Post-traumatic Stress Disorder (PTSD)

Posttraumatic stress disorder (PTSD) can develop after exposure to actual or threatened traumatic events.

Posttraumatic stress disorder (PTSD) is a trauma- or stressor-related disorder that can develop after exposure to actual or threatened death, serious injury, or sexual violence, according to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5).

Traumatic events that may trigger PTSD include

• violent personal assaults,
• natural or human-caused disasters, such as terrorist attacks,
• motor vehicle accidents,
• rape,
• physical or sexual abuse,
• severe emotional abuse, or
• wartime violence, including military combat.

What happens when you have PTSD?

PTSD is a disorder in which your brain continues to react with excessive fear and nervousness after you have experienced or witnessed trauma or terrifying event, even though the original trauma is over. Our brains can react by staying in overdrive and being hyper-alert to the next possible trauma.

What does a PTSD attack feel like?

People with PTSD will re-experience the trauma by having intrusive memories, flashbacks, or nightmares about the event, even though the trauma is in the past.

After a traumatic event, we can also become numb and shut down our feelings, and try to avoid situations that might cause us to remember the trauma. For other individuals, the effects on emotions and behavior can show up as depression, irritability, or risky behavior.

Epidemiology

• Statistics show that PTSD is relatively common. In any given year, up to 3.6% of Americans may have PTSD.
• The diagnosis of PTSD was developed by studying soldiers who had returned from war, and it was originally referred to as the "soldier's heart" (American Civil War) and later as "shell shock" (World Wars I and II).
• You can also get PTSD by being near a trauma or witnessing it. Professionals who are exposed to the aftermath of trauma (for example, first responders to car crashes or violent deaths) in their daily work can also develop PTSD.
• PTSD can also be caused by more long-term trauma such as ongoing sexual abuse of children or having a life-threatening medical illness as a child or adult.

When you are afraid, your body activates the "fight or flight" response, a response common to other animals as well as our evolutionary ancestors.

With this response, the brain activates the sympathetic nervous system, including the release of adrenaline (epinephrine) in the body, which is responsible for increasing blood pressure, heart rate, and increasing glucose to muscles, readying the body for a physical response (fight or flight).

However, once the immediate danger (which may or may not have actually existed) is gone, the body begins a process of shutting down the stress response, and this process involves the release of another hormone known as cortisol.

If your body does not generate enough cortisol to shut down the flight or stress reaction, you may continue to feel the stress effects of the adrenaline.

Trauma victims who develop post-traumatic stress disorder often have higher levels of other stimulating hormones (catecholamines) under normal conditions in which the threat of trauma is not present as well as lower levels of cortisol. This combination of higher than normal arousal levels and lower than normal levels of the calming hormones of the changes creates the conditions for PTSD.

After a month in this heightened state with stress hormones elevated and cortisol levels lowered, you may develop further physical changes, such as heightened hearing. This cascade of physical changes, one triggering another, suggests that early intervention may be the key to heading off the effects of post-traumatic stress disorder.

Not everyone exposed to a traumatic event has an abnormal reaction and some who initially experience symptoms find that they resolve in a relatively short period of time. The presence of PTSD symptoms lasting one month or less after trauma is known as an acute stress disorder. Another area of research is to understand why some people are able to recover, while others develop the long-term difficulties of PTSD.

Specific brain regions are also associated with PTSD and the physical responses in the rest of the body.

• The amygdala is a deep brain region that is highly sensitive to detecting possible threats based on input from our senses. When activated, it alerts the body to danger and activates hormonal systems.
• The hippocampus is the structure associated with memory formation. Abnormal memory consolidation may also be associated with a risk for PTSD. Some studies showed that a reduction of hippocampus volumes is related to PTSD.

After a trauma in which you think you might die, see someone die, or become seriously injured, and you feel intense fear, helplessness, or horror, it is very common to become distressed and anxious.

You may have trouble sleeping, have nightmares, think about the trauma a lot, try to avoid the site of the trauma, and/or try to avoid feelings at all and become more numb.

When these symptoms occur shortly after the trauma, and they are severe enough to impair functioning, acute stress disorder is diagnosed.

For most people, this distressing period passes within about four weeks. PTSD is diagnosed when these symptoms continue to interfere with daily life and persist more than a month after the initial trauma.

There are four main types of symptoms related to PTSD:

1. Re-experiencing: intrusive memories, nightmares, and/or flashbacks of the trauma
2. Avoidance: trying to avoid thoughts, feelings, situations, or people who might remind you of the trauma
3. Negative changes in thinking and mood: Symptoms may include the inability to remember parts of the traumatic event, negative beliefs, and feelings about one's self, inability to enjoy the pleasurable activity, or excessive self-blame for the trauma or its consequences. Those with PTSD may show emotional detachment, social isolation, and loneliness.
4. Changes in arousal or reactivity: Problems can include always being on alert (hypervigilance), trouble sleeping, agitation, irritability, hostility, difficulty concentrating, exaggerated startle response, or heightened reactivity to stimuli. People with PTSD may also be more likely to engage in reckless or risky behaviors.

There are also other symptoms and diagnoses often associated with PTSD:

• Panic attacks: a feeling of intense fear, which can be accompanied by shortness of breath, dizziness, sweating, nausea, and a racing heart
• Physical symptoms: chronic pain, headaches, stomach pain, diarrhea, tightness or burning in the chest, muscle cramps, or low back pain
• Feelings of mistrust: losing trust in others and thinking the world is a dangerous place
• Problems in daily living: having problems functioning in your job, at school, or in social situations
• Substance abuse: using drugs or alcohol to cope with the emotional pain
• Relationship problems: having problems with intimacy or feeling detached from your family and friends
• Depression: persistent sad, anxious, or empty mood; loss of interest in once-enjoyed activities; feelings of guilt and shame; or hopelessness about the future (other symptoms of depression may also develop)
• Suicidal thoughts: thoughts about taking one's own life

PTSD is often associated with other psychiatric and physical problems.

• A majority of men and women with PTSD also have another psychiatric disorder. Nearly half suffer from major depression, and a significant percentage suffer from anxiety disorders and social phobia.
• They also are more likely to engage in risky health behaviors such as alcohol abuse and drug abuse.
• Veterans who have been diagnosed with psychiatric conditions have a significantly higher prevalence of all cardiovascular disease risk factors (tobacco use, hypertension, dyslipidemia, obesity, and diabetes) than those without mental health diagnoses.

Children and adolescents also experience trauma and may develop PTSD. Children and teenagers still have the same four categories of symptoms. However, the physical, emotional, and anxiety symptoms of PTSD may be different than those seen in adults.

Following the trauma, children may initially show agitated or confused behavior. They also may show intense fear, helplessness, anger, sadness, horror, or denial. Children who experience repeated trauma may develop a kind of emotional numbing to deaden or block the pain and trauma.

1. For children with PTSD, the re-experiencing symptoms may appear with
   • having frequent memories of the event, or in young children, play in which some or all of the trauma is repeated over and over (This reenacting play is not always seen as distressing in children);
   • having upsetting and frightening dreams, although it is not always clear that the nightmares are related to the trauma;
   • developing repeated physical or emotional symptoms when the child is reminded of the event; or
   • experiencing flashbacks, or dissociative episodes, when they feel like the event is happening again.
2. Children with PTSD avoid situations or places that remind them of the trauma. They may also become less responsive emotionally, depressed, and more detached from their feelings than their peers. They may avoid people or conversations that remind them of the trauma, resulting in social isolation or withdrawal.
3. The negative changes in thinking and mood are characterized by more negative emotions such as fear and sadness, less interest in activities they used to enjoy, and reduced expression of positive emotions like excitement and happiness.
4. Arousal and reactivity changes more often appear as irritable and angry outbursts—often without warning—that may be accompanied by aggressive, hostile, or destructive behavior. Affected children will also commonly have sleep problems (including insomnia and disrupted sleep), are easily startled, and may have trouble with concentration and focus.

In addition to these core symptoms of PTSD, children may also show the following symptoms:

• Worry about dying at an early age
• Having physical symptoms such as headaches and stomachaches
• Acting younger than their age (for example, clingy or whiny behavior, thumb-sucking, or starting to wet the bed again)

• Research has shown that different types of trauma create different rates of PTSD and that it can change the biochemistry of the brain. The combination of severe trauma, along with previous exposure to trauma creates the highest risk for PTSD. The more severe a trauma, the more likely you are to develop PTSD.
• If you have already experienced a trauma and you have low cortisol, your brain may be sensitized to trauma and react in a less functional manner to protect you from PTSD. Low levels of cortisol during trauma may cause you to remember the scary event even more than the average person. Low cortisol may become a marker for those who might develop PTSD after a trauma.
• Personal trauma such as rape or sexual abuse leads to a greater risk for PTSD as well. This may be due to the sense of personal betrayal that accompanies these types of traumas. Women suffer from higher rates of PTSD, and rape is thought to be the most likely trauma that may cause a woman to develop PTSD. This may be due to the intense helplessness of a smaller, less strong woman who is assaulted by a male.
• People who are prone to PTSD over-respond to cues that resemble danger cues. They also still activate the danger response even as the danger cues decline. We are even learning that PTSD vulnerability can be passed on to the next generation in utero. Studies show that women who were exposed to 9/11 and developed PTSD while pregnant note that their infants have lower than expected cortisol levels. It is hypothesized that during fetal development, the fetal brain's ability to process cortisol is negatively affected by their mother's hormones.
• Major depression, as well as chronic daily stress, can cause chronically elevated levels of cortisol. The cortisol is constantly produced in an effort to reduce the hyperarousal state of excess flight or flight hormones. People with PTSD cannot mount this high cortisol response and may contribute to some of their symptoms.

PTSD is diagnosed using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and requires:

• exposure to a trauma involving actual or threatened death, serious injury, or sexual violence;
• persistence of the following symptoms for at least a month; and
• the symptoms cause significant impairment and are not better explained by another medical or psychiatric condition.

Specific diagnostic criteria from the DSM-5 are as follows:

• A. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
  • Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
  • Recurrent distressing dreams in which the content and/or effect of the dream are related to the traumatic event(s).
  • Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)
  • Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
  • Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
• B. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:
  • Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
  • Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
• C. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
  • Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).
  • Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (for example, 'I am bad,' 'No one can be trusted,' 'The world is completely dangerous,' 'My whole nervous system is permanently ruined').
  • Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) lead the individual to blame himself/herself or others.
  • Persistent negative emotional state (for example, fear, horror, anger, guilt, or shame).
  • Markedly diminished interest or participation in significant activities.
  • Feelings of detachment or estrangement from others.
  • Persistent inability to experience positive emotions (for example, inability to experience happiness, satisfaction, or loving feelings).
• D. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
  • Irritable behavior and angry outbursts (with little or no provocation) are typically expressed as verbal or physical aggression toward people or objects.
  • Reckless or self-destructive behavior.
  • Hypervigilance.
  • Exaggerated startle response.
  • Problems with concentration.
  • Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

PTSD is a clinical diagnosis; there are no laboratory tests or brain-imaging studies currently used in clinical practice to diagnose PTSD. Brain imaging studies are underway to learn more about the brain in the PTSD condition, but these are not used in everyday medical practice.

A physical exam and some blood tests may be necessary to rule out medical conditions that may mimic PTSD, such as hyperthyroidism, which can create an anxiety state.

Most people bounce back from traumatic events such as car crashes or assaults, including rape. Short term, most of us would experience some PTSD symptoms. A smaller percentage of people have symptoms that are bad enough to interfere with day-to-day function and are diagnosed with acute stress disorder.

Most of these people will also recover within the first month, but a subset of those with ASD will have symptoms lasting longer than a month and are diagnosed with PTSD. We know that some people recover from PTSD at later times—maybe six months, a year, or even longer. However, some people will have long-term or chronic PTSD symptoms.

At any time after the trauma, if any symptoms are serious enough to affect job performance or the ability to function in day-to-day life, you should consult a licensed mental health professional. Depending on how long the symptoms have caused problems, and which symptoms are worst, different treatments will be appropriate.

Although it may seem painful to remember your trauma, many studies show that avoiding it continues to cause problems. Talking about it with a professional is helpful to many people with PTSD.

As with most psychiatric disorders, there are both psychotherapy and medication (psychopharmacologic) ways of treating PTSD.

Either type of treatment can be effective for people with PTSD, but the best type of treatment for an individual should be determined by working with a mental health professional.

Psychotherapy for PTSD

• The best evidence for psychotherapy treatments of PTSD is for exposure-based therapies, including prolonged exposure therapy (PE), trauma-focused cognitive behavioral therapy (TFCBT), and eye movement desensitization and reprocessing (EMDR).
• Many other psychotherapy approaches are used by therapists, but there are fewer studies and less evidence about how effective they are.
• The studies that have been published show that other therapies (non-trauma-focused CBT, psychodynamic psychotherapy, narrative exposure therapy, and others) are more effective than not receiving therapy.
• Exposure therapies are based on the principle that people can extinguish a fear response by repeated exposures without negative consequences (a process known as exposure and response prevention).
• Cognitive-behavioral therapies (CBT) involve the identification of dysfunctional/negative thoughts and behaviors, and with structured therapy sessions and between-session assignments, work to change them.
• TFCBT specifically addresses thoughts, fears, and behaviors related to the traumatic event.
• The theory is that more completely processing the trauma will allow the person to resolve issues around the trauma and reduce PTSD symptoms.
• EMDR is a specific type of therapy that follows similar principles to TFCBT but specifically pairs a procedure of controlled eye movements linked to processing memories of the trauma.
• Psychodynamic psychotherapy helps you become more aware of your current feelings and understand how your past affects the way you feel now. This, in turn, may help in coping with intense feelings from past trauma.

• Most specialists who treat mental health disorders such as depression and anxiety also have experience in treating PTSD, particularly since it is a relatively common disorder.
• You may find that some professional therapists and counselors (clinical psychologists, clinical social workers, professional counselors) will specialize in trauma-related disorders and have certification with some of the specific therapies, such as EMDR.
• Medication treatment of PTSD is best managed by psychiatrists who have extensive training in assessing and treating these disorders.
• Nurse practitioners with certification in psychiatry also have experience with PTSD treatment and work with psychiatrists.

• A few medications have been shown to directly reduce the symptoms and distress of PTSD.
• The first-line medication treatment for PTSD is the serotonin-specific reuptake inhibitor (SSRI) class of medications. Two SSRIs, sertraline (Zoloft) and paroxetine (Paxil), have been approved by the U.S. Food and Drug Administration (FDA) for the treatment of post-traumatic stress disorder.
• Most other SSRIs have also been studied and are successfully used in clinical practice for PTSD as well. SSRIs can improve a wide range of PTSD symptoms including re-experiencing, avoidance, hyperarousal, and can improve quality of life. Taking SSRIs for a longer amount of time (36 weeks or more) seems to improve symptoms more. There also seems to be a risk of worsened symptoms if someone stops taking SSRIs after improvement.
• Prazosin (Minipress) is an older blood pressure medication that has now been studied extensively for the treatment of PTSD. Prazosin works by blocking some of the effects of the fight or flight nervous system.
• After initial trials using prazosin to reduce re-experiencing nightmares in combat veterans with PTSD, prazosin has now been shown to be effective for reducing many symptoms of PTSD, regardless of the type of trauma.
• Prazosin can improve nightmares, sleep time, hyperarousal, and general PTSD symptoms. The U.S. Food and Drug Administration (FDA) has not approved prazosin use for PTSD, but it has been more widely used by psychiatrists in recent years.
• For children, there is not as much evidence to support the use of antidepressants, prazosin, or other arousal-dampening medicines (for example, clonidine or propranolol that block some of the effects of adrenaline) as well as for the use of other medications. You should consult a child and adolescent psychiatrist for further information.
• In addition to PTSD-specific medications, some people may also require medication to help them with anxiety, depression, addictions, or other psychiatric conditions present along with PTSD. It is important to have a psychiatrist, or other medical doctor experienced with PTSD, to evaluate which medications would be best and will not interfere with PTSD treatment.
• For example, the benzodiazepines (including medicines like alprazolam [Xanax], diazepam [Valium], lorazepam [Ativan], and others), a class of medicines used for treating some anxiety, may actually worsen PTSD and make it harder to treat.

• Many investigators have tried to learn how PTSD can be prevented after people have experienced traumatic events. The military has tried to collect information on new recruits, including psychological screening, to better understand why some people develop PTSD and others do not.
• Additionally, other studies are investigating whether laboratory markers, such as low cortisol levels, may help predict who might develop PTSD. We still do not completely understand psychological or laboratory predictors, but hopefully, these and other studies will lead to better diagnosis and treatment in the future.
• There have been studies trying a variety of medications given after a traumatic event to see if they can prevent PTSD. The idea has been that certain medications may be able to lower the intense physiologic arousal right after trauma and prevent the brain from forming traumatic memories.
• Propranolol, a beta-blocker medication that prevents some of the effects of adrenaline, showed initial promise in research studies, but later studies were not as convincing. Because cortisol levels seem to be lower in PTSD, hydrocortisone (a drug similar to cortisol) was given after a traumatic event and reduced the rates of PTSD development.
• In a single study, morphine administered after combat trauma in soldiers during the Iraq war also reduced PTSD rates. Morphine might prevent the consolidation of fear memories in the amygdala, but further studies will be needed to prove both how effective it might be and how it works.
• Family support, clergy support, psychotherapy, and education about the medical aspects of PTSD are all important in preventing PTSD.
• Efforts to reduce the frequency of traumatic events, such as child abuse and neglect or sexual trauma, are also important ways that we can reduce rates of PTSD and associated depression and suicide.

• The prognosis for PTSD depends upon the severity and length of time a person has suffered from the disorder. The majority of patients with PTSD respond to psychotherapy.
• There are often residual symptoms, however, and we cannot yet predict who will respond best. Studies have shown in other conditions such as OCD (obsessive compulsive disorder) that psychotherapy can actually change how the brain's chemistry functions. It is reasonable to assume that these changes are possible in PTSD as well.
• There are significant risks to a person with PTSD if they do not receive treatment. The symptoms of PTSD are likely to continue to interfere with their function at home, at work, and in their relationships.
• They may lose their job and/or family due to their irritability, anxiety, or numbness interfering with their ability to love and to work. Suicide is also a risk with untreated PTSD.

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National Institute of Mental Health, Post-Traumatic Stress Disorder (PTSD)

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