmental risk factors include family dysfunction, childhood adversity, cultural variables, family history of psychiatric illness. The greater the magnitude of the trauma, the greater the risk for PTSD—witnessing atrocities, severe personal injury, perpetrating violence. Inappropriate coping mechanisms, lack of social support or family instability or financial instability may further worsen outcomes.

Other factors, called resilience factors, can help reduce the risk of the disorder. Some of these resilience factors are present before the trauma and others become important during and after a traumatic event. Resilience factors that may reduce the risk of PTSD include seeking out support from other people, such as mental health professionals, friends and family, finding a support group after a traumatic event, feeling good about one's own actions in the face of danger, having a coping strategy, or a way of getting through the bad event and learning from it, and being able to act and respond effectively despite feeling fear.

Treatments

Treatment for PTSD typically begins with a detailed evaluation, and development of a treatment plan that meets the unique needs of the survivor. The main treatments for people with PTSD are psychotherapy, medications, or both. Due to differences in experience and consequence of the trauma, treatment varies and is tailored to the symptoms and needs of the individual. Treatment by a mental health care provider who is experienced with PTSD allows for people to lead more balanced and functional lives. Some people with PTSD may need to try different treatments to see what works for their symptoms.

If someone with PTSD is going through an ongoing trauma, such as being in an abusive relationship, treatment may include helping find safety. PTSD-specific-treatment can begin only when the survivor is safely removed from the crisis situation. Individuals who experience other symptoms of a panic disorder, depression, substance abuse, and feeling suicidal may need treatment to focus on those issues as well.

Other strategies for treatment include:

• Educating trauma survivors and their families about risks related to PTSD, how PTSD affects survivors and their loved ones, and other problems commonly associated with PTSD symptoms. Understanding that PTSD is a medically recognized disorder is essential for effective treatment. • Exposure to the event via imagery allows the survivor to re-experience the event in a safe, controlled environment. A professional can carefully examine reactions and beliefs in relation to that event. • Examining and resolving strong feelings such as shame, anger, or guilt, which are common among survivors of trauma. • Teaching the survivor to cope with post-traumatic memories, reminders, reactions, and feelings without avoiding them or becoming overwhelmed or emotionally numb. Trauma memories usually do not go away entirely as a result of therapy, but new coping skills can make them more manageable.

Medications

The U.S. Food and Drug Administration (FDA) has approved two medications for treating adults with PTSD, sertraline (Zoloft) and paroxetine (Paxil) which are selective serotonin reuptake inhibitors (SSRIs). Both of these medications are antidepressants, which are also used to treat depression. They may help control PTSD symptoms such as sadness, worry, anger, and feeling numb inside. Using medications co-jointly with therapy or prior to starting therapy may make it easier to use treatment effectively. If an antidepressant is prescribed, it may need to be taken for several days or weeks before noticing significant improvement. It is important to not get discouraged and prematurely stop taking medications before they've had a chance to work. An adjustment in dosage or a switch to another SSRI may help address these issues. It is important to work collaboratively with your doctor.

Sometimes people taking these medications have side effects. The effects can be annoying, but they usually go away. However, medications affect everyone differently. Any side effects or unusual reactions should be reported to a doctor immediately.

The most common side effects of antidepressants like sertraline and paroxetine are:

• Headaches, which usually goes away within a few days. • Nausea, which usually goes away within a few days. • Sleeplessness or drowsiness, which may occur during the first few weeks but then goes away. Sometimes the medication dose needs to be reduced or the time of day it is taken needs to be adjusted to help lessen these side effects. • Agitation (feeling jittery). • Sexual problems, which can affect both men and women, including reduced sex drive, and problems having and enjoying sex.

There are other types of medications which doctors may also prescribe, such as the following: Benzodiazepines may be given to help people relax and sleep more easily, although there is potential for developing dependence. Antipsychotics may be prescribed to people who experience more severe agitation, suspiciousness, or paranoia. Other antidepressants like fluoxetine (Prozac) and citalopram (Celexa) can help people with PTSD feel less tense or sad. For people with PTSD who also have other anxiety disorders or depression, antidepressants may be useful in reducing symptoms of these co-occurring illnesses. The potential side-effects related to the use of these medications involves a dialogue with your provider.

Similarly, antidepressant medications called tricyclics are given at low doses and gradually increased. Tricyclics have been around longer than SSRIs and have been more widely studied for treating anxiety disorders. They are as effective as the SSRIs, but many physicians and patients prefer the newer drugs because the tricyclics sometimes cause dizziness, dry mouth, drowsiness, and weight gain. Mood stabilizers such as lamotrigine and divalproex sodium may also be helping in treating symptoms.

Psychotherapy

Therapy is well-regarded in the treatment of PTSD. It involves talking with a mental health professional to work through the experience and its impact on the individual. Psychotherapy can occur one-on-one or in a group format. Therapy for PTSD usually lasts until the individual has learned to manage and cope with their experience and is able to be more functional. 

Many types of psychotherapy can help people with PTSD. Some types target the symptoms of PTSD directly. Other therapies focus on social, family, or job-related problems. The doctor or therapist may combine different therapies depending on each person's needs.

Cognitive behavioral therapy, or CBT, has been found to be quite effective in treating PTSD. There are several parts to CBT, including:

• Exposure therapy: This therapy helps people be more aware of their experience. It may expose them to the memory of the trauma they experienced in a safe way. It uses mental imagery, writing, or visits to the place where the event happened. The therapist uses these tools to help people with PTSD cope with their feelings. • Cognitive restructuring: This therapy helps people make sense of their memories and experiences. Sometimes people remember the event differently than how it actually happened. They may feel guilt or shame about what is not their fault. The therapist helps people with PTSD look at what happened in a realistic way. • Stress inoculation training: This therapy tries to reduce PTSD symptoms by teaching a person how to reduce anxiety when confronting anxiety provoking situations. Like cognitive restructuring, this treatment helps people look at their experiences in a healthy way.

There are also other types of treatment that can help people with PTSD and a client may want to discuss with their therapist about therapy options and treatment focus that may include:

• Learning about trauma and its effects • Using relaxation and anger management skills • Improving sleep, diet, and exercise habits • Identifying and dealing with guilt, shame, and other feelings about the event • Focusing on our reactions to PTSD symptoms—for example, therapy helps people visit places and people that are reminders of the trauma

Eye movement desensitization and reprocessing (EMDR) is a relatively new treatment of traumatic memories that involves elements of exposure therapy and cognitive behavioral therapy, combined with techniques (sounds, eye movements, hand taps) that create an alteration of attention. There is some evidence that the therapeutic element unique to EMDR, attentional alteration, may be helpful in accessing and processing traumatic material.

Brief psychodynamic psychotherapy focuses on the emotional conflicts caused by the traumatic event. This therapy helps a person understand how the past affects the way you feel now. Through the retelling of the traumatic event to a calm and empathic counselor, the survivor achieves a greater sense of self-esteem, develops effective ways of thinking and coping, and more successfully deals with the intense emotions that emerge during therapy. The therapist helps the survivor identify current life situations that set off traumatic memories and worsen PTSD symptoms.

Group treatment is an ideal therapeutic setting because trauma survivors are able to seek help and support while sharing traumatic material in a safe environment. As group members achieve greater understanding and resolution of their trauma, they often feel more confident and able to trust themselves as well as others. As they discuss and share trauma-related shame, guilt, fear, rage, doubt, and self-condemnation, they learn to focus on the present rather than the past. Telling one's story and directly facing the grief, guilt, and anxiety related to trauma enables many survivors to cope with their symptoms, memories, and other aspects of life.

Family therapy is a type of counseling that involves your whole family, as PTSD can affect the entire family. Your kids or your partner may not understand why you get angry sometimes, or why you're under so much stress. They may feel scared, guilty, or even angry about your condition. In family therapy, a therapist helps you and your family to communicate, maintain good relationships and cope with tough emotions. Your family can learn more about PTSD and how it is treated. In such therapy, each person can express his or her fears and concerns. It's important to be honest about your feelings and to listen to others. You can talk about your PTSD symptoms and what triggers them. You also can discuss the important parts of your treatment and recovery. By doing this, your family will be better prepared to help you. You may consider having individual therapy for your PTSD symptoms and family therapy to help you in your relationships.

References

  • American Journal of Psychiatry
  • Journal of Psychopharmacology
  • Journal of Traumatic Stress
  • National Comorbidity Survey Replication
  • Biological Psychiatry
  • Annual Review of Psychology
  • National Institutes of Health - National Library of Medicine
  • National Institute of Mental Health
  • US Department of Health and Human Services
  • Hippocampal Volume in Women Victimized by Childhood Sexual Abuse.
  • National Center for PTSD, U.S. Department of Veterans Affairs
  • Canadian Journal of Psychiatry
  • Psychiatric Clinics of North America
  • Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-V)

Last reviewed 04/03/2017