Post-Traumatic Stress Disorder (PTSD)
Overview
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.[1] Most people who go through traumatic events may have temporary difficulty adjusting and coping, but with time and good self-care, they can often get better. If the symptoms get worse, last for months or even years, and interfere with your day-to-day functioning, you may have PTSD.
The most common types of events which lead to the development of PTSD include:
Combat exposure
Childhood physical abuse
Being threatened with a weapon
An accident[2]
Many other traumatic events also can lead to PTSD, such as the sudden, unexpected loss of a loved one,[3] fire, natural disaster, mugging, robbery, plane crash, torture, kidnapping, life-threatening medical diagnosis, terrorist attack, and other extreme or life-threatening events.[4]
Diagnosis
Post-traumatic stress disorder symptoms may start within one month of a traumatic event, but sometimes symptoms may not appear until years after the event and often after some type of trigger/reminder happens.[5] To be diagnosed with PTSD, an adult must have all of the following symptoms for at least 1 month:
At least one re-experiencing symptom
At least one avoidance symptom
At least two cognition and mood symptoms
At least two arousal and reactivity symptoms[6]
SYMPTOMS
PTSD symptoms cause significant problems in social or work situations, as well as in relationships. They can also interfere with your ability to go about your normal daily tasks. PTSD symptoms are generally grouped into four types: intrusive memories, avoidance, negative changes in thinking and mood, and changes in physical and emotional reactions. Symptoms can vary over time or vary from person to person.
1.Re-Experiencing/Intrusive memories
Recurrent, unwanted distressing memories of the traumatic event
Reliving the traumatic event as if it were happening again (flashbacks), including physical symptoms like a racing heart and/or sweating
Upsetting dreams or nightmares about the traumatic event
Severe emotional distress or physical reactions to something that reminds you of the traumatic event[7]
2.Avoidance
Symptoms of avoidance may include:
Avoiding thoughts, feelings, thinking or talking about anything related to the traumatic event
Avoiding places, activities, people or objects that remind you of the traumatic event[8,9]
Symptoms of avoidance may cause someone to change their lifestyle and daily routine to avoid something that triggers a memory response of the traumatic event. For example, a person who may have been in a car accident may stop driving or riding in a car and someone who may have been attacked at night might stop going out after dusk and/or would avoid the area where they were assaulted.
3.Cognitive/Mood Changes
Negative thoughts about yourself, other people or the world
Hopelessness about the future
Memory problems, including not remembering important aspects of the traumatic event
Difficulty maintaining close relationships
Feeling detached from family and friends
Lack of interest in activities you once enjoyed
Difficulty experiencing positive emotions
Feeling emotionally numb
4.Changes in Physical and Emotional Reactions (aka “Arousal Symptoms”)
Being easily startled or frightened
Always being on guard for danger
Self-destructive behavior, such as drinking too much or driving too fast
Trouble sleeping/insomnia
Trouble concentrating
Irritability, angry outbursts or aggressive behavior
Overwhelming guilt or shame
For children 6 years old and younger, signs and symptoms may also include:
Re-enacting the traumatic event or aspects of the traumatic event through play
Frightening dreams that may or may not include aspects of the traumatic event
Intensity of Symptoms
PTSD symptoms can vary in intensity over time. PTSD symptoms may increase when a person is stressed, in general, or when they come across reminders of what they endured. For example, a car backfiring may lead to reliving combat experiences. Or seeing a report on the news about a sexual assault may lead to feeling overcome by memories of one’s own assault.
Causes
Someone can develop post-traumatic stress disorder when they personally experience, see or learn about an event involving actual or threatened death, serious injury or sexual violation. As with most mental health problems, medical professionals believe PTSD is caused by a complex mix of:
Stressful experiences, including the amount and severity of trauma you've gone through in life
Inherited mental health risks, such as a family history of anxiety and depression
Inherited features of one’s personality (i.e. your temperament)
The way one’s brain regulates the chemicals and hormones the body releases in response to stress
Risk Factors
People of all ages can have post-traumatic stress disorder. However, some factors may make you more-likely to develop PTSD after a traumatic event, such as:
Experiencing intense or long-lasting trauma
Having experienced other trauma earlier in life, such as childhood abuse
Having a job that increases your risk of being exposed to traumatic events, such as military personnel and first-responders
Having other mental health problems, such as anxiety or depression
Having problems with substance misuse, such as excess drinking or drug use
Lacking a support system (e.g. family and/or friends)
Having blood relatives with mental health problems, including anxiety or depression
Complications
Post-traumatic stress disorder can disrupt one’s whole life ― their career, relationships, health and enjoyment of everyday activities. PTSD may also increase your risk of other mental health problems, such as:
Depression and anxiety
Issues with drugs or alcohol use
Prevention
After surviving a traumatic event, many people initially experience symptoms similar to PTSD. They often experience common reactions to a traumatic event: the inability to stop thinking about the event; fear, anxiety, anger, depression and guilt. However, the majority of people exposed to trauma do not develop long-term post-traumatic stress disorder.
A key factor in preventing normal stress reactions from becoming PTSD include getting timely help and support. Depending on the degree of stress endured via the trauma, the level of support needed may vary from the level of family, friends and/or faith community to the professional level of a mental health professional for a brief course of therapy. Additionally, while support from others is likely to lessen trauma responses from becoming PTSD, it may also lessen the likelihood of one engaging in unhealthy and self-destructive coping methods, such as misuse of alcohol, drugs or participating in risky behaviors.[10]
TRAUMA REMINDERS
Anniversaries
The anniversary of a traumatic event can cause some survivors to have an increase in distress. Anniversary reactions can range from feeling mildly upset for a limited duration to a more acute reaction, involving severe mental health or medical symptoms.
Triggers may occur on the exact anniversary date or in the general time-frame surrounding the anniversary. Anniversary reactions may occur because of the way a traumatic experience is saved in memory. Because memories of trauma contain information about the danger that the event involved, thee memory helps us to be aware of when we should be afraid, how we should look at such situations, how to feel in that situation, and what to think. The trauma memory, therefore, is a biologic response gives information that may help one stay safe.[11]
Triggers
People respond to traumatic events in a number of ways. Typical responses include feeling concern, anger, fear, or helplessness. Research indicates that people who have been through trauma, loss, or hardship in the past may be more-likely than others to be affected by new, potentially traumatic events.
In response to new traumatic events, people may:
Have general distress or see an increase in their PTSD symptoms
Become quick to anger, sleep poorly, or drink more heavily
Try to avoid all reminders or media about the incident, or shy away from social situations in general
Recent traumatic events may also trigger old and disturbing memories. When facing a new traumatic event some people prepare for the worst based on their past experiences, such as:
Becoming overly protective, vigilant, and guarded
Becoming preoccupied by danger
Attempting to avoid being shocked by, or unprepared for, what may happen in the future[12]
PTSD COHORT PRESENTATION
PTSD in Older Veterans
For many Veterans, memories of their wartime experiences can still be upsetting long after they served in combat. Many older Veterans find they have PTSD symptoms even 50 or more years after their wartime experience. Some symptoms of combat PTSD include having nightmares or feeling like you are reliving the event, avoiding situations that remind you of the event, being easily startled, and loss of interest in activities.[13]
There are a number of reasons why symptoms of PTSD may increase with age:
Having retired from work may make your symptoms feel worse, because you have more time to think and fewer things to distract you from your memories.
Having medical problems and feeling like you are not as strong as you used to be also can increase symptoms.
Bad news on the television and scenes from current wars may bring back traumatic memories.
Trying to then stop using drugs or alcohol later in life, without another, healthier way of coping, this can make PTSD symptoms seem worse.[14]
PTSD in Children and Teens
Trauma happens to people of all ages. If diagnosed with PTSD, the symptoms in children and teens can look different from those in adults. Children may be more likely to show signs of PTSD in their play while teenagers may be more impulsive. As in adults, trauma focused cognitive behavioral therapy is the most effective treatment.
Children, aged 5-12, may not have flashbacks or problems remembering parts of the trauma, the way adults with PTSD often do. Children tend to sometimes put the events of the trauma in the wrong order as well as think there were signs that the trauma was impending. Therefore, some children look for the same signs to signal another trauma is going to happen, and that if they pay attention, they can avoid future traumas.
Children of this age might also show signs of PTSD in their play and are likely to keep repeating a part of the trauma. For example, a child might always want to play shooting games after witnessing a school shooting. Children may also find ways to fit parts of the trauma into their daily lives. For example, a child might carry a gun to school after seeing a school shooting.[15]
Treatment Options
PTSD Therapy with Strongest Evidence of Support: Trauma-Focused Psychotherapies
Trauma-focused psychotherapies are the most highly-recommended type of treatment for PTSD. In this type of therapy, treatment focuses on the memory of the traumatic event or its meaning. These treatments use different techniques to help you process your traumatic experience: while some therapies involve visualizing, talking, or thinking about the traumatic memory, others focus on changing unhelpful beliefs about the trauma. Trauma-focused psychotherapies usually last from 8-16 sessions.
The trauma-focused psychotherapies with the strongest evidence are:
Prolonged Exposure (PE)
Prolonged Exposure is one specific type of Cognitive Behavioral Therapy (CBT). PE helps you gradually approach trauma-related memories, feelings, and situations that remind one of the trauma. It involves talking about your trauma with a provider and doing some of the things you have avoided since the trauma. By confronting these challenges, one can gain control and decrease their PTSD symptoms.
Cognitive Processing Therapy (CPT)
Cognitive Processing Therapy is one specific type of Cognitive Behavioral Therapy (CBT). CPT teaches you to reframe negative thoughts about the trauma by talking with your therapist about your negative thoughts and performing short writing assignments. In essence, CPT will help one evaluate and change their upsetting thoughts, thusly also changing how they feel. Cognitive Processing Therapy includes a series of 12 sessions of psychotherapy.
Eye Movement Desensitization and Reprocessing (EMDR)
Eye Movement Desensitization and Reprocessing is a type of psychotherapy. EMDR was initially developed in 1987 for the treatment of PTSD and is guided by the Adaptive Information Processing model. EMDR is an individual therapy typically delivered one to two times per week for a total of 6-12 sessions, although some people benefit from fewer sessions. Sessions can be conducted on consecutive days or spread out.
The Adaptive Information Processing model considers symptoms of PTSD and other disorders (unless physically or chemically based) to result from past disturbing experiences that continue to cause distress because the memory was not adequately processed. Unprocessed memories contain the emotions, thoughts, beliefs and physical sensations that occurred at the time of the event. When the traumatic memories are triggered, the stored disturbing elements are re-experienced, causing the symptoms of PTSD and/or other disorders.
Unlike other treatments that focus on directly altering the emotions, thoughts and responses resulting from traumatic experiences, EMDR therapy focuses directly on the memory, and is intended to change the way that the memory is stored in the brain, thereby reducing and eliminating the problematic symptoms.[16]
Other types of trauma-focused psychotherapy that are also recommended for people with PTSD include:[17]
Brief Eclectic Psychotherapy (BEP)
A therapy in which you practice relaxation skills, recall details of the traumatic memory, re-frame negative thoughts about the trauma, write a letter about the traumatic event, and hold a farewell ritual to leave trauma in the past.
Narrative Exposure Therapy (NET)
Developed for people who have experienced trauma from ongoing war, conflict, and organized violence. You talk through stressful life events in order (from birth to the present day) and put them together into a story.
Written Narrative Exposure
Involves writing about the trauma during sessions. Your provider gives instructions on the writing assignment, allows you to complete the writing alone, and then returns at the end of the session to briefly discuss any reactions to the writing assignment.
PTSD Therapy with Some Evidence of Support
Some psychotherapies do not focus on the traumatic event, but help you process your reactions to the trauma and manage symptoms related to PTSD. The research behind the following treatments is not as strong as the research supporting trauma-focused psychotherapies (listed above). However, these psychotherapies may be a good option if you are not interested in trauma-focused psychotherapy, or if it is not available:
Stress Inoculation Training (SIT)
A cognitive-behavioral therapy that teaches skills and techniques to manage stress and reduce anxiety.
Present-Centered Therapy (PCT)
Focuses on current life problems that are related to PTSD.
Interpersonal Psychotherapy (IPT)
Focuses on the impact of trauma on interpersonal relationships.
Medications to Treat PTSD
Medications that have been shown to be helpful in treating PTSD symptoms are some of the same anti-anxiety medications also used for symptoms of depression and anxiety. Antidepressant medications such as SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin-norepinephrine reuptake inhibitors) affect the level of naturally occurring chemicals in the brain called serotonin and/or norepinephrine, which play a role in brain cell communication and affect how you feel.
The four most-effective antidepressant medications recommended for PTSD include:
Sertraline (Zoloft)
Paroxetine (Paxil)
Fluoxetine (Prozac)
Venlafaxine (Effexor)
There are also other medications that may be helpful, although the evidence behind them is not as strong as for SSRIs and SNRIs (listed above). These include:
Nefazodone (Serzone): A serotonin reuptake inhibitor (SRI) that works by changing the levels and activity of naturally occurring chemical signals in the brain.
Imipramine (Tofranil): A tricyclic antidepressant (TCA) which acts by altering naturally occurring chemicals which help brain cells communicate and can lift mood.
Phenelzine (Nardil): A monoamine oxidase inhibitor (MAOI) which inactivates a naturally-occurring enzyme which breaks down the neurotransmitters serotonin, norepinephrine and dopamine.
NOTE: this information is not intended as medical advice and one should consult with a psychiatrist or primary care physician before starting, stopping, or changing any course of medication.
Choosing a Treatment Option for PTSD
No one treatment is right for everyone. You can discuss treatment options with your health care provider, and determine which ones are best for you based on the benefits, risks, and side effects of each treatment. Some people are uncomfortable with the idea of seeking treatment because of concerns with stigma or worries about having to talk about difficult life experiences. However, treatment provides the opportunity to improve symptoms, personal and professional relationships, and quality of life. Incorporating self-care is also an important step to healing.
Other Treatments for PTSD
There may be other options available such as certain complementary and integrative medicine approaches (like yoga, meditation, or acupuncture), biological treatments (like hyperbaric oxygen therapy or transcranial magnetic stimulation), or online treatment programs. While these treatments do not have strong research behind them at this time, you and your therapist can discuss the benefits and risks of these options to determine whether or not they are right for you.
Peer Support Groups
Peer support groups are a place where you can discuss day-to-day problems with other people who have been through trauma. While Support groups have not been shown to reduce PTSD symptoms, they could be a good addition to one’s treatment by giving a sense of connection to other people. Support groups can also help family members or friends who are caring for someone with PTSD. Peer support groups are often led by someone who has been through a trauma. Groups often meet in person, but many groups also provide online support. Support groups can help one cope with memories of the trauma or other parts of life that you are having trouble dealing with as a result of the event.
Possible benefits of joining a support group include:
Knowing that others are going through something similar
Learning tips on how to handle day-to-day challenges
Meeting new friends or connecting to others
Learning how to talk about things that bother you or how to ask for help
Learning to trust other people
Hearing about helpful new perspectives from others[18]
Mindfulness Practice in the Treatment of Traumatic Stress
Mindfulness involves paying attention to and accepting your feelings, thoughts, and sensations. Practicing mindfulness can help one cope with stress and/or difficult emotions.
Mindfulness is a way of thinking and focusing that can help you become more aware of your present experiences by:
Paying attention to and being aware of the present moment
Accepting or being willing to experience your thoughts and feelings without judging them
While researchers have not yet studied the effects of mindfulness practice in helping trauma survivors diagnosed with PTSD, research has shown mindfulness to be helpful with other anxiety problems. Further, it has also been shown to help with symptoms of PTSD, such as avoidance and hyper-arousal. For example, focusing on the inhale and exhale of your breathing is one way to concentrate on the present moment. Mindfulness involves allowing your thoughts and feelings to pass in their natural course without either clinging to them or pushing them away. The process is about being willing to notice where your thoughts take you, and then bringing your attention back to the present.[19]
While peer support groups and practicing mindfulness can be important components of dealing with PTSD, they are not effective substitutes for treating PTSD. If you experience symptoms after a trauma that last more than a month, or are significantly impacting your life, please seek professional help.
For more information, click here to access an interview with Psychologist Robyn Walser on trauma & addiction.
Additionally, you may click here to access an interview with Psychologist Michele Bedard-Gilligan on trauma & recovery.
To access our PTSD Self-Care Tips, click here.
Contributed by: Jennifer (Ghahari) Smith, Ph.D.
references
1 “Post-traumatic Stress Disorder (PTSD),” Mayo Clinic (accessed 6-22-20) www.mayoclinic.org/diseases-conditions/post-traumatic-stress-disorder/symptoms-causes/syc-20355967
2 Ibid.
3 “Post-traumatic Stress Disorder,” National Institute of Mental Health (accessed 6-22-20) www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml
4 Mayo Clinic
5 Ibid.
6 National Institute of Mental Health
7 Ibid.
8 Ibid.
9 Mayo Clinic
10 Ibid.
11 “PTSD: National Center for PTSD – Trauma Reminders: Anniversaries,” U.S. Department of Veterans Affairs (accessed 6-23-20) www.ptsd.va.gov/understand/what/anniversary_reactions.asp
12 “PTSD: National Center for PTSD – Trauma Reminders: Triggers,” U.S. Department of Veterans Affairs (accessed 6-23-20) www.ptsd.va.gov/understand/what/trauma_triggers.asp
13 Ibid.
14 “PTSD: National Center for PTSD – Aging Veterans and Posttraumatic Stress Symptoms,” U.S. Department of Veterans Affairs (accessed 6-23-20) www.ptsd.va.gov/understand/what/aging_veterans.asp
15 “PTSD: National Center for PTSD – PTSD in Children and Teens,” U.S. Department of Veterans Affairs (accessed 6-23-20) www.ptsd.va.gov/understand/what/teens_ptsd.asp
16 “Eye Movement Desensitization and Reprocessing (EMDR) Therapy,” American Psychological Association (accessed 6-24-20) www.apa.org/ptsd-guideline/treatments/eye-movement-reprocessing
17 Mayo Clinic
18 “PTSD: National Center for PTSD – Peer Support Groups,” U.S. Department of Veterans Affairs (accessed 6-23-20) www.ptsd.va.gov/gethelp/peer_support.asp
19 “PTSD: National Center for PTSD – Mindfulness Practice in the Treatment of Traumatic Stress,” U.S. Department of Veterans Affairs (accessed 6-23-20) www.ptsd.va.gov/gethelp/mindfulness_tx.asp