Post-Traumatic Stress Disorder

Content provided by the Faculty of the Harvard Medical School

What Is It?

In post-traumatic stress disorder (PTSD), a group of distressing symptoms occur after a frightening incident. A person must have directly experienced or witnessed the event, which must have involved serious physical injury or the threat of injury or death. By definition, the trauma must cause a strong experience of intense fear, horror or helplessness. Some psychological and physiological arousal seems to be a key to developing this disorder.

Some common PTSD stressors include:

  • Serious motor vehicle accidents, plane crashes and boating accidents

  • Industrial accidents

  • Natural disasters (tornadoes, hurricanes, volcanic eruptions)

  • Robberies, muggings and shootings

  • Military combat (PTSD was first diagnosed in soldiers and was known as shell shock or war neurosis)

  • Rape, incest and child abuse

  • Hostage situations and kidnappings

  • Political torture

  • Imprisonment in a concentration camp

  • Refugee status

In the United States, physical assault and rape are the most common stressors causing PTSD in women, and military combat is the most common PTSD stressor in men. People directly affected by the events of 9/11, Hurricane Katrina, or by combat experiences in Iraq or Afghanistan may develop PTSD, although most will not.

Acute PTSD is the term used when symptoms develop within the first one to three months after a traumatic event. The term PTSD with delayed onset is used when symptoms surface six months or more after the traumatic event.

Most people who are exposed to terrible trauma do not develop PTSD. The severity of the stressor does not necessarily line up with the severity of symptoms.

It is not clear what makes some people more likely to develop PTSD. Certain people may have a higher risk of PTSD because of a genetic (inherited) predisposition toward a more intense reaction to stress. Some may be more likely to link reminders of stressful events to current life situations, or to allow painful memories to resurface. Other important factors are the person's personality, lifetime experience of other episodes of trauma (especially in childhood) and current social support (having loving and concerned friends and relatives).

People with PTSD are more likely to have a personality disorder. They also are more likely to have depression and to abuse substances.

An estimated 1% to 3% of all people in the United States have full-fledged PTSD, with an additional 5% to 15% having milder forms of the illness. Although PTSD can develop at any time in life, the disorder occurs more frequently in young adults than in any other group. This may be because young adults are more frequently exposed to the types of stressors that can cause PTSD. The risk of developing PTSD is also higher than average in people who are poor, unmarried or socially isolated, perhaps because they have fewer supports and resources helping them to cope.

Symptoms

To be diagnosed with PTSD, you must have a history of having been exposed to a severe traumatic experience that caused feelings of intense fear, helplessness or horror. At some later time, you may begin to have the following symptoms:

  • Experiencing intrusive mental images, thoughts or nightmares related to the traumatic event

  • Feeling as if the trauma is recurring

  • Having marked anxiety and physical distress (shortness of breath, dizziness, palpitations, sweating)

  • Avoiding all reminders (thoughts, people, conversations, activities) of the trauma

  • Being unable to remember important details about the trauma

  • Losing interest in activities that were once enjoyable

  • Feeling detached or disconnected from other people

  • Feeling emotionally numb (unable to experience normal emotions, such as love)

  • Believing that your life will be shorter than originally expected

  • Feeling aroused (having trouble sleeping, being irritable, lacking concentration, constantly guarding against danger and feeling easily startled

According to the definition, PTSD symptoms must last for at least one month and must seriously affect your ability to function normally at home, at work or in social situations.

Diagnosis

In addition to asking about the traumatic events that triggered your symptoms, your doctor will ask about your life history and will ask you to describe both positive experiences and negative or traumatic ones. Your current circumstances are very important. Here are sample questions your doctor may ask:

  • What experiences have been traumatic and what was your reaction?

  • Do you have nightmares or frightening recollections of the trauma that intrude on your everyday life?

  • Do situations, conversations, people or things remind you of the trauma? How do you react to these reminders?

  • What is your current emotional state?

  • Do you feel irritable or edgy? Do you startle easily?

  • Is your sleep disturbed?

  • Do you have difficulty concentrating?

  • Has your interest in everyday or pleasurable activities fallen off?

  • Is anything making your anxiety worse, such as medical problems or stress?

  • Do you drink too much coffee or alcohol, smoke cigarettes or use drugs? (Drug or alcohol dependency and withdrawal sometimes can cause symptoms that mimic those of PTSD.)

  • Can you describe your important relationships?

  • Do you get support from family or friends?

  • How do you feel about the future?

Your doctor will check out whether another problem is at the root of your distress. You may have an anxiety disorder other than PTSD (for example, panic disorder). Or perhaps you have a mood disorder, such as depression or bipolar illness. Don't be surprised by detailed questions about drug or alcohol use. If you have a problem with substances, treatment is essential.

Expected Duration

By definition, symptoms of PTSD must last for at least one month. However, untreated PTSD can be long-lasting. Symptoms may come and go over many years. For example, according to one study of World War II prisoners of war, 29% of those who developed PTSD still had symptoms more than 40 years after the conflict ended.

Prevention

Some trauma cannot be prevented, but it can be a great source of relief to receive counseling and supportive therapy immediately afterward. Don't let others push you to describe all the details of the trauma because such conversations may re-expose you to the trauma as you relive it in your mind. (A technique called "critical incident stress debriefing," has not been shown to reduce risk. In fact, there is evidence that it can increase risk of developing PTSD. The term, debriefing, refers to a process of asking detailed questions about a traumatic experience.)

Not all victims of a trauma want treatment, and that should be respected because most victims recover on their own with the support of family and friends. Treatment, however, should be made available to those who want it. In the aftermath of a traumatic event, health professionals should attend to a victim's basic physical and emotional needs first, providing reassurance and emphasizing coping.

Treatment

Treatment can take a long time, which may explain the high dropout rate. Some researchers have found that three-quarters of people with PTSD stop treatment. However, treatment (usually a combination of medications and psychotherapy) can be helpful if you stick with it.

Medications People respond to severe stress in many different ways. Your doctor may recommend medications for prominent symptoms. Several classes of medications are commonly prescribed to treat PTSD:

  • Antidepressants — Selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants and several new antidepressants are used to treat chronic problems with anxiety, depression and irritability. SSRIs include sertraline (Zoloft), paroxetine (Paxil), fluoxetine (Prozac), paroxetine (Paxil) and citalopram (Celexa). If an SSRI does not work, or you can't tolerate the side effects, your doctor may suggest one of the relatively new antidepressants, such as venlafaxine (Effexor), or one of the older tricyclic antidepressants, such as imipramine (Tofranil) and amitriptyline (Elavil).

  • Antianxiety drugs — Benzodiazepines are a family of medicines that work well in the treatment of anxiety, including the symptoms of PTSD. They include diazepam (Valium), alprazolam (Xanax), clonazepam (Klonopin) and lorazepam (Ativan). These drugs bring rapid relief from anxiety symptoms, but many are concerned that they can lead to drug dependence. Fortunately, at least in one long-term study, veterans with PTSD did not develop unusual problems with the use of benzodiazepines. As an alternative, doctors may prescribe the antianxiety drug buspirone (BuSpar). Buspirone takes longer to work than do benzodiazepines, but it may be safer for long-term use in certain patients.

  • Mood stabilizers — These medications also are used to treat mood problems. They are sometimes used alone and sometimes used in combination with antidepressants or antianxiety medications. Examples are valproic acid (Depakote) and lithium (sold under several brand names).

  • Adrenergic inhibitors — These fall into two groups, the alpha-adrenergic agonists (for example, prazosin and clonidine) and beta-blockers (like propranolol and metoprolol). These medications alter nerve pathways that bring about the physical symptoms of anxiety, such as tremor or rapid heartbeat. Although theoretically such drugs may block symptoms of PTSD, controlled studies have not yet proven them to be effective at preventing the disorder.

Psychotherapy The aim of psychotherapy is to help a person cope with painful memories and manage emotional and physical reactions to stress. A variety of techniques can be helpful. Regardless of the technique used, education about human responses to trauma is valuable. Psychotherapy and education can help family members understand the disorder and cope with its effects.

If you have had a frightening experience, it can change your view of the world. Dealing with the stress of a traumatic event can be more difficult if you see yourself as a victim and your self-image centers on your experience of being a victim. If psychotherapy reinforces this belief, it can be counterproductive. In psychotherapy, you can recognize that tragedy, violence and evil are human experiences, that the desire for revenge or compensation is normal, but that many parts of your life remain in your control. The goal is to help you live the best life you can despite the frightening experience.

Two of the techniques that can be helpful:

  • Psychodynamic psychotherapy focuses on how the trauma has impaired your ability to manage emotions or soothe yourself in times of stress. The psychotherapy takes into account your unique experiences in life. People often become overwhelmed by a detailed remembering of traumatic events, so it is not a good idea to devote too much attention to the trauma itself, especially in the early phases of psychotherapy. In later phases, when you feel more secure, you can confront ideas and situations that get in the way of putting your self-concept back together. Reconstructing traumatic events should not be a goal in itself.

  • Cognitive behavioral therapy helps by trying to change the negative thinking that follows a trauma. There are several types, aimed at teaching a person to recognize the origin of the symptoms and modify his or her psychological and physical reactions to reminders of the trauma.

When To Call a Professional

If you have been exposed to one of the traumatic stressors that can trigger PTSD or if you already have PTSD symptoms, consult your doctor. He or she can direct you to a qualified therapist who will help you to identify your reactions to the trauma and deal with them.

Prognosis

The long-term outlook for PTSD varies widely and depends on many factors, such as your ability to cope with stress, your personality or temperament, a history of depression, the use of substances, the nature of social support, your level of ongoing stress and your ability to stay in treatment. Overall, about 30% of people eventually recover completely with proper treatment, and another 40% get better, even though less-intense symptoms may remain. Treatment with psychotherapy and/or medications, such as SSRIs, has been very helpful. Even without formal treatment, many people receive the support they need to make a successful adjustment as time puts distance between them and the traumatic event.

Additional Info

American Psychiatric Association 1000 Wilson Blvd. Suite 1825 Arlington, VA 22209-3901 Phone: 703-907-7300 Toll-Free: 1-888-357-7924 Email: apa@psych.orghttp://www.psych.org/

National Institute of Mental Health Office of Communications 6001 Executive Blvd. Room 8184, MSC 9663 Bethesda, MD 20892-9663 Phone: 301-443-4513 Toll-Free: 1-866-615-6464 TTY: 301-443-8431 Fax: 301-443-4279 Email: nimhinfo@nih.govhttp://www.nimh.nih.gov/

Last Annual Review Date: 2010-08-24T00:00:00-06:00 Copyright: Medical content reviewed by the Faculty of the Harvard Medical School. Copyright 2010 by Harvard University. All rights reserved. Used with permission of StayWell.

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