14. Posttraumatic Stress Disorder ( PTSD )

Definition

By Mayo Clinic Staff

Post-traumatic stress disorder (PTSD) is a mental health condition that's triggered by a terrifying event — either experiencing it or witnessing it. Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event.

Many people who go through traumatic events have difficulty adjusting and coping for a while, but they don't have PTSD — with time and good self-care, they usually get better. But if the symptoms get worse or last for months or even years and interfere with your functioning, you may have PTSD.

Getting effective treatment after PTSD symptoms develop can be critical to reduce symptoms and improve function.

PTSD facts

• Posttraumatic stress disorder (PTSD) is an emotional illness that was first formally diagnosed in soldiers and war veterans and is usually caused by terribly frightening, life-threatening, or otherwise highly unsafe experiences but can also be caused by devastating life events like unemployment or divorce.
• PTSD symptom types include re-experiencing the trauma, avoidance, emotional numbing, and hyperarousal.
• PTSD has a lifetime prevalence of 7%-30%, with about 5 million people suffering from the illness in any one year. Girls, women, and ethnic minorities develop PTSD more than boys, men, and Caucasians.
• Complex posttraumatic stress disorder (C-PTSD) usually results from prolonged exposure to traumatic event(s) and is characterized by long-lasting problems that affect many aspects of emotional and social functioning.
• Symptoms of C-PTSD include problems regulating feelings, dissociation, or depersonalization, persistent depressive feelings, seeing the perpetrator of trauma as all powerful, preoccupation with the perpetrator, and a severe change in what gives the sufferer meaning.
• Untreated PTSD can have devastating, far-reaching consequences for sufferers' medical, emotional, and vocational functioning and relationships, their families, and for society. Children with PTSD can experience significantly negative effects on their social and emotional development, as well as their ability to learn.
• Although almost any event that is life threatening or that severely compromises the emotional well-being of an individual may cause PTSD, such events usually include experiencing or witnessing a severe accident or physical injury, getting a frightening medical diagnosis, being the victim of a crime or torture, exposure to combat, disaster, or terrorist attack, enduring any form of abuse, or involvement in civil conflict.
• Issues that tend to put people at higher risk for developing PTSD include female gender, minority status, increased duration or severity of, as well as exposure to, the trauma experienced, having an emotional condition prior to the event, and having little social support. Risk factors for children and adolescents also include having any learning disability or experiencing violence in the home.
• Disaster preparedness training may be a protective factor for PTSD as can rapid intervention and certain personal, interpersonal, and environmental factors.
• Medicines that treat depression (for example, serotonergicantidepressants or SSRIs) or that decrease the heart rate (for example, propranolol) are thought to be effective tools in the prevention of PTSD when given in the days immediately after an individual experiences a traumatic event.
• SSRIs seem to be most effective in treating people whose PTSD is the result of noncombat-related trauma.
• Individuals who wonder if they may be suffering from PTSD may benefit from taking a self-test as they consider meeting with a health-care professional. Professionals may use a clinical interview in adults, children, or adolescents, or one of a number of structured tests with children or adolescents to assess for the presence of this illness.
• Diagnosing PTSD can present a challenge for professionals since sufferers often come for evaluation of something that seems to be unrelated to that illness at first. Those symptoms tend to be physical complaints, depression, or substance abuse. Also, PTSD often co-occurs with other anxiety disorders, manic depression, or with eating disorders.
• Challenges for the assessment of PTSD in children and adolescents include an adult caretakers' tendency to be unaware of the extent of the young person's symptoms and the tendency for children and teensto express symptoms of the illness in ways that are quite different from adults.
• Treatments for PTSD usually include psychological and medical treatments. Education about the illness, helping the individual talk about the trauma directly, exploration and modification of inaccurate ways of thinking about it, and teaching the person ways to manage symptoms and are the usual techniques used in psychotherapy. Family and couples' counseling, parenting classes, and education about conflict resolution are other useful psychotherapeutic interventions.
• Directly addressing the sleep problems that are associated with PTSD has been found to help alleviate those problems, thereby decreasing the symptoms of PTSD in general.
• Medications that are usually used to help PTSD sufferers include serotonergic antidepressants (SSRIs) and medicines that help decrease the physical symptoms associated with illness. Other potentially helpful medications for managing PTSD include mood stabilizers and antipsychotics. Tranquilizers have been associated with withdrawal symptoms and other problems and have not been found to be significantly effective for helping individuals with PTSD.
• Some ways that are often suggested for PTSD patients to cope with this illness include learning more about the illness, occupational therapy including service dog therapy, talking to others for support, using relaxation techniques, participating in treatment, increasing positive lifestyle practices, and minimizing negative lifestyle practices.

• What is posttraumatic stress disorder (PTSD)?

  Posttraumatic stress disorder (PTSD) is an emotional illness that that is classified as an anxiety disorder and usually develops as a result of a terribly frightening, life-threatening, or otherwise highly unsafe experience. PTSD sufferers re-experience the traumatic event or events in some way, tend to avoid places, people, or other things that remind them of the event (avoidance), and are exquisitely sensitive to normal life experiences (hyperarousal). Although this condition has likely existed since human beings have endured trauma, PTSD has only been recognized as a formal diagnosis since 1980. However, it was called by different names as early as the American Civil War, when combat veterans were referred to as suffering from "soldier's heart." In World War I, symptoms that were generally consistent with this syndrome were referred to in the military as "combatfatigue." Soldiers who developed such symptoms in World War II were said to be suffering from "gross stress reaction," and many troops in Vietnam who had symptoms of what is now called PTSD were assessed as having "post-Vietnam syndrome." PTSD has also been called "battle fatigue" and "shell shock."
  Complex posttraumatic stress disorder (C-PTSD) usually results from prolonged exposure to a traumatic event or series thereof and is characterized by long-lasting problems with many aspects of emotional and social functioning.
  Statistics regarding this illness indicate that approximately 7%-8% of people in the United States will likely develop PTSD in their lifetime, with the lifetime occurrence (prevalence) in combat veterans and rape victims ranging from 10% to as high as 30%. Somewhat higher rates of this disorder have been found to occur in African Americans, Hispanics, and Native Americans compared to Caucasians in the United States. Some of those differences are thought to be due to higher rates of dissociation soon before and after the traumatic event (peritraumatic), a tendency for individuals from minority ethnic groups to blame themselves, have less social support, and an increased exposure to racism for those ethnic groups, as well as differences between how ethnic groups may express distress. In military populations, many of the differences have been found to be the result of increased exposure to combat at younger ages for minority groups. Other important facts about PTSD include the estimate of 5 million people who suffer from PTSD at any one time in the United States and the fact that women are twice as likely as men to develop PTSD.
  Almost half of individuals who use outpatient mental-health services have been found to suffer from PTSD. As evidenced by the occurrence of stress in many individuals in the United States in the days following the 2001 terrorist attacks, not being physically present at a traumatic event does not guarantee that one will not suffer from traumatic stress that can lead to the development of PTSD.
  PTSD statistics in children and teens reveal that up to more than 40% have endured at least one traumatic event, resulting in the development of PTSD in up to 15% of girls and 6% of boys. On average, 3%-6% of high school students in the United States and as many as 30%-60% of children who have survived specific disasters have PTSD. Up to 100% of children who have seen a parent killed or endured sexual assault or abuse tend to develop PTSD, and more than one-third of youths who are exposed to community violence (for example, a shooting, stabbing, or other assault) will suffer from the disorder.

• What are the effects of PTSD?

  Although not all individuals who have been traumatized develop PTSD, there can be significant physical consequences of being traumatized. For example, research indicates that people who have been exposed to an extreme stressor sometimes have a smaller hippocampus (a region of the brain that plays a role in memory) than people who have not been exposed to trauma. This is significant in understanding the effects of trauma in general and the impact of PTSD, specifically since the hippocampus is the part of the brain that is thought to have an important role in developing new memories about life events. Also, whether or not a traumatized person goes on to develop PTSD, they seem to be at risk for higher use of cigarettes, alcohol, and marijuana. Conversely, people whose PTSD is treated also tend to have better success at overcoming a substance-abuse problem.
  Untreated PTSD can have devastating, far-reaching consequences for sufferers' functioning and relationships, their families, and for society. Complications of PTSD in women who are pregnant include having other emotional problems, poor health behaviors, and memory problems. Women who were sexually abused at earlier ages are more likely to develop complex PTSD and borderline personality disorder. Babies who are born to mothers who suffer from this illness during pregnancy are more likely to experience a change in at least one chemical in their body that makes it more likely (predisposes) the baby to develop PTSD later in life. Individuals who suffer from this illness are at risk of having more medical problems, as well as trouble reproducing. Emotionally, PTSD sufferers may struggle more to achieve as good an outcome from mental-health treatment as that of people with other emotional problems. In children and teens, PTSD can have significantly negative effects on their social and emotional development, as well as on their ability to learn.
  Economically, PTSD can have significant consequences as well. As of 2005, more than 200,000 veterans were receiving disability compensation for this illness, at a cost of $4.3 billion. This represents an 80% increase in the number of military people receiving disability benefits for PTSD and an increase of 149% in the amount of disability benefits paid compared to those numbers five years earlier.

• What causes PTSD?

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  Virtually any trauma, defined as an event that is life-threatening or that severely compromises the physical or emotional well-being of an individual or causes intense fear, may cause PTSD. Such events often include either experiencing or witnessing a severe accident or physical injury, receiving a life-threatening medical diagnosis, being the victim of kidnapping or torture, exposure to war combat or to a natural disaster, exposure to other disaster (for example, plane crash) or terrorist attack, being the victim of rape, mugging, robbery, or assault, enduring physical, sexual, emotional, or other forms of abuse, as well as involvement in civil conflict. Although the diagnosis of PTSD currently requires that the sufferer has a history of experiencing a traumatic event as defined here, people may develop PTSD in reaction to events that may not qualify as traumatic but can be devastating life events like divorce or unemployment.

  What are PTSD risk factors and protective factors?

  Issues that tend to put people at higher risk for developing PTSD include increased duration of a traumatic event, higher number of traumatic events endured, higher severity of the trauma experienced, having an emotional condition prior to the event, or having little social support in the form of family or friends. In addition to those risk factors, children and adolescents, females, minority groups and people with learning disabilities or violence in the home seem to have a greater risk of developing PTSD after a traumatic event.

  What are PTSD symptoms and signs?

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  The following three groups of symptom criteria are required to assign the diagnosis of PTSD in the context of an individual who has a history of being exposed to an actual or perceived threat of death, serious injury, or sexual violence to self or others that does not involve exposure through media unless that is work related:
  • Recurrent re-experiencing of the trauma (for example, troublesome memories, flashbacks that are usually caused by reminders of the traumatic events, recurring nightmares about the trauma and/or dissociative reliving of the trauma): In children, this may include repetitive play about the trauma.
  • Avoidance to the point of having a phobia of places, people, and experiences that remind the sufferer of the trauma, or a general numbing of emotional responsiveness
  • Negative changes in thinking and trouble remembering important aspects of the trauma, holding negative beliefs about him or herself, a tendency to blame oneself for the trauma, a persistently negative emotional state, inability to have positive emotions, low interest or participation in significant activities, and feeling detached from others
  • Significant changes in arousal and reactivity related to the traumatic event(s), including sleep problems, trouble concentrating, irritability, anger, poor concentration, blackouts or difficulty remembering things, reckless or self-destructive behavior, increased tendency and reaction to being startled, and hypervigilance (excessive watchfulness) to threat
  The emotional numbing of PTSD may present as a lack of interest in activities that used to be enjoyed (anhedonia), emotional deadness, distancing oneself from people, and/or a sense of a foreshortened future (for example, not being able to think about the future or make future plans, not believing one will live much longer). At least one re-experiencing symptom, one avoidance symptom, two negative changes in mood or thinking, and two hyperarousal symptoms must be present for at least one month and must cause significant distress or impairment in functioning in order for the diagnosis of PTSD to be assigned.
  A similar disorder in terms of symptom repertoire is acute stress disorder. The major differences between the two disorders are that acute stress disorder symptoms persist from three days to one month after the trauma exposure, and a fewer number of traumatic symptoms are required to make the diagnosis as compared to PTSD.
  In children, re-experiencing the trauma may occur through repeated play that has trauma-related themes instead of or in addition to memories, and distressing dreams may have more general content rather than of the traumatic event itself. As in adults, at least one re-experiencing symptom, one avoidance/numbing symptom, and two hyperarousal symptoms must be present for at least one month and must cause significant distress or functional impairment in order for the diagnosis of PTSD to be assigned. When symptoms have been present for three days to one month, a diagnosis of acute stress disorder (ASD) can be made.
  Symptoms of PTSD that tend to be associated with C-PTSD include problems regulating feelings, which can result in suicidal thoughts, explosive anger, or passive aggressive behaviors, a tendency to forget the trauma or feel detached from one's life (dissociation) or body (depersonalization), persistent feelings of helplessness, shame, guilt, or being completely different from others, feeling the perpetrator of trauma is all powerful, and preoccupation with either revenge against or allegiance with the perpetrator, and severe change in those things that give the sufferer meaning, like a loss of spiritual faith or an ongoing sense of helplessness, hopelessness, or despair.

• How is PTSD assessed?

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  For individuals who may be wondering if they should seek evaluation for PTSD by their medical or mental-health professional, self-tests may be useful. The National Institute of Mental Health offers a self-test for PTSD. The assessment of PTSD can be difficult for practitioners to make since sufferers often come to the professional's office complaining of symptoms other than anxiety associated with a traumatic experience. Those symptoms tend to include body symptoms (somatization), depression, or drug addiction. Studies of Iraq war veterans indicate that these individuals tend to show more physical symptoms of PTSD as opposed to describing the associated emotional problems.
  Individuals with PTSD may present with a history of making suicide attempts. In addition to depression and substance-use disorders, the diagnosis of PTSD often co-occurs (is comorbid) with bipolar disorder(manic depression), eating disorders, and other anxiety disorders like obsessive compulsive disorder (OCD), panic disorder, social anxiety disorder, and generalized anxiety disorder.
  Most health-care professionals who examine a child or teenager for PTSD will interview both the parent and the child, usually separately, in order to allow each party to speak freely. Interviewing the child in addition to the adults in his or her life is quite important given that while the child or adolescent's parent or guardian may have a unique perspective, there are naturally things the young person may be thinking, feeling, or doing that the adult is not aware of. Another challenge for diagnosing PTSD in children, particularly in younger children, is that they may express their symptoms differently from adults. For example, symptoms in children may include the child going backward or regressing in their development, becoming accident prone, engaging in risky behaviors, becoming clingy, or suffering from more physical complaints as compared to adults with PTSD. Traumatized younger children may also have trouble sitting still, focusing, or managing their impulses and therefore be mistaken as suffering from attention deficit hyperactivity disorder (ADHD).
  Sometimes, professionals will use a rating scale or a structured psychiatric interview for children in its entirety or just the portion that assesses PTSD in order to test for PTSD. Examples of such tools include the Diagnostic Interview for Children and Adolescents-Revised (DICA-R), the Diagnostic Interview Schedule for Children-Version IV (DISC-IV), and the Schedule for Affective Disorders and Schizophrenia for School Age Children (K-SADS). There are also some PTSD-specific structured interviews, like the Clinician-Administered PTSD Scale-Child and Adolescent Version, the Child PTSD Checklist, and the Child PTSD Symptom Scale. For the assessment of the severity of PTSD symptoms in children, structured interviews like the Child Posttraumatic Stress Reaction Index, the Child and Adolescent Trauma Survey, and the Trauma Symptom Checklist for Children are sometimes used. The Child Trauma Screening Questionnaire has been found by some professionals to be useful in predicting which children who endure a traumatic event will go on to develop PTSD.

• What is the treatment for PTSD?

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  Treatments for PTSD usually include psychological and medical interventions. Providing information about the illness, helping the individual manage the trauma by talking about it directly, teaching the person ways to manage symptoms of PTSD, and exploration and modification of inaccurate ways of thinking about the trauma are the usual techniques used in psychotherapy for this illness. Education of PTSD sufferers usually involves teaching individuals about what PTSD is, how many others suffer from the same illness, that it is caused by extraordinary stress rather than personalweakness, how it is treated, and what to expect in treatment. This education thereby increases the likelihood that inaccurate ideas the person may have about the illness are dispelled, and any shame they may feel about having it is minimized. This may be particularly important in populations like military personnel that may feel particularly stigmatized by the idea of seeing a mental-health professional and therefore avoid doing so.
  Teaching people with PTSD practical approaches to coping with what can be very intense and disturbing symptoms has been found to be another useful way to treat the illness. Specifically, helping sufferers learn how to manage their anger and anxiety, improve their communication skills, and use breathing and other relaxation techniques can help individuals with PTSD gain a sense of mastery over their emotional and physical symptoms. The health-care professional might also use exposure-based cognitive behavioral therapy by having the person with PTSD recall their traumatic experiences using images or verbal recall while using the coping mechanisms they learned. Individual or group cognitive behavioral psychotherapy can help people with PTSD recognize and adjust trauma-related thoughts and beliefs by educating sufferers about the relationships between thoughts and feelings, exploring common negative thoughts held by traumatized individuals, developing alternative interpretations, and by practicing new ways of looking at things. This treatment also involves practicing learned techniques in real-life situations.
  Eye-movement desensitization and reprocessing (EMDR) is a form of cognitive therapy in which the health-care professional guides the person with PTSD in talking about the trauma suffered and the negative feelings associated with the events, while focusing on the professional's rapidly moving finger. While some research indicates this treatment may be effective, it is unclear if this is any more effective than cognitive therapy that is done without the use of rapid eye movement.
  Helping PTSD sufferers maintain their employment and other tasks of their daily lives is an important part of treatment. Occupational therapy (OT) is an important treatment modality in that regard, in that it focuses on rehabilitation and recovery through participation in activities. This can range from assisting helping people with PTSD regain independence in basic self-care to helping them reintegrate into previously held work and community roles. Another potentially powerfully positive activity-based intervention for individuals with PTSD can be the use of a service dog. Particularly toward the completion of more conventional treatments, service dogs have been found to be effective in improving PTSD suffers' sense of safety, responsibility, optimism, and self-awareness.
  Families of PTSD individuals, as well as the sufferer, may benefit from family counseling, couples counseling, parenting classes, and conflict-resolution education. Family members may also be able to provide relevant history about their loved one (for example, about emotions and behaviors,drug abuse, sleeping habits, and socialization) that people with the illness are unable or unwilling to share.
  Directly addressing the sleep problems that can be part of PTSD has been found to not only help alleviate those problems but to thereby help decrease the symptoms of PTSD in general. Specifically, rehearsing adaptive ways of coping with nightmares (imagery rehearsal therapy), training in relaxation techniques, positive self-talk, and screening for other sleep problems have been found to be particularly helpful in decreasing the sleep problems associated with PTSD.
  Medications that are usually used to help PTSD sufferers include serotonergic antidepressants (SSRIs), like fluoxetine (Prozac), sertraline(Zoloft), and paroxetine (Paxil), and medicines that help decrease the physical symptoms associated with illness, like prazosin (Minipress),clonidine (Catapres), guanfacine (Tenex), and propranolol. Individuals with PTSD are much less likely to experience a relapse of their illness if antidepressant treatment is continued for at least a year. SSRIs are the first group of medications that have received approval by the U.S. Food and Drug Administration (FDA) for the treatment of PTSD. Treatment guidelines provided by the American Psychiatric Association describe these medicines as being particularly helpful for people whose PTSD is the result of trauma that is not combat related. SSRIs tend to help PTSD sufferers modify information that is taken in from the environment (stimuli) and to decrease fear. Research also shows that this group of medicines tends to decrease anxiety, depression, and panic. SSRIs may also help reduce aggression, impulsivity, and suicidal thoughts that can be associated with this disorder. For combat-related PTSD, there is more and more evidence that prazosin can be particularly helpful. Although other medications like duloxetine(Cymbalta), bupropion (Wellbutrin), venlafaxine (Effexor), anddesvenlafaxine (Pristiq) are sometimes used to treat PTSD, there is little research that has studied their effectiveness in treating this illness.
  Other less directly effective but nevertheless potentially helpful medications for managing PTSD include mood stabilizers like lamotrigine (Lamictal),tiagabine (Gabitril), and divalproex sodium (Depakote), as well as mood stabilizers that are also antipsychotics, like risperidone (Risperdal),olanzapine (Zyprexa), quetiapine (Seroquel), aripiprazole (Abilify), asenapine (Saphris), and paliperidone (Invega). Antipsychotic medicines seem to be most useful in the treatment of PTSD in those who suffer from agitation, dissociation, hypervigilance, intense suspiciousness (paranoia), or brief breaks in being in touch with reality (brief psychotic reactions). The antipsychotic medications are also being increasingly found to be helpful treatment options for managing PTSD when used in combination with an SSRI.
  Benzodiazepines (tranquilizers) such as diazepam (Valium) and alprazolam(Xanax) have unfortunately been associated with a number of problems, including withdrawal symptoms, and risks of overdose and addiction, and have not been found to be significantly effective for helping individuals with PTSD.

• What is the prognosis for PTSD?

  A number of factors are thought to improve the prognosis (outlook) for people with PTSD. They include personal attributes like above-average cognitive abilities, high self-esteem and optimism, interpersonal abilities like good social skills, problem solving, and impulse control, and external factors like secure attachment, sense of safety, and environmental stability.

  Is it possible to prevent PTSD?

  While disaster-preparedness training is generally seen as a good idea in terms of improving the immediate physical safety and logistical issues involved with a traumatic event, such training may also provide important preventive factors against developing PTSD. That is as evidenced by the fact that those with more professional-level training and experience (for example, police, firefighters, mental-health professionals, paramedics, and other medical professionals) tend to develop PTSD less often when coping with disaster than those without the benefit of such training or experience. People who have been traumatized but are not members of those professions have been found to be less likely to develop PTSD if they receive imaging exposure and therapeutic processing by trained professionals within a day of the trauma and weekly sessions for at least two weeks thereafter.
  There are medications that have been found to help prevent the development of PTSD. Some medicines that treat depression, decrease the heart rate, or increase the action of other body chemicals are thought to be effective tools in the prevention of PTSD when given in the days immediately after an individual experiences a traumatic event.

  How can people cope with PTSD?

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  Some ways that are often suggested for PTSD patients to cope with this illness include learning more about the disorder as well as talking to friends, family, professionals, and PTSD survivors for support. Joining a support group may be helpful. Other tips include reducing stress by using relaxation techniques (for example, breathing exercises, positive imagery), actively participating in treatment as recommended by professionals, increasing positive lifestyle practices (for example, exercise, healthy eating, distracting oneself through keeping a healthy work schedule if employed, volunteering whether employed or not), and minimizing negative lifestyle practices like substance abuse, social isolation, working to excess, and self-destructive or suicidal behaviors.

• Where can people get help for PTSD?

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  Air Force Palace HART
  Phone: 800-774-1361
  Email: severelyinjured@militaryonesource.com
  American Love and Appreciation Fund (for veterans)
  305-673-2856
  Army Wounded Warrior Program
  Phone: 800-237-1336 or 800-833-6622
  DHSD Deployment Helpline
  Phone: 800-497-6261
  Marine for Life
  Phone: 866-645-8762
  Email: injuredsupport@M4L.usmc.mil
  Military One Source
  Phone: 800-342-9647
  http://www.militaryonesource.com/
  Military Severely Injured Center
  Phone: 800-774-1361
  Email: severelyinjured@militaryonesource.com
  National Coalition Against Sexual Assault
  Phone: 717-728-9764
  National Alliance for Mentally Ill
  Phone: 800-950-6264
  National Mental Health Association
  Phone: 800-969-6642
  Navy Safe Harbor
  Phone: 800-774-1361
  Email: severelyinjured@militaryonesource.com
  Operation Comfort (for veterans and their families)
  Phone: 866-632-7868 (1-866-NEAR TO U)
  PTSD Information Hotline
  Phone: 802-296-6300
  PTSD Sanctuary
  Phone: 800-THERAPIST
  Rape, Abuse and Incest National Network
  Phone: 800-656-HOPE
  http://www.rainn.org

  The future

  As the use of the Internet continues to expand, so will Internet psychiatry. This is particularly true given that it may be quite useful in specifically providing access to psychotherapy for individuals with PTSD. Other areas that researchers are targeting to improve recovery for PTSD sufferers include expanding research on eye movement desensitization and reprocessing (EMDR), studying how PTSD can be more specifically treated in various ethnic groups, and discovering how to best prevent people from developing the illness. For military personnel, the more access to care that can be made available and the more comfortable active duty and veteran military men and women can be made to seek those services, the better the outcome that can be expected for service individuals with PTSD.
  Medically reviewed by Marina Katz, MD; American Board of Psychiatry & Neurology
  
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