Post Traumatic Stress Disorder (PTSD)

What is post-traumatic stress disorder (PTSD)?

Post-traumatic stress disorder, also known as PTSD and sometimes written as post traumatic stress disorder or posttraumatic stress disorder, is a condition that sometimes develops after a person experiences or witnesses a life-threatening, terrifying or otherwise deeply traumatic[1] event. Examples include:[2][3][4]

  • Combat
  • Natural disasters like floods, fires or earthquakes
  • Terrorist attacks
  • Car accidents
  • Physical or sexual assault

Experiencing a heart attack[5] or the sudden, unexpected death of a loved one can also lead to PTSD in susceptible people.[1]

After a trauma, it is normal to experience flashbacks, nightmares or intrusive memories. Many people may feel tense, scared or helpless, have difficulty sleeping and struggle to go about their daily activities. Within a few weeks, however, most people will start to feel better. If symptoms of a stress reaction persist, a person may be diagnosed with PTSD.[2][3][4][1]

While post-traumatic stress disorder can affect people of any age and gender, it seems to be more prevalent among some groups. These include female victims of rape, refugees, firefighters, and teenagers who have experienced car accidents.[6][7]

Generally, the outlook for PTSD is good, and most people will get better even without treatment. However, recovery without treatment may take months or even years. Treatment, which typically involves psychotherapy, sometimes with medication, may help to alleviate the symptoms and shorten the duration of PTSD. In a minority of people, PTSD may become a chronic condition.[2][1][6][7][8]

Acute stress disorder (acute stress reaction)

Most people will experience some of the symptoms present in PTSD soon, days or weeks after a traumatic event. If the symptoms dissipate within a month, the condition is called acute stress disorder (ASD) or acute stress reaction.[1] Treatment, if deemed necessary, may include psychotherapy and a short-term course of beta-blockers, to alleviate some of the physical symptoms, or other appropriate anti-anxiety medication.[9]

If symptoms persist for more than 30 days, a diagnosis of PTSD may be considered.[5]

PTSD symptoms

Symptoms of PTSD typically present soon after a traumatic event. Sometimes, however, a number of months may pass before symptoms appear.[2][1] Rarely, symptoms of PTSD may first be experienced more than a year after the event.[7]

PTSD symptoms can be divided into four categories. Most people with PTSD will experience symptoms from each of the following categories for longer than one month:[2][1][6][7]

  • Re-experiencing (reliving) symptoms: Recurring thoughts, bad memories, nightmares or flashbacks of the trauma. These are distressing.
  • Avoidance symptoms: Avoiding situations or people that serve as reminders of the trauma or avoiding talking or thinking about it. Some people may spend unusual amounts of time on hobbies or work.[10] Conversely, others may ruminate excessively on the trauma.[7]
  • Arousal symptoms: Feeling anxious or hyper alert, difficulty concentrating or sleeping, irritability and outbursts of anger, startling easily.
  • Mood and cognition symptoms: Guilt, shame, negative thoughts, loss of interest in enjoyable activities, feeling that the world is dangerous, feeling numb or detached, difficulty remembering the trauma, derealization (feeling like one’s perceptions are not real),[11] an inability to feel optimistic, happy or loving.

Physical symptoms of PTSD may also be present. These can include:

  • Muscle pain
  • Diarrhea
  • An irregular heartbeat
  • Headaches

Some people experiencing PTSD may also act recklessly or impulsively[12] or abuse alcohol or drugs.[10]

If any symptoms have been present for longer than four weeks, are causing serious distress or are interfering with daily life, it is advisable to see a healthcare practitioner without delay.[2]

PTSD causes

Post-traumatic stress disorder can develop after a person of any age experiences or witnesses a deeply traumatic event – often one that is life-threatening or perceived as life-threatening. Examples include:[6][7][11]

  • Natural disasters
  • Serious accidents
  • Sexual assault and other severe types of assault
  • Combat
  • Mass conflict
  • Torture
  • Terrorist attacks
  • Seeing someone being killed

Domestic violence, heart attacks, strokes, severe injury, sudden severe illness, hospitalization in an Intensive Care Unit (ICU) and the sudden, unexpected death of a loved one may also lead to PTSD.[1][7][5] Less severe, but still serious traumatic events may also cause PTSD-like symptoms in certain people.[6]

Seeing a traumatic event on television or in other media is not typically considered a trigger for PTSD.[5][12]

Risk factors

Not everyone who experiences trauma will go on to experience PTSD. A number of factors may increase the risk of a person developing the condition. These include:[6][5][11]

  • Being female
  • Being in a racial or ethnic minority[6][13]
  • Low levels of education
  • Low socioeconomic status
  • Being separated, divorced or widowed
  • Childhood abuse or adversity
  • Previous exposure to trauma
  • Personal or family history of mental health conditions
  • Severe additional stress after the trauma[1]
  • Lack of social support
  • Severity of initial reaction to the trauma

In addition, certain types of trauma are thought to be more likely to lead to PTSD than others. These include traumatic events that are:[10]

  • Sudden and unexpected
  • Continue for a long time
  • Allow no means of escape
  • Are man-made
  • Cause mutilation or multiple deaths
  • Involve children

Certain people are considered to be at higher risk than the general population of developing PTSD. These include:[6][7]

  • Female victims of rape
  • Refugees
  • Asylum seekers
  • Emergency response workers such as the police, firefighters and paramedics

Military service

Soldiers and other members of the military may also have an increased risk of PTSD. The following factors are thought to contribute to the development of PTSD in military personnel:[7][5]

  • Having a combat role in war
  • Severe injury during combat, especially traumatic brain injury
  • Serious accidents
  • Low rank
  • Low morale
  • Low education
  • Leaving the service
  • Lack of social support
  • Being unmarried
  • Childhood adversity

Diagnosis of PTSD

After taking a person’s history and performing a physical examination, a healthcare practitioner will typically diagnose post-traumatic stress disorder using the following criteria:[1][5][12]

  • Exposure to actual or threatened death, serious injury or sexual violence: This may involve direct experience of a traumatic event, witnessing an event, a close relative or friend directly experiencing an event, or exposure to traumatic events as part of one’s job.
  • One or more intrusive, re-experiencing symptoms: This may involve recurrent distressing memories, nightmares, flashbacks or distress, when reminded of the trauma.
  • One or more avoidance symptom: This may involve avoiding people, places and other external triggers that may remind one of the trauma or trying to avoid thinking about it.
  • Two or more arousal symptoms: These may include irritability and angry outbursts, reckless behavior, feeling hyper alert, startling easily, difficulty concentrating or sleep disturbances.
  • Two or more mood and cognition symptoms: These may include inability to remember the trauma or aspects thereof, negative thoughts about oneself or the world, guilt, shame or other negative emotions, loss of interest in enjoyable activities, detachment or an inability to feel positive emotions like happiness or love.

For a diagnosis of PTSD to be made, the symptoms should first appear after a traumatic event, persist for longer than a month, cause significant distress or marked difficulty in social and job situations and not be caused by substance abuse or another health condition.[5]

The above criteria for a diagnosis of PTSD apply to anyone older than six. Diagnosis of PTSD in children younger than six may be based on different criteria (see the section titled PTSD in children below).

Prevention of PTSD

While it may not be possible to prevent the development of PTSD, the following interventions may be helpful:

  • Support from family and friends: This may help a person to recover after a traumatic event.[3]
  • Minimizing stress: Trying to avoid other sources of stress as much as possible may also aid recovery after a traumatic event.[3]
  • Psychotherapy: Multiple (4-12) sessions of trauma-focused cognitive behavioral therapy (TFCBT) or certain other types of therapy may help people affected by PTSD to manage the condition. Single counseling sessions may do more harm than good.[13]
  • Medication: Early studies suggest that prompt treatment with hydrocortisone after exposure to a traumatic event may reduce the likelihood of developing PTSD. However, more research is needed.[13] Clonidine is another possible medication with this effect that requires more research.[6]

In addition, post-deployment support may be useful for members of the military who have been involved in combat situations.

Screening may be helpful for people who have experienced natural disasters, as well as for asylum seekers and refugees, as they are considered to have a relatively high risk of developing PTSD. Treatment can then be recommended where necessary.[6][7]

PTSD treatment

A number of effective treatments are available for post-traumatic stress disorder. The primary treatment is psychotherapy, which is sometimes combined with medication.[3]

If symptoms of PTSD are mild and less than a month has passed since the traumatic event, a diagnosis of ASD may be made and the condition managed accordingly. However, where symptoms are moderate or severe and persist, one or more of the types of treatment below will typically be recommended.[6][7]

Psychotherapy

While various types of psychotherapy exist, the following are considered to be most effective and are often recommended for the treatment of PTSD:

  • Exposure therapy: This type of therapy allows people to confront their trauma in a safe, guided manner so that it can be processed emotionally, thereby lessening distress.[14]
  • Trauma-focused cognitive behavioral therapy (TFCBT): This type of therapy helps people to identify and change unhelpful thought patterns and behaviors related to the trauma, thereby aiding recovery. Cognitive Processing Therapy (CPT) is a type of TFCBT that is widely used in the treatment of PTSD.[6][7][14]
  • Eye movement desensitization and reprocessing (EMDR): A form of CBT that uses specific eye movements to help ease distress from trauma.[6][7][14]

Depending on the individual, group therapy, mindfulness-based stress reduction and other types of therapeutic intervention may also be considered.[6][10][14]

Medication

If psychotherapy alone does not seem to be adequate for a person affected by PTSD, medication may be prescribed. PTSD medication may include:

  • Selective serotonin reuptake inhibitors (SSRIs): These antidepressants may reduce the symptoms of PTSD by acting on chemicals in the brain. SSRIs typically require 2-4 weeks to start working and are taken for a number of months. Examples of SSRIs prescribed for PTSD include fluoxetine, paroxetine and sertraline.[6][7][10][15]
  • Serotonin-norepinephrine reuptake inhibitors (SNRIs): Similar to SSRIs, these antidepressants may reduce the symptoms of PTSD by altering chemicals in the brain. Venlafaxine is the SNRI typically prescribed for PTSD.[6][7][15]
  • Other antidepressants: There is currently insufficient evidence to support the use of tricyclic antidepressants, monoamine oxidase inhibitors (MAOIs) and other types of antidepressants in the treatment of PTSD.[15] However, these may be prescribed at the discretion of a doctor in certain situations.
  • Anti-anxiety medication: Benzodiazepines like diazepam are sometimes prescribed to reduce the symptoms of anxiety, over-alertness and sleep disturbances in PTSD. However, because they are highly addictive, they should not be used for longer than a week or two.[6][10][15]

Where treatment with an SSRI or SNRI is not effective or sufficient, other medications may occasionally be recommended. These include antipsychotics like quetiapine and risperidone, as well as other medications like clonidine and prazosin, which are sometimes used in the management of anxiety, attention deficit hyperactivity disorder (ADHD) and PTSD (though their efficacy in the treatment of PTSD require more research).[7][15]

Other remedies

Though evidence of effectiveness is lacking, some people may find the following to be helpful as part of their treatment of PTSD:[10][11][16]

  • Mindfulness and meditation practices
  • Yoga
  • Acupuncture
  • Massage
  • Service animals such as dogs
  • Support groups[6]

Related health complications of PTSD

PTSD is associated with a number of possible physical and mental health complications.

Physical complications

People with post-traumatic stress disorder seem to have a higher risk of developing a range of physical health conditions. These include muscle, joint and nerve pain; stomach and intestinal issues and problems with the heart and lungs.[7]

Mental health complications

PTSD often seems to occur with other mental health conditions like depression or anxiety. There also appears to be a high rate of substance abuse among people with PTSD.[1][6][7][12]

People affected by PTSD may have an increased risk of suicide.[17] If someone shows signs of crisis, it is essential to contact a suicide prevention lifeline or emergency services without delay.

Other complications

PTSD may also cause difficulties in relationships with partners, friends and family. A person with PTSD may experience challenges with trust, intimacy, communication and problem-solving.[4] Therapy may be recommended to help with this.

In some cases, PTSD may become a chronic condition that lasts years. However, research suggests that Cognitive Processing Therapy (CPT) may be effective in treating even complicated cases of long duration.[7][12]

Complex PTSD

Complex PTSD has been proposed as a separate diagnosis for the symptoms that result from long-term, chronic, trauma, such as ongoing domestic abuse. People who have been exposed to trauma of an extended duration may experience additional symptoms to those commonly reported in PTSD – one example being changes in identity.[12][18]

While complex PTSD is not medically accepted as a separate diagnosis to PTSD, there seems to be an understanding that cases of prolonged trauma may require specialized treatment approaches.[12][18]

PTSD in children

While people of any age can develop PTSD after a traumatic event, the symptoms may be different in children – particularly those who are very young.[19]

Symptoms of post-traumatic stress disorder in children

PTSD symptoms vary from child to child. While some of the symptoms may be the same as those experienced by adults, in children the following may also be present:[19][20]

  • Repeated re-enactment of the traumatic event while playing
  • Mixing up the order of the traumatic event
  • False identification of “signs” predicting the trauma and belief that future trauma can be prevented by monitoring for similar “signs”
  • Nightmares that are not obviously about the trauma
  • Fear of sleeping alone
  • Blaming of self or those close to them
  • Tantrums and aggression towards others
  • Separation anxiety
  • Difficulties at school

In teenagers, symptoms of PTSD are usually similar to those of adults. However, they are more likely to act aggressively or recklessly as part of the condition.[20]

Causes

The causes of PTSD in children are largely the same as those in adults. Experiencing trauma in the form of animal bites, major surgery, emotional abuse, bullying and neglect may also be considered as potential causes of PTSD in young children.[21]

Risk factors

Factors that are thought to affect a child’s risk of developing PTSD include:[21]

  • The severity of the trauma
  • The child’s proximity and relationship to the trauma
  • Being female[20]
  • The duration of the trauma
  • Recurrence of trauma
  • Available support from caregivers

Diagnosis

The criteria outlined above are used to diagnose PTSD in anyone over the age of six. In younger children, the following criteria are typically used:[19]

  • Exposure to actual or threatened death, serious injury or sexual violence: This may involve direct experience of a traumatic event, witnessing an event or a caregiver directly experiencing an event.
  • One or more intrusive (re-experiencing) symptom: This may involve recurrent, distressing memories of the event, these may be expressed as repeated re-enactment of the trauma through play, or sometimes drawing, which does not always seem upsetting to the child,[22] nightmares not necessarily specific to the trauma, flashbacks or visible distress when reminded of the trauma.
  • One or more avoidance or mood and cognition symptom: This may involve attempting to avoid people, places and other external triggers that may remind the child of the trauma, more frequent negative moods, e.g. noticeable guilt, shame, sadness or similar emotions, loss of interest in enjoyable activities such as playing, being withdrawn or reduced expression of positive emotions like happiness or love.
  • Two or more arousal symptoms: These may include irritability and angry outbursts (including tantrums), being hypervigilant, startling easily or being difficult to calm,[23] difficulty concentrating or sleep disturbances.

Additional indications of PTSD in young children may include a sudden regression in developmental skills, e.g. bedwetting, thumb-sucking, making baby-talk,[24][25] the appearance of new or old fears, unexplained accidents, behaving recklessly, separation anxiety, e.g. clinging to a caregiver, and the reporting of physical ailments like stomachaches and headaches. Children may also become hyperactive and seem easily distracted.[26]

For a diagnosis of PTSD to be made, the symptoms should first appear after a traumatic event, persist for longer than a month, cause significant distress or marked difficulty at school or in relationships with caregivers, siblings or peers, and not be caused by a substance or another health condition.[19]

Caregivers are advised to monitor for significant changes in a child’s behavior, play and sleep patterns and consult with a child healthcare specialist, should anything seem amiss.

Prevention

While it may not be possible to prevent PTSD in children, steps can be taken to minimize the risk of them developing the condition. These include:[21]

  • Teaching children to say no to anyone who threatens them or makes them feel uncomfortable.
  • Ensuring that they have access to appropriate support in the event that they experience trauma.

Treatment

Children and teenagers affected by PTSD are typically treated in the same way as adults. Trauma-focused cognitive behavioral therapy (TFCBT), sometimes in combination with medication, may be recommended.[21][20]

Post-traumatic stress disorder FAQs

Q: Is it possible to develop PTSD from a relationship?
A: One of the criteria for PTSD is exposure to actual or threatened death, serious injury or sexual violence.[5] It is possible that severe trauma such as domestic or sexual abuse may occur in an intimate relationship,[7] and that PTSD may develop as a result.

Q: Can PTSD be cured?
A: While there is no specific cure for PTSD, the condition can be treated and managed with therapy and medication.[11] Many people find that their symptoms disappear completely over time, while in others they may fade or lessen.[2]

Other names for post-traumatic stress disorder

  • PTSD
  • Post-traumatic stress injury (not a confirmed term)
  • Shellshock

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  2. U.S. Department of Veterans Affairs – National Center for PTSD. “What Is PTSD?” September 15, 2017. Accessed January 10, 2018.

  3. Beyond Blue. “PTSD.” Accessed January 10, 2018.

  4. Anxiety and Depression Association of America. “Posttraumatic Stress Disorder (PTSD).” Accessed January 10, 2018.

  5. UpToDate. “Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, assessment, and diagnosis.” November 2, 2017. Accessed January 12, 2018.

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  13. Occupational Medicine. “Post-traumatic stress disorder.” September, 2007. Accessed January 13, 2018.

  14. UpToDate. “Psychotherapy for posttraumatic stress disorder in adults.” February 3, 2017. Accessed January 15, 2018.

  15. UpToDate. “Pharmacotherapy for posttraumatic stress disorder in adults.” February 3, 2017. Accessed January 16, 2018.

  16. National Alliance on Mental Illness. “Posttraumatic Stress Disorder: Treatment.” December, 2017. Accessed January 16, 2018.

  17. U.S. Department of Veterans Affairs – National Center for PTSD. “Suicide and PTSD.” May 31, 2017. Accessed January 18, 2018.

  18. U.S. Department of Veterans Affairs – National Center for PTSD. “Complex PTSD.” February 23, 2016. Accessed January 18, 2018.

  19. UpToDate. “Posttraumatic stress disorder in children and adolescents: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis.” January 4, 2018. Accessed January 19, 2018.

  20. U.S. Department of Veterans Affairs – National Center for PTSD. “PTSD in Children and Teens.” August 13, 2015. Accessed January 19, 2018.

  21. Stanford Children’s Health. “Post-Traumatic Stress Disorder in Children.” Accessed January 19, 2018.

  22. National Collaborating Centre for Mental Health (UK). “Post-Traumatic Stress Disorder: The Management of PTSD in Adults and Children in Primary and Secondary Care.” 2005. Accessed February 20, 2018.

  23. Child Welfare. “Parenting a Child Who Has Experienced Trauma.” November, 2014. Accessed February 20, 2018.

  24. American Psychiatric Association. “Parents May Not Recognize PTSD Symptoms in Young Children.” January 11, 2017. Accessed February 20, 2018.

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  26. World Psychiatry. “Post-traumatic stress disorder in children.” June, 2005. Accessed February 20, 2018.