Imagine experiencing or witnessing a tragic or terrifying event, and then reliving the experience for months – or even years – after it occurred.
That’s what people who suffer from post-traumatic stress disorder (PTSD) experience.
PTSD is a serious mental health condition that can develop after a person has experienced or witnessed a traumatic or terrifying event in which serious physical harm occurred or was threatened.
Once referred to as “shell shock” and “battle fatigue syndrome,” PTSD was first brought to public attention by war veterans, but the disorder does not only affect those who have been in combat – it can result from any traumatic incident. These include kidnapping, abuse, serious accidents, natural disasters such as floods or earthquakes, violent attacks such as a mugging, rape, or torture, or being held captive.
The triggering event may be something that threatened the person’s life or the life of someone close to him or her. Or it could be something witnessed, such as mass destruction after a plane crash or a hurricane.
Symptoms may include flashbacks, nightmares, and severe anxiety, as well as uncontrollable thoughts about the event.
While it is normal to experience difficulty adjusting after going through a traumatic event or witnessing a tragedy, over time, symptoms should get better.
If they don’t improve, or symptoms become worse and interfere with functioning and quality of life, the person may have PTSD.
PTSD used to be classified as an anxiety disorder, but is now listed under Trauma and Stress-related Disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This move could help de-stigmatize PTSD since it is no longer an anxiety related mental illness, but a disorder connected to an external event.
Causes of PTSD
You can develop PTSD when you go through or witness an event involving actual or threatened death, serious injury, or sexual violation.
Experts aren’t sure why some people develop PTSD. As with most mental health problems, it is probably caused by a complex mix of:
- Inherited mental health risks, such as an increased risk of anxiety and depression
- Life experiences, including the amount and severity of trauma you’ve gone through since early childhood
- Inherited aspects of your personality (temperament)
- The way your brain regulates the chemicals and hormones your body releases in response to stress
Symptoms of PTSD
Post-traumatic stress disorder symptoms may start within three months of a traumatic event, but sometimes they may not appear until years after the event. These symptoms cause significant problems in social or work situations and in relationships.
PTSD symptoms are generally grouped into four types: intrusive memories, avoidance, negative changes in thinking and mood, or changes in emotional reactions.
- Recurrent, unwanted distressing memories of the traumatic event
- Reliving the traumatic event as if it were happening again (flashbacks)
- Upsetting dreams about the traumatic event
- Severe emotional distress or physical reactions to something that reminds you of the event
- Trying to avoid thinking or talking about the traumatic event
- Avoiding places, activities or people that remind you of the traumatic event
Negative changes in thinking and mood
- Negative feelings about yourself or other people
- Inability to experience positive emotions
- Feeling emotionally numb
- Lack of interest in activities you once enjoyed
- Hopelessness about the future
- Memory problems, including not remembering important aspects of the traumatic event
- Difficulty maintaining close relationships
Changes in emotional reactions
- Irritability, angry outbursts or aggressive behavior
- Always being on guard for danger
- Overwhelming guilt or shame
- Self-destructive behavior, such as drinking too much or driving too fast
- Trouble concentrating
- Trouble sleeping
- Being easily startled or frightened
Diagnosis of PTSD
Post-traumatic stress disorder is diagnosed based on signs and symptoms and a thorough psychological evaluation. Your health care provider will likely ask you to describe your signs and symptoms and the event that led up to them. You may also have a physical exam to check for medical problems.
To be diagnosed with PTSD, you must meet criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association. This manual is used by mental health providers to diagnose mental conditions and by insurance companies to reimburse for treatment.
Diagnostic criteria for PTSD include a history of exposure to a traumatic event that meets specific stipulations and symptoms from each of the four symptom clusters listed above.
There are 8 DSM-5 diagnostic criteria for post-traumatic stress disorder (source: the National Center for PTSD):
Criterion A: stressor
The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as follows: (one required)
- Direct exposure.
- Witnessing, in person.
- Indirectly, by learning that a close relative or close friend was exposed to trauma. If the event involved actual or threatened death, it must have been violent or accidental.
- Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties (e.g., first responders, collecting body parts; professionals repeatedly exposed to details of child abuse). This does not include indirect non-professional exposure through electronic media, television, movies, or pictures.
Criterion B: intrusion symptoms
The traumatic event is persistently re-experienced in the following way(s): (one required)
- Recurrent, involuntary, and intrusive memories. Note: Children older than six may express this symptom in repetitive play.
- Traumatic nightmares. Note: Children may have frightening dreams without content related to the trauma(s).
- Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness. Note: Children may reenact the event in play.
- Intense or prolonged distress after exposure to traumatic reminders.
- Marked physiologic reactivity after exposure to trauma-related stimuli.
Criterion C: avoidance
Persistent effortful avoidance of distressing trauma-related stimuli after the event:(one required)
- Trauma-related thoughts or feelings.
- Trauma-related external reminders (e.g., people, places, conversations, activities, objects, or situations).
Criterion D: negative alterations in cognitions and mood
Negative alterations in cognitions and mood that began or worsened after the traumatic event: (two required)
- Inability to recall key features of the traumatic event (usually dissociative amnesia; not due to head injury, alcohol, or drugs).
- Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., “I am bad,” “The world is completely dangerous”).
- Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences.
- Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or shame).
- Markedly diminished interest in (pre-traumatic) significant activities.
- Feeling alienated from others (e.g., detachment or estrangement).
- Constricted affect: persistent inability to experience positive emotions.
Criterion E: alterations in arousal and reactivity
Trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event: (two required)
- Irritable or aggressive behavior
- Self-destructive or reckless behavior
- Exaggerated startle response
- Problems in concentration
- Sleep disturbance
Criterion F: duration
Persistence of symptoms (in Criteria B, C, D, and E) for more than one month.
Criterion G: functional significance
Significant symptom-related distress or functional impairment (e.g., social, occupational).
Criterion H: exclusion
Disturbance is not due to medication, substance use, or other illness.
PTSD Risk Factors
Post-traumatic stress disorder can develop at any age, but some factors can increase a person’s risk of developing PTSD after a traumatic event occurs (source: Mayo Clinic):
- Experiencing intense or long-lasting trauma
- Having experienced other trauma earlier in life, including childhood abuse or neglect
- 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
- Lacking a good support system of family and friends
- Having biological (blood) relatives with mental health problems, including PTSD or depression
The National Institute of Mental Health (NIMH) lists the following resilience factors that may reduce the risk of PTSD:
- Seeking out support from other people, such as friends and family
- Finding a support group after a traumatic event
- Feeling good about one’s own actions in the face of danger
- Having a coping strategy, or a way of getting through the bad event and learning from it
- Being able to act and respond effectively despite feeling fear
PTSD Treatment Options
There are two main types of treatment for PTSD: psychotherapy (“talk” therapy) and medication. Sometimes, a combination of both is used.
Because PTSD is caused by trauma, a three-phase treatment protocol is often used, as outlined by PsychCentral:
- Phase 1: Achieving patient safety, reducing symptoms, and increasing competencies This is a skills-building phase and therapists can use any evidence-based therapy that has outcomes of improving emotion regulation, increasing distress tolerance, mindfulness, interpersonal effectiveness, cognitive restructuring, behavioral changes, and relaxation. This phase can also help move someone out of crisis to prepare for the next phase.
- Phase 2: Review and reappraisal of trauma memories There are different techniques for doing this, but the success of this phase depends on one’s ability to tolerate the discomfort of reviewing memories. People with single-incident trauma may be ready to withstand exposure with minimal distress tolerance training, but people with complex trauma may need months of skills-building support in order to be ready to face and process their trauma.
- Phase 3: Consolidating the gains The therapist helps the client apply new skills and adaptive understanding of themselves and their trauma experience. This phase can also include “booster” sessions to reinforce skills, increase professional and informal support systems, and create an ongoing care plan.
Psychotherapy techniques commonly recommended for PTSD include group psychotherapy, cognitive-behavioral therapy, and eye movement desensitization and reprocessing (EMDR).
Many people want to talk about their trauma with others who have had similar experiences. In group therapy, you talk with a group of people who also have been through trauma and who have PTSD. Sharing your story with others may help you feel more comfortable talking about your trauma. Group therapy allows sufferers to build relationships with others who understand what they’ve been through.
To date, research shows that cognitive behavioral therapy (CBT) is the most effective type of counseling for PTSD. There are several parts to CBT, including:
- Exposure therapy. This therapy helps people face and control their fear. It exposes them to the trauma they experienced while in a safe setting. Mental imagery, writing, virtual reality programs, or visits to the place where the event happened are used. This allows people to gain control over their thoughts and feelings about the trauma. A therapist also might guide a patient to focus on memories that are less upsetting before talking about worse ones. This is called “desensitization,” and it allows people to deal with bad memories a little bit at a time. A sufferer might be asked to remember a lot of bad memories at once in a technique called “flooding,” which is used to help people learn not to feel overwhelmed.
- Cognitive restructuring. This therapy helps people make sense of the bad memories. Sometimes people remember the event differently than how it actually happened. They may feel guilt or shame about events that are not their fault.
- Stress inoculation training. This therapy tries to reduce PTSD symptoms by teaching a person how to reduce anxiety. Like cognitive restructuring, this treatment helps people look at their memories in a healthy way.
Eye Movement Desensitization and Reprocessing (EMDR)
EMDR is a fairly new, nontraditional type of psychotherapy, and is growing in popularity, particularly for treating PTSD.
The goal of EMDR is to reduce the long-lasting effects of distressing memories by developing more adaptive coping mechanisms. An eight-phase approach is used that includes having the patient recall distressing images while receiving one of several types of bilateral sensory input, such as side to side eye movements. EMDR helps people reprocess traumatic information until it is no longer psychologically disruptive.
As mentioned above, psychotherapy is the primary treatment for PTSD because while medications may treat some of the symptoms commonly associated with the disorder, they will not relieve a person of the flashbacks or feelings associated with the original trauma.
If one is receiving medication from their doctor, they should always seek a psychotherapy referral as well.
Currently, two selective serotonin reuptake inhibitor (SSRI) antidepressants have been approved by the U.S. Food and Drug Administration (FDA) for the treatment of PTSD in adults.
These medications can help decrease depression, anxiety, and panic, and can help improve sleep problems and concentration. They also can reduce aggression, impulsivity, and suicidal thoughts.
It is important to remember that SSRIs do have side effects, and in 2005, the FDA ordered that a “black box” warning label be placed on all antidepressant medications to alert the public about the potential increased risk of suicidal thinking or attempts in children and adolescents taking antidepressants. In 2007, the FDA proposed that makers of all antidepressant medications extend the warning to include young adults up through age 24. A “black box” warning is the most serious type of warning on prescription drug labeling. Because of this, close monitoring of patients of all ages taking antidepressants is recommended.
- Benzodiazepines. These medications may be given to help people relax and sleep. People who take benzodiazepines may have memory problems or become dependent on the medication. While these drugs can provide rapid relief for anxiety, there is some data that suggests that over the long run, benzodiazepines can make PTSD worse.
- Atypical antipsychotics. These medications are usually given to people with other mental disorders, like schizophrenia, and some studies have shown they are NOT effective for PTSD. They include medications such as risperidone (Risperdal), olanzapine (Zyprexa), and quetiapine (Seroquel). 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).
- Other antidepressants. Like sertraline and paroxetine, the antidepressants fluoxetine (Prozac) and citalopram (Celexa) can help people with PTSD feel less tense or sad. For people with PTSD who also have other anxiety disorders or depression, antidepressants may be useful in reducing symptoms of these co-occurring illnesses.
- Mood stabilizers. Less directly effective, but possibly helpful, mood stabilizers like lamotrigine (Lamictal), tiagabine (Gabitril), and divalproex sodium (Depakote) may help manage symptoms of PTSD.
- Prazosin. If symptoms include insomnia or recurrent nightmares, a drug called prazosin (Minipress) may help. Although not specifically FDA-approved for PTSD treatment, prazosin may reduce or suppress nightmares in many people with PTSD.
Medications for PTSD should only be prescribed by a psychiatrist. Sometimes, more than one medication will be prescribed for people who do not respond to a single prescription. Close monitoring is crucial, and as stated previously, psychotherapy is the primary treatment option for PTSD and has been proven to be more effective than medication alone.
Living With PTSD
If you suspect that you or someone you care about has PTSD, it is important to seek professional help. Don’t try to go it alone.
Here are some additional tips for managing PTSD.
- Follow your treatment plan. Although it may take a while to feel benefits from therapy or medications, try to remain patient. Remind yourself that it takes time, and you are moving forward.
- Educate yourself about PTSD. Knowledge is power, and can help you understand what you’re feeling so you can develop coping strategies that work for you.
- Take care of yourself. Get enough rest, eat a healthy diet, exercise, and take time to relax.
- Don’t self-medicate. Alcohol and drugs may numb your feelings, but it isn’t healthy, can stall your progress, and can lead to additional problems.
- Seek support. Surround yourself with supportive and caring people. How much you share is up to you, but staying connected can really help you heal. Ask your health professional for help finding a support group, or contact veterans’ organizations or your community’s social services system.
Remember, PTSD is treatable. If you think you or someone you care about could have PTSD, consulting with a professional practitioner would be beneficial. It is important to understand that you are diagnosed based on the symptoms you report, so finding a practitioner you are comfortable enough to be open and honest with is important.