Table of Contents:
You're reading about:
Post-traumatic stress disorder (PTSD) is a psychological disorder that develops in response to a shocking, frightening, or traumatic event. This event can include being exposed to actual or threatened death, serious injury, and/or sexual violation. Examples of such events include exposure to military combat, sexual assault, natural disasters, and motor vehicle accidents.
It is common and expected for most people to experience fear and anxiety during and immediately following a traumatic event, and most people tend to naturally recover from these reactions as time goes on. However, when a person continues to experience persistent trauma and stress-related symptoms for more than six months, a diagnosis of PTSD should be considered. These symptoms include re-experiencing the traumatic memory in an unwanted and disturbing way, avoiding thoughts, feelings and situations that remind the individual of the event, experiencing intense negative moods or having negative thoughts associated with (e.g. thinking it’s your fault or feeling depressed), as well as feeling overly aroused since the event (e.g. feeling hypervigilant).
PTSD symptoms can develop immediately following trauma or have a delayed onset (i.e. more than six months after the trauma occurs) and is most likely to run a chronic course. Unfortunately, it is quite common for individuals with PTSD to develop a co-occurring psychiatric condition, such as Major Depressive Disorder, an anxiety disorder, and quite commonly individuals with PTSD can develop a substance abuse problem. Given the potential for PTSD to develop a chronic course with added suffering from co-occurring psychiatric disorders, it is important for individuals experiencing symptoms of PTSD to reach out for help as soon as possible.
Many people think about PTSD in terms of military combat and veterans but PTSD can develop from other types of traumatic experiences. Answer a few simple questions to see if you might be experiencing symptoms of PTSD.
For a diagnosis of PTSD, all of the following criteria must be met - at least one for A, B, and C - and at least two for D and E. Symptoms must be present for at least a month, must be functionally impairing, and not be caused by substance abuse, medication, or other medical condition.
Trauma survivors must have been exposed to actual or threatened:
The exposure can be:
These symptoms include ways that someone mentally re-experiences the event. This could look like:
Avoidant symptoms describe ways that someone may try to avoid any memory of the event, and must include one of the following:
This criterion is new with DSM-5, but captures many symptoms that have long been observed by PTSD sufferers and clinicians. Basically, there is a decline in someone’s mood or thought patterns, which can include:
Increased arousal symptoms are used to describe the ways that the brain remains “on edge,” wary and watchful of further threats. Symptoms include the following:
There are multiple effective treatment interventions for PTSD. These options include both psychological/therapeutic treatments and medical treatments. The good news is that treatment research from the last 30 years has produced significant advances in effective psychotherapeutic and psychopharmacological interventions for PTSD. There is compelling evidence that cognitive-behavioral therapies (CBTs) and selective serotonin reuptake inhibitors (SSRIs) are successful in reducing PTSD symptoms, with treatment gains from CBT maintained at follow-ups of a year or more (see Taylor et al., 2003).
The value of a given PTSD treatment is determined by researchers and clinicians primarily through the use of randomized control trials (RCTs). RCTs are designed to show that the measured outcomes of a specific treatment can be attributed to that specific treatment rather than to outside variables such as expectancy (Kraemer, 2004). Evidence-based treatments for PTSD include Prolonged Exposure Therapy (PE; Foa, Rothbaum, Riggs, & Murdock, 1991; Foa, Dancu, et al., 1999; Foa et al., 2005), Cognitive Processing Therapy (CPT; Resick & Schnicke, 1993), and Eye Movement Desensitization and Reprocessing (EMDR; Rothbaum, Astin, & Marsteller, 2005). Fortunately, results from a meta-analysis indicate that the type of trauma experienced (e.g. combat/terror, childhood sexual abuse, sexual assault, natural disaster) did not affect treatment response to PTSD-specific treatments (Powers, Halpern, Ferenschak, Gillihan, & Foa, 2010). This indicates that the above treatment interventions are effective for various trauma experiences if PTSD is present.
PE, CPT, and EMDR have been found to be effective in targeting and reducing PTSD symptoms. These three empirically-supported psychosocial treatments have also been found to successfully improve overall functioning in PTSD patients and to help patients maintain these improvements over time.
PE is an evidence-based CBT shown to be a reliable and safe intervention for individuals with PTSD (van Minnen, Harned, Zoellner, & Mills, 2012). PE has three main core components, which are “in vivo” exposure, which refers to real life interaction with trauma reminders, “imaginal” exposure, which refers to the patient’s revisiting of the trauma memory, and processing of imaginal exposure, which is the time where patients reevaluate negative trauma-related thoughts about themselves, others, and the world. The other components of PE include breathing retraining and psychoeducation about the nature of trauma reactions and the rationale for exposure therapy (Foa, Hembree, & Rothbaum, 2007). The main goal of PE is to facilitate new learning by helping patients confront trauma-related thoughts, memories, feelings, objects, and activities in a safe environment (Foa, Huppert, & Cahill, 2006).
CPT is another evidence-based CBT that was developed to treat PTSD and related symptoms (Resick & Schnicke, 1992). CPT is supported by the cognitive trauma theory of PTSD, which asserts that avoidance and problematic interpretations of the trauma lead to the onset and maintenance of PTSD (Resick & Schnicke, 1993). CPT states that therapy should target two main “stuck points,” or patterns of thinking, that interfere with natural recovery. The first stuck point is assimilation and the second is over-accommodation. A primary goal of CPT is to help patients integrate new information with previously existing thought patterns in a more accurate, helpful way.
EMDR was developed as a short-term, treatment designed for individuals who are symptomatic following a traumatic experience (Shapiro, 1995, 1996). EMDR is now supported by the adaptive information processing (AIP) model, which focuses on how the brain internally processes information and stores memories (Solomon & Shapiro, 2008). According to AIP, traumatic memories left insufficiently processed lead to distorted thoughts and problematic behaviors and reactions (Shapiro, 2007). The primary goal of EMDR is to encourage processing of the trauma memory with the underlying hypothesis that processing will help correct distorted thoughts and maladaptive behaviors. One of this therapy’s unique characteristics is its use of bilateral physical stimulation, such as side-to-side eye movements, alternating hand taps, or alternating auditory tones while the person undergoing treatment is mentally concentrating on parts of various life experiences.
Pharmacotherapy is another first-line treatment for PTSD as supported by evidence from multi-site RCTs. The U.S. Food and Drug Administration (FDA) approved sertraline and paroxetine as pharmacological treatments of choice for PTSD (Friedman & Davidson, 2014). Both sertraline (brand name: Zoloft) and paroxetine (brand names: Pexeva, Paxil) are SSRIs that increase the neurotransmitter serotonin in the synaptic cleft (therefore increasing brain activity stimulated by serotonergic stimulation) by inhibiting its reuptake. RCTs have demonstrated that SSRIs are safe, well-tolerated, and effective treatments for PTSD as opposed to placebo and can produce remission in 30% of patients (e.g., Brady et al., 2000; Davidson, Rothbaum, van der Kolk, Sikes, & Farfel, 2001; Londborg et al., 2001; Marshall, Beebe, Oldham, & Zaninelli, 2001; Tucker & Trautman, 2000). While SSRIs can be effective, the results of the medication have not been shown to last after discontinuation.
Although Prolonged Exposure is highly supported and evidence based, patients may be interested in other new treatment options and alternatives. There are other treatment methods with some preliminary research support that may also help individuals with PTSD. Although not yet empirically supported, researchers are working to strengthen these up and coming treatment options to be viable treatment alternatives or enhancements to PE.
Virtual reality methodologies have been used as a way to enhance engagement in existing Prolonged Exposure therapy. Especially when people have experienced combat-related traumas, the use of virtual reality enables patients to be immersed in safe and controllable situations that will allow them to confront their traumas. Virtual reality headsets can provide the patient with auditory and visual experiences which simulate situations related to their past traumas and lessen the need for patients to recall all of the details on their own. The use of virtual reality seems like a promising addition to Prolonged Exposure and its use has been supported in many preliminary studies. However, further controlled and standardized studies are needed to standardize treatment protocol and examine treatment outcomes. One of the main limitations of VR is that the scenarios are developed for very specific situations and each traumatic event would require a new VR environment. This would be very expensive, and potentially limit the accessibility of the already underutilized treatment of PE.
TMS is a type of treatment most commonly used for hard to treat depression. It’s a noninvasive procedure that stimulates nerve cells in the brain by using magnetic fields from a special treatment machine. Although the specifics of how TMS works are unclear, it is thought to activate areas of the brain responsible for mood control by delivering a painless magnetic pulse. TMS is starting to be studied as a way to treat patients with both PTSD and depression. The initial results have been promising but limited, and further control trials should be conducted to examine the clinical application of TMS as a treatment for PTSD.
Yoga therapy has been explored as a way to enhance and compliment empirically supported treatment options for PTSD. Typical yoga practices would be altered to be “trauma sensitive” meaning that it’s been adapted to specifically address certain symptoms of PTSD. The primary use of yoga is to address mindfulness - the idea is that other treatment options may fail to holistically address all aspects of a person’s well-being. This treatment would focus on increasing the ability to be present in the moment, increasing the connection between the self and the body, and personal growth.
PTSD is a disorder that many people experience with varying frequency. In general, roughly 3.6% of adults in the United States had PTSD in the past year, while about 6.8% had PTSD in their lifetime (Kessler, Chiu, Demler, & Walters, 2005). Additionally, women were more than twice as likely as men to have PTSD both in the last year and during their lifetime. In children and adolescents, PTSD rates ranged from about 3-6% (Kilpatrick et al., 2003). Prevalence of PTSD in military populations weighs in at more than double of that in civilians, with current PTSD in veterans who had deployed in service of Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) at about 13.8% (Tanielian & Jaycox, 2008). PTSD rates are even worse still in inner city populations, with a lifetime prevalence of about 46.2% from exposure to traumatic events including accidents, interpersonal violence, and sexual assault (Gillespie et al., 2009).
Anyone experiencing a traumatic event has some risk for developing PTSD. Not everyone who experiences a traumatic event goes on to develop PTSD; in fact, most people who experience trauma do not go on to develop PTSD.
Any type of traumatic experience can increase the risk for PTSD. For example, sexual assault, physical assault, combat, natural disaster, and car accidents are all examples of traumatic experiences, and each of these are associated with increased risk for PTSD. Some types of trauma are more likely than others to contribute to the development of PTSD; however, each trauma and each person’s response to that trauma is unique.
Some people have a higher chance of developing PTSD in response to trauma based on factors present before the trauma. These factors tend to be outside of the person’s control. Biological factors, such as inherited genes, can make us more or less likely to respond to a traumatic event with symptoms of PTSD. Additionally, growing up in a stressful environment or experiencing other traumas in the past can increase the chance that a person will respond to trauma with PTSD. The experience of mental health or psychological symptoms prior to trauma can also increase the chance that an individual will experience PTSD symptoms in response to trauma. Although each of these factors increase the risk for developing PTSD, it does not mean that PTSD is inevitable for an individual with these risk factors. In fact, many people with these risk factors do not go on to develop PTSD in response to trauma. It is also possible to develop PTSD even if you do not have any risk factors prior to the experience of trauma.
Most people experience PTSD-like symptoms in the weeks after a traumatic event. For many, these symptoms begin to go away on their own and they experience a natural recovery. For others, these symptoms linger for longer (at least one month) and that is when a diagnosis of PTSD is made. A lack of social support after experiencing trauma can increase someone’s risk for developing PTSD. Similarly, being discouraged from talking about or disclosing trauma can also increase the chance that an individual develops PTSD. The experience of other major life stressors soon after trauma can also increase the chance of developing PTSD symptoms. Following trauma, positive social support and connection are thought to be important in promoting psychological healing and recovery.
According to the DSM-5, for those living in the Unites States, 8.7% of the US population will have PTSD at some point in their lifetime. For adults, within the last 12 months, approximately 3.5% of the US population will have a current PTSD diagnosis. While certain characteristics can impact the development of PTSD, rates of PTSD are highest for survivors of sexual assault, military combat personnel, and refugee survivors of ethnic or political forms of imprisonment/genocide.
PTSD is rarely the only concern a person has once the disorder becomes chronic. In fact, PTSD is second only to depression in the likelihood of a person presenting with multiple psychiatric diagnoses. For example, among people with PTSD, they are 92% likely to also have another anxiety disorder or a mood disorder like depression. More specifically, 69% of people with PTSD also have a current depression diagnosis, 23% of people with PTSD also have panic disorder, and 23% of people with PTSD also have OCD. Additionally, 25% of people with PTSD also have concurrent medical concerns. For instance, people with PTSD are twice as likely as someone without PTSD to have gastrointestinal concerns, are over three times as likely to have a metabolic or autoimmune issue, and two and a half times more likely to have a neurological problem.
There is a wide range of reported prevalence rates for this comorbidity – with different studies reporting anywhere from 30-60% of people presenting for treatment of a substance use disorder (SUD) also meeting criteria for PTSD. Similarly, a person presenting for PTSD treatment is approximately two times more likely to also have a SUD. There are varying ideas about why this comorbidity is so prevalent, but the self-medication hypothesis has the most support.
Research suggests that quite often a person is likely to develop PTSD first and then learn that using substances can help him/her cope with the devastating impact of living with PTSD. People often find this solution quite helpful in the short-term, but over time, usually leaves a person with two chronic, interconnected, and very debilitating problems that are difficult to tease apart from one another. Further complicating the clinical picture is that most PTSD clinicians do not treat SUD and most SUD clinicians don’t treat PTSD. This is particularly problematic for this group of individuals because PTSD has a unique impact on SUD treatment that few other psychiatric disorders have.
The presence of PTSD often leads to early SUD treatment dropout, a more rapid relapse rate to substance use after SUD treatment ends, and a more complicated presenting list of problems at the beginning of treatment. The good news is that more and more research is now confirming that these two disorders can be treated simultaneously without increasing the risk for SUD treatment failure. In fact, research and clinical practice is showing that by working on PTSD and SUD simultaneously, that not only does PTSD get better, but it is the reduction of PTSD symptom severity that causes a reduction in SUD use. The reverse is not true – reducing SUD use does not decrease PTSD symptom severity. The key at this point is to train clinicians to treat both disorders at the same time versus continuing to adhere to the idea of obtaining a period of sobriety first and then working on trauma related symptoms later. In fact, for an individual to have their best chance at lasting sobriety/reduced substance use, addressing PTSD symptoms appears critical to driving substance use behaviors down.
Similarly, the co-morbid rates of borderline personality disorder (BPD) and PTSD vary by study, however, it is agreed upon that these two disorders often co-occur. A study among PTSD treatment seeking veterans reported that up to 76% also met criteria for BPD and another study found that 56% of people with BPD also met criteria for PTSD. Once again, either of these disorders alone can be incredibly debilitating, but when paired together the course of treatment can be much more complicated.
It is suggested that some of the most dangerous behaviors associated with BPD (suicidality and non-suicidal self-injury like cutting) can be very effective at reducing the distress caused by PTSD symptoms. As with initial substance use, these behaviors often bring short term relief from PTSD symptoms but unfortunately, what seems to occur in the long term, is a painful and chronic back and forth between ongoing PTSD symptoms and the need for coping with those symptoms by relying on self-injurious behaviors. One of the most effective treatments for BPD, dialectical behavior therapy (DBT), has now incorporated one of the most effective treatments for PTSD, prolonged exposure therapy (PE), with very good results. In fact, by treating PTSD as early as possible in the DBT process, we are seeing that not only does the severity of the PTSD lessen, but those with BPD who treat their PTSD also experience significant reductions in suicidal thinking, suicide attempts, and non-suicidal self-injury behaviors.
Once again, by delivering a concurrent treatment model for both presenting problems, addressing the symptoms of PTSD enhances the outcomes of DBT. We do not see addressing PTSD causing an increase in BPD symptom severity. The exact opposite actually occurs. The take home message is that concurrently treating both disorders sooner versus later gives a person the best chance at recovery from both.
The prevalence rates for eating disorders (anorexia nervosa, bulimia nervosa, binge eating disorder) in the United States vary by gender and disorder (anywhere from 0.5% for men with anorexia up to 3.5% of women with binge eating disorder), and the devastating impact of eating disorders is undeniable. As one researcher reported, eating disorders have the highest mortality rates of any mental illness. The emerging theme across these comorbid populations is that we actually don’t know just how prevalent the two disorders are together. However, recent studies indicated that 100% of people with anorexia or bulimia had a trauma history and so did 90-98% of people with binge eating disorder.
Having a trauma history doesn’t mean they have comorbid PTSD, however, there is evidence to suggest that people with bulimia and binge eating disorder are at particularly high risk for also having PTSD. One study reported up to 37% of people with bulimia and 21% of people with binge eating disorder have also met criteria for PTSD in their lifetime. Of particular concern is the comorbidity of binging and purging behaviors and PTSD. For example, when a person with anorexia also engages in binging and purging behaviors their risk for PTSD is significantly greater than those who are mainly engaged in restrictive behaviors. Once again, the relationship between binging and purging is associated with an effective short term relief from PTSD related distress.
Research indicates that those who engage in binging and purging experience a self-soothing short-term experience that is very relieving and likely to increase the use of those behaviors the next time a person feels distress associated with their PTSD symptoms. Therefore, another chronic and vicious cycle of relying on certain coping behaviors in the short term that ultimately creates two difficult disorders to address over the long term. Furthermore, PTSD has a unique negative impact on eating disorder treatment, making it more likely that people with eating disorders and PTSD won’t benefit from treatment. Therefore, again, the treatment goal is to provide concurrent treatment for both disorders simultaneously. This remains an idea that is growing more popular within the ED field but actual implementation of treatment research demonstrating how concurrent treatment in this population could be done effectively remains scarce.
For those not familiar with PNES, this can be an extraordinarily debilitating disorder without a lot of evidence based treatments for it. PNES behaviorally resembles epilepsy in that both will experience seizures but those with PNES do not demonstrate epileptiform activity during recording of brain waves using EEG. Therefore, PNES is a diagnosis given due to the symptoms of seizures but the seizures are conceived of as symptoms of an underlying psychological condition which means PNES must be treated by mental health professionals.
Given the psychiatric complexity associated with PNES it is not surprising that up to 90% of people with PNES have a trauma history and varying studies report that anywhere from 22-100% of people with PNES also have PTSD or subthreshold PTSD symptoms. There is limited research in treating people with PNES and PTSD, but some initial pilot data has been very promising. Especially interesting is that when the PTSD is effectively treated, out of 13 pilot cases, all experienced a significant decrease in seizure frequency and many experienced their seizures stopping completely. The theme remains that when the underlying PTSD is addressed the benefits of PTSD treatment extend well beyond the reduction of PTSD symptoms.
By addressing PTSD, clinicians are also more effectively able to treat a variety of other comorbid conditions that are functionally related to the development of PTSD. There is a growing amount of evidence supporting the idea that decreases in PTSD symptom severity are the cause of other comorbid symptom severity reduction.
There is tremendous interest in the idea of preventing the development of PTSD after a person is exposed to a traumatic event. However, to date, this remains a frustratingly elusive discovery. One of the first dilemmas is that we still cannot reliably predict who will develop PTSD after a person is exposed to a trauma. We know that the vast majority of people will respond to a trauma with symptoms of acute stress disorder in the initial days and weeks following a traumatic event. We also know that the vast majority of people will naturally recover from acute stress disorder, without any professional intervention, and never go on to develop PTSD. Therefore, being able to predict those people that will go on to develop PTSD is essential to being able to develop prevention strategies. We need to better understand why PTSD develops in some people but not others in order to better design prevention programs.
One of the most well known and most commonly used prevention interventions, critical incident stress debriefing (CISD), has a mixed history of results. For example, following the 9/11 terrorist attacks CISD was frequently used among survivors and was found to be rather ineffective. Not only has CISD been unreliable in its effectiveness, but there is also some data that suggests CISD may increase the development of PTSD in some people. In a research review of the literature in 2002, the authors concluded that CISD did not provide any overall benefit to its recipients, and in some cases, CISD was detrimental when compared to minimal or no intervention at all.
Slightly more promising, but still limited in its ability to prevent PTSD, another study looked at administering the beta blocker medication propranolol within 6 hours of experiencing a trauma and was continued daily for up to ten days post the trauma. Initial outcomes demonstrated that 18% of people taking the propranolol went on to develop PTSD compared to 30% who took a placebo.
Lastly, an early intervention study at Emory University in Atlanta sought to provide a shortened, pre-emptive cognitive behavioral therapy for survivors of rape. Patients were recruited from emergency room departments after surviving a sexual assault and were randomly assigned to either the treatment intervention or a control group. Results were promising that a modified version of prolonged exposure therapy was effective at reducing post-traumatic stress reactions over 12 weeks of treatment and follow up. However, to date, there is no absolute solution to the prevention dilemma.
One thing is known for sure though, if a person is still experiencing symptoms of PTSD 6 months after the trauma occurred it is very important that person seek professional help because with each month that passes it becomes less and less likely that this person will naturally recover from their PTSD.
Following the experience of a traumatic event it is expected that most people will struggle in the days thereafter. Normalizing this experience and validating it as the way our bodies naturally react to surviving a trauma is very important for both the survivor and the loved ones of the survivor. For some people, recovery may be fast – a week to a month – and without much help from professionals or loved ones. For others, recovery can be more of a process and can require patience and time.
Remembering that this is a process is important as it can be very frustrating to not see results. Additionally, forgetting about what happened is often not associated with recovery. Despite the memory of the trauma remaining, healing from a trauma is associated with being able to live with the memory of what happened with less distress, experiencing fewer symptoms, and increased confidence and competence in one’s ability to function day to day. There are certain coping strategies that are considered to be more effective and helpful than others. The National Center for PTSD has some very helpful suggestions and information for survivors and loved ones of survivors. Tips they offer include:
A frequent question asked by many is how friends and family members can be supportive for their loved ones. Here are just a few suggestions to try when offering support to a loved one.
If your loved one is struggling with anxiety and distress related to a past traumatic event, try to remain positive and optimistic for them. For the sufferer, it may feel like they will always be haunted by their past thus making their future seem bleak. We recommend striking a balance between validating that what the person experienced was truly horrific while remaining optimistic about their ability to overcome their anxiety.
It may sound simple, but listening to your friend or family member can go a long way. By listening to your loved one and offering unconditional support, you are communicating you care about them. Even if you don’t have any answers for their concerns, they will likely feel your support and concern which can be comforting by itself.
Although you will not fully understand what it is like to have PTSD, you can likely relate to the feelings being experienced (e.g. fear and anxiety). If you can find a way to connect with the feelings your loved one is experiencing and then communicate your understanding, you will have found a common ground that can greatly show your support for them.
If your loved one is not in treatment, it’s always best to encourage they reach out for professional help. If they are currently in treatment, let them know you’re there to help. This may involve talking about their progress and treatment victories. In exposure-based therapies, this may include participating in certain exposures (e.g. walking through a park together, driving over a bridge, or watching certain movies or TV shows on repeat). While we encourage people to offer this kind of support, it is important to mention that we do not recommend discussing specific horrific details of trauma events (e.g. gruesome details of military combat or sexual assault) with the sufferer. However, it may be worthwhile to discuss how the event has affected their life and their goals for the future.
Many of the ideas written here are further discussed on the National PTSD website:
Grants and Funding: We proudly support the research and programs of 501(c)(3) non-profit organizations and institutions such as: the Anxiety Disorders program of the Jane & Terry Semel Institute for Neuroscience & Human Behavior at the University of California, Los Angeles; the Pacific Institute of Medical Research; the International Foundation for Research and Education on Depression (iFred); and SchoolsForHope.org, an iFred educational project. Working with these partners enables Anxiety.org to extend its commitment to its mission. All the donations received, as well as 100% of Anxiety.org revenue in 2019, will be contributed to build, develop, and further the understanding, investigation, discovery, and treatment of the full spectrum of anxiety and related disorders.