What is Post-Traumatic Stress Disorder?
Post-traumatic stress disorder (PTSD) is a psychological condition that occurs in response to a shocking or traumatic event. Such events include exposure to actual or potential death, serious injury or sexual violation. Examples include military combat, sexual assault, natural disasters and car accidents.
While fear and anxiety are typical immediate reactions to trauma, most people naturally recover from these reactions over time. However, if a person experiences persistent trauma and stress-related symptoms for more than six months, a diagnosis of PTSD should be considered. These symptoms include unpleasant and disturbing memories of the traumatic event; avoidance of thoughts, feelings, and situations associated with the event; intense negative mood or thoughts (such as self-blame or depression); and heightened arousal (such as hypervigilance).
PTSD symptoms can manifest immediately after the trauma or have a delayed onset, occurring more than six months later. The condition is often chronic and unfortunately often co-occurs with other psychiatric disorders such as major depressive disorder, anxiety disorders and substance abuse problems. Given the potential for chronicity and the added burden of co-morbid conditions, it is critical that people experiencing PTSD symptoms seek help promptly.
PTSD Screener: Do I have PTSD?
Although post-traumatic stress disorder (PTSD) is often associated with military combat and veterans, it can result from many types of traumatic experiences. By answering a short series of questions, you can determine whether you may be experiencing symptoms associated with PTSD.Take The Quiz
Diagnostic Criteria for Post-Traumatic Stress Disorder (DSM-5)
To receive a diagnosis of PTSD, the following criteria must be met: at least one criterion from A, B, and C, and at least two criteria from D and E. Symptoms should persist for at least one month, cause functional impairment, and not be attributed to substance abuse, medication, or other medical conditions.
Criterion A: Traumatic event
Trauma survivors must have been exposed to an actual or threatened event resulting in
- Serious injury
- Sexual violence
Exposure can occur through:
- Direct experience
- Indirect experience through learning about an event that happens to a close relative or friend (indirect exposure to death should be accidental or violent)
- Repeated or extreme indirect exposure to qualifying events, usually through professionals (non-professional exposure through the media is not considered).
Criterion B: Intrusion or re-experiencing
These symptoms involve mental re-experiencing of the event, including
- Intrusive thoughts or memories
- Nightmares related to the trauma
- Flashbacks, feeling that the event is happening again
- Intense emotional distress or physiological reactions (e.g., increased heart rate, difficulty breathing) when triggered by reminders of the trauma, such as images or specific places.
Criterion C: Avoidance symptoms
Avoidance symptoms involve efforts to avoid any reminder of the event and must include one of the following
- Avoidance of thoughts or feelings associated with the trauma
- Avoidance of people or situations associated with the trauma
Criterion D: Negative mood and cognitive changes
This criterion, introduced in the DSM-5, encompasses several symptoms observed in people with PTSD. It includes a decline in mood or thought patterns, including
- Trauma-related memory problems
- Negative thoughts or beliefs about oneself or the world
- Self-blame or blame of others for the trauma, regardless of direct involvement
- Persistent intense feelings related to the trauma (e.g., horror, shame, sadness)
- A marked loss of interest in activities previously enjoyed
- Feeling detached, isolated, or disconnected from others
Criterion E: Increased arousal symptoms
Increased arousal symptoms describe the brain’s heightened state of vigilance and anticipation of further threats. Symptoms consist of
- Difficulty concentrating
- Irritability, frequent outbursts of anger
- Difficulty sleeping, including difficulty falling or staying asleep
- Excessive startle response
Effective treatments for PTSD include psychological/therapeutic interventions and medical approaches. Fortunately, the past three decades have seen significant advances in research into successful psychotherapeutic and psychopharmacological interventions for PTSD. Cognitive-behavioural therapies (CBT) and selective serotonin reuptake inhibitors (SSRIs) have shown compelling evidence in reducing PTSD symptoms, with CBT sustaining treatment gains even one year after treatment (Taylor et al., 2003).
The effectiveness of PTSD treatments is primarily determined by randomised control trials (RCTs), which attribute measured outcomes to specific treatments rather than to external 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 desensitisation and reprocessing (EMDR; Rothbaum, Astin, & Marsteller, 2005).
Importantly, a meta-analysis has shown that treatment response to these interventions is not influenced by the type of trauma experienced (e.g. combat, childhood sexual abuse, sexual assault, natural disaster), suggesting their effectiveness across different trauma experiences when PTSD is present (Powers, Halpern, Ferenschak, Gillihan, & Foa, 2010).
Prolonged exposure therapy (PE)
PE is a safe and evidence-based cognitive behavioural therapy (CBT) for people with PTSD (van Minnen, Harned, Zoellner, & Mills, 2012). It has three core components: ‘in vivo’ exposure, which involves real-life interaction with trauma reminders; ‘imaginal’ exposure, in which patients re-experience the trauma memory; and processing of imaginal exposure, which involves re-evaluating negative trauma-related thoughts about oneself, others, and the world.
Other components include breathing retraining and psychoeducation about trauma reactions and the rationale for exposure therapy (Foa, Hembree, & Rothbaum, 2007). The primary 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).
Cognitive Processing Therapy (CPT)
CPT is another evidence-based CBT designed to treat PTSD and related symptoms (Resick & Schnicke, 1992). It is based on the cognitive trauma theory of PTSD, which posits that avoidance and distorted interpretations of the trauma contribute to the onset and maintenance of the disorder (Resick & Schnicke, 1993). CPT targets two main ‘stuck points’ or cognitive patterns that impede natural recovery: assimilation and over-accommodation. The therapy aims to help patients integrate new information into pre-existing thought patterns in a more accurate and constructive way.
Eye Movement Desensitisation and Reprocessing (EMDR)
EMDR is a short-term treatment originally developed for people with post-traumatic symptoms (Shapiro, 1995, 1996). It now operates within the adaptive information processing (AIP) model, which examines how the brain internally processes information and stores memories (Solomon & Shapiro, 2008). According to the AIP model, inadequately processed traumatic memories lead to distorted thoughts and maladaptive behaviours (Shapiro, 2007).
The primary goal of EMDR is to facilitate the processing of traumatic memories, with the hypothesis that processing will correct distorted thoughts and maladaptive behaviours. Specifically, EMDR uses bilateral physical stimulation (e.g., eye movements, alternating hand taps, auditory tones) while the person focuses on different aspects of life experiences.
Pharmacotherapy is the first-line treatment for PTSD, supported by evidence from multi-site randomised control trials (RCTs). Sertraline (Zoloft) and paroxetine (Pexeva, Paxil), both selective serotonin reuptake inhibitors (SSRIs), are FDA-approved as the preferred pharmacological treatments for PTSD (Friedman & Davidson, 2014). These drugs increase serotonin levels in the brain by inhibiting its reuptake, thereby enhancing brain activity associated with serotonergic stimulation.
RCTs have demonstrated the safety, tolerability and efficacy of SSRIs in the treatment of PTSD compared with placebo, with remission observed in approximately 30% of patients (Brady et al, 2000; Davidson et al, 2001; Londborg et al, 2001; Marshall et al, 2001; Tucker & Trautman, 2000). It should be noted, however, that the effects of medication may not last after discontinuation.
While Prolonged Exposure remains a strongly supported, evidence-based therapy, individuals with PTSD may be interested in exploring other emerging treatment options and alternatives. Several treatment approaches, although not yet empirically supported, show promise and may provide additional benefits or serve as alternatives to Prolonged Exposure Therapy.
Virtual reality (VR) has been used to enhance engagement in Prolonged Exposure Therapy. Particularly beneficial for individuals with combat-related trauma, VR allows patients to experience immersive, controlled environments that facilitate confrontation with their trauma. By providing auditory and visual experiences that simulate past traumas, VR reduces the reliance on patients’ independent recall.
Preliminary studies support the use of VR as a valuable adjunct to Prolonged Exposure Therapy. However, further research with controlled and standardised trials is needed to establish treatment protocols and examine outcomes. A limitation of VR is the development of specific scenarios for each traumatic event, which can be costly and may limit access to the already underused Prolonged Exposure Therapy.
Transcranial magnetic stimulation (TMS)
Primarily used for treatment-resistant depression, TMS is a non-invasive procedure that uses magnetic fields to stimulate nerve cells in the brain. Although the exact mechanisms are unclear, TMS is thought to activate brain regions involved in mood regulation by delivering painless magnetic pulses. Researchers are investigating the use of TMS as a treatment for both PTSD and depression, and early results are promising. However, further controlled trials are needed to explore the clinical application of TMS in the treatment of PTSD.
Yoga therapy has been investigated as a complementary approach to complement empirically supported treatments for PTSD. Yoga practices are tailored to be ‘trauma-sensitive’ and specifically address PTSD symptoms. The focus is on mindfulness, as other treatments may not comprehensively address all aspects of well-being. Yoga therapy aims to increase present-moment awareness, strengthen the mind-body connection and promote personal growth.
The prevalence of PTSD
The prevalence of PTSD varies between individuals and populations. In the United States, about 3.6% of adults had PTSD in the past year, while about 6.8% had PTSD at some point in their lives (Kessler, Chiu, Demler, & Walters, 2005). Women were more than twice as likely as men to have experienced PTSD both in the past year and in their lifetime. Among children and adolescents, PTSD rates ranged from about 3% to 6% (Kilpatrick et al., 2003).
In military populations, the prevalence of PTSD is more than double that of civilians, with current rates among veterans who served in Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) at approximately 13.8% (Tanielian & Jaycox, 2008). Inner-city populations have even higher rates, with a lifetime prevalence of approximately 46.2%, due to exposure to traumatic events such as accidents, interpersonal violence, and sexual assault (Gillespie et al., 2009).
Causes and risk factors
Experiencing a traumatic event increases the risk of developing PTSD, although not everyone who experiences a trauma will develop the disorder. Several types of trauma, including sexual assault, physical assault, combat, natural disasters and car accidents, are associated with an increased risk of PTSD. However, the likelihood of developing PTSD can vary depending on the type of trauma and the individual’s unique response.
Factors before the trauma
Certain pre-existing factors can increase the likelihood of developing PTSD after a trauma, even though they are beyond an individual’s control. Biological factors, such as inherited genes, can influence how likely a person is to develop PTSD in response to a traumatic event. Growing up in a stressful environment or having a history of trauma can also increase the risk.
Pre-existing mental health or psychological symptoms also contribute to the likelihood of experiencing PTSD symptoms after a trauma. However, it is important to note that having these risk factors does not guarantee the development of PTSD, as many people with these factors do not develop the disorder. Similarly, it is possible to develop PTSD without having any of these risk factors.
Factors after the trauma
After a traumatic event, most people experience PTSD-like symptoms in the weeks immediately following the event. For many people, these symptoms naturally subside over time as part of the normal recovery process. For some, however, the symptoms persist for a longer period of time (at least a month), leading to a diagnosis of PTSD.
Lack of social support after trauma increases the risk of developing PTSD, as does discouragement from discussing or disclosing the traumatic experience. Experiencing other major life stressors shortly after the trauma can also increase the likelihood of PTSD symptoms. Positive social support and connectedness are thought to play a crucial role in promoting psychological healing and recovery after trauma.
PTSD prevalence and comorbidity rates
In the United States, approximately 8.7% of the population will experience PTSD at some point in their lives, with approximately 3.5% having a current diagnosis within the past year (DSM-5). Certain populations, such as survivors of sexual assault, military combatants, and refugees who have experienced imprisonment or genocide, have higher rates of PTSD.
PTSD rarely occurs in isolation and is often associated with other psychiatric diagnoses. Depression is the most common comorbidity, with people with PTSD having a 92% chance of also having another anxiety or mood disorder such as depression. Specifically, 69% of people with PTSD have a current diagnosis of depression, 23% have panic disorder and 23% have obsessive-compulsive disorder. In addition, 25% of people with PTSD also have a co-occurring medical condition. Compared to those without PTSD, people with PTSD are twice as likely to have gastrointestinal problems, more than three times as likely to have metabolic or autoimmune problems, and two and a half times as likely to have neurological problems.
Most common comorbidity diagnoses with PTSD
PTSD and substance use disorders
Rates of comorbidity between PTSD and substance use disorders (SUDs) vary, with estimates ranging from 30% to 60% of people seeking treatment for SUDs also meeting criteria for PTSD. Conversely, individuals seeking treatment for PTSD are about twice as likely to have a co-occurring SUD. The self-medication hypothesis suggests that people with PTSD may turn to substances to cope with the distress caused by the disorder.
While this may provide short-term relief, it often leads to chronic and intertwined problems. The presence of PTSD can lead to early dropout from SUD treatment, higher relapse rates and a more complex clinical presentation. However, research shows that treating both disorders simultaneously can be effective, and that reducing the severity of PTSD symptoms can lead to a reduction in SUD use.
PTSD and Borderline Personality Disorder (BPD)
PTSD and borderline personality disorder (BPD) often co-occur, although specific rates of comorbidity vary. Studies have reported rates of up to 76% of veterans seeking treatment for PTSD meeting criteria for BPD, and 56% of individuals with BPD meeting criteria for PTSD. The distress caused by PTSD symptoms may lead individuals with BPD to engage in self-injurious behaviours as a coping mechanism.
While these behaviours provide temporary relief, they contribute to a cycle of persistent PTSD symptoms and reliance on self-injury. Concurrent treatment models that address both disorders, such as dialectical behaviour therapy (DBT) combined with prolonged exposure therapy (PE), have shown positive results. Treating PTSD early in the BPD treatment process can lead to a reduction in PTSD severity, as well as significant reductions in suicidal ideation and self-injurious behaviours.
Addressing comorbidities concurrently and early in treatment offers the best chance of recovery from both disorders. Treating PTSD at the same time does not worsen the symptoms of comorbid disorders, but rather improves treatment outcomes.
PTSD and eating disorders
The prevalence of eating disorders varies by gender and specific disorder, with rates ranging from 0.5% for men with anorexia nervosa to 3.5% for women with binge eating disorder in the United States. Eating disorders have the highest mortality rates among mental illnesses. Although the exact prevalence of comorbid PTSD and eating disorders is unclear, recent studies suggest that individuals with anorexia nervosa, bulimia nervosa and binge eating disorder often have a history of trauma. Approximately 100% of people with anorexia or bulimia have experienced trauma, as have 90-98% of people with binge eating disorder.
While having a history of trauma does not necessarily mean having comorbid PTSD, there is evidence that people with bulimia and binge eating disorder are at higher risk of also having PTSD. Up to 37% of people with bulimia and 21% of people with binge eating disorder have met criteria for PTSD in their lifetime. Of particular concern is the comorbidity between bingeing and purging behaviours and PTSD. Individuals with anorexia who engage in binging and purging behaviours have a significantly higher risk of developing PTSD than those who engage primarily in restricting behaviours. Binging and purging behaviours provide short-term relief from distress related to PTSD symptoms, contributing to a chronic and cyclical pattern of reliance on these behaviours as a coping mechanism.
Research suggests that individuals who engage in binging and purging behaviours experience short-term self-soothing and relief, which reinforces the use of these behaviours in response to PTSD-related distress. This creates a challenging cycle that requires both disorders to be addressed in treatment. PTSD also has a unique negative impact on eating disorder treatment, making it less likely that individuals with comorbid eating disorders and PTSD will benefit from treatment. Therefore, the goal of treatment is to provide concurrent treatment for both disorders, although research on effective concurrent treatment in this population is limited.
PTSD and non-epileptic seizures (PNES)
Non-epileptic seizures (PNES) can be a debilitating condition for which there are few evidence-based treatments. PNES is similar to epilepsy in that people experience seizures, but people with PNES do not show epileptiform activity on brain wave recordings using EEG. Therefore, PNES is considered a diagnosis based on seizure symptoms, conceptualised as manifestations of an underlying psychological condition that requires treatment 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 history of trauma, and studies report comorbid PTSD or subthreshold PTSD symptoms in between 22% and 100% of people with PNES. There is limited research on the treatment of individuals with comorbid PNES and PTSD, but early pilot data show promising results. Interestingly, effective treatment of PTSD has led to a significant reduction in seizure frequency and, in some cases, cessation of seizures. Addressing the underlying PTSD not only reduces PTSD symptoms, but also has broader beneficial effects on related comorbid conditions.
By addressing PTSD, clinicians can more effectively treat several comorbid conditions that are functionally related to the development of PTSD. Evidence supports the idea that reductions in the severity of PTSD symptoms are responsible for improvements in other comorbid symptoms.
Efforts to prevent the development of PTSD after exposure to trauma have been the subject of much interest, but concrete prevention strategies remain elusive. One of the challenges is the inability to reliably predict who will develop PTSD following trauma. Most people initially experience symptoms of acute stress disorder following a traumatic event, but the majority recover naturally without professional intervention and do not develop PTSD. Identifying those who will develop PTSD is crucial for effective prevention strategies. More research is needed to understand why some people develop PTSD and others do not, which can inform the design of prevention programmes.
One commonly used prevention intervention, critical incident stress debriefing (CISD), has had mixed results. Following the 9/11 terrorist attacks, CISD was widely used with survivors, but was found to be largely ineffective. Moreover, some evidence suggests that CISD may actually increase the risk of developing PTSD in certain individuals. A 2002 review of the literature concluded that CISD provided no overall benefit and in some cases could be harmful compared with minimal or no intervention.
Another trial looked at the use of the beta-blocker drug propranolol as a preventive measure. Participants were given propranolol within 6 hours of exposure to trauma and continued daily for up to ten days. Initial results showed that 18% of those taking propranolol developed PTSD, compared to 30% in the placebo group. While this was promising, its effectiveness in preventing PTSD is still limited.
A study conducted at Emory University in Atlanta focused on early intervention for survivors of sexual assault using a shortened version of cognitive behavioural therapy. Participants were randomly assigned to either the treatment intervention or a control group. The results showed that the modified version of prolonged exposure therapy was effective in reducing post-traumatic stress reactions over 12 weeks of treatment and follow-up. However, no definitive solution to the challenge of prevention has yet been found.
A key point to note is that if a person is still experiencing PTSD symptoms six months after the trauma, it is crucial for them to seek professional help. The longer symptoms persist, the less likely natural recovery becomes, emphasising the importance of timely intervention.
Coping with PTSD
After experiencing a traumatic event, it is common for individuals to struggle in the aftermath. It is important to normalise and validate these struggles, both for the survivor and their loved ones. Recovery from trauma can take different lengths of time, with some people recovering relatively quickly without professional help, while others may need more time and support.
It is important to recognise that the healing process takes time, as frustration can arise from not seeing immediate results. It is also important to understand that recovery does not necessarily mean forgetting what happened. Healing from trauma involves learning to live with the memory of the event with less distress, fewer symptoms, and increased confidence and competence in daily functioning. Certain coping strategies have been found to be effective and helpful. The National Centre for PTSD provides useful suggestions and information for survivors and their loved ones, including the following tips
- Learn about common reactions and symptoms experienced by trauma survivors and those with PTSD. Understanding that others are going through similar struggles can be reassuring, and knowing that effective treatments are available can provide hope.
- If possible, talk to someone about your experiences. It is common for survivors to feel reluctant to open up because of the range of emotions associated with PTSD. Loved ones should not push survivors to talk, but they can let them know that they are there to listen when they are ready. Simply offering a listening ear with care, love and empathy can be incredibly powerful.
- Try different relaxation strategies to see what works for you. There are many options, including diaphragmatic breathing, mindfulness meditation, yoga, progressive muscle relaxation, exercise, prayer, listening to music, watching funny shows or films, going for walks, surrounding yourself with comforting smells or objects, and taking baths. It may take some practice to find the techniques that work best for you, so be patient and open-minded.
- Hold on to the idea that the memories cannot harm you in the same way as the trauma itself. Although memories can cause intense physical and emotional pain, they are not as dangerous as the traumatic event itself. When people with PTSD experience re-experiencing symptoms, it is important to remember that having a memory of the event is different from being in the event itself.
Supporting those diagnosed with PTSD
Many people ask how they can support friends and family members who have been diagnosed with post-traumatic stress disorder (PTSD). Here we present a brief set of recommendations for effectively helping a loved one through their journey.
Amidst the turmoil of anxiety and distress caused by a traumatic past event, it is important to maintain a positive and optimistic outlook for your loved one. While acknowledging the gravity of their experience, strike a balance by instilling faith in their ability to triumph over fear and reclaim their future.
Practice active listening
The seemingly simple act of listening to your friend or family member can make a profound difference. By genuinely listening and offering unwavering support, you convey your care and concern. Even if you do not have solutions to their concerns, your presence alone can be a source of comfort.
While it is impossible to fully understand the experience of PTSD, you can relate to the emotional turmoil that accompanies it, such as fear and anxiety. By empathising with your loved one’s feelings and effectively communicating your understanding, you create a common ground that greatly strengthens your support.
Talking about treatment
For those who are not in treatment, it is important to encourage them to seek professional help. For those already in treatment, let them know that you are available to support them on their journey. This may include discussing their progress and celebrating treatment milestones. For exposure-based therapies, consider taking part in certain activities together, such as walking through a park, crossing a bridge, or watching certain films or TV shows repeatedly. While such support is beneficial, it is important to note that discussing explicit and gruesome details of traumatic events, such as combat or sexual assault, is discouraged. However, exploring the impact of the event on their lives and aspirations for the future can prove fruitful.
By implementing these strategies, you can play an important role in supporting your loved one diagnosed with PTSD and contribute to their healing and resilience.
Finding a Qualified Therapist
Many of the ideas written here are discussed further on the National PTSD website:
David A. Yusko, Psy.D., is the Clinical Director at the Center for the Treatment and Study of Anxiety (CTSA) in the Perelman School of Medicine at the University of Pennsylvania. He joined the faculty in 2006 after completing his doctoral internship at Montefiore Hospital in New York City. He received his Psy.D. in clinical psychology from the Graduate School of Applied and Professional Psychology at Rutgers University where his training specialized in cognitive behavioral treatments for addictive behaviors.