What is Post-Traumatic Stress Disorder (PTSD)?
Despite what many people think, trauma is quite common. Post-Traumatic Stress Disorder (PTSD)—on the other hand— is not. Most people will experience a traumatic event in their lifetime but will not go onto developing PTSD.
Immediately following a traumatic event, many people will have symptoms of PTSD. For example, it is quite normal to have upsetting flashbacks, feel tense or nervous, or have trouble sleeping after being injured in a car accident.
However, over time, for most people, these symptoms naturally decrease. They gradually recover and are never diagnosed with PTSD. Yet there are some people whose symptoms do not decrease, and they are unable to recover naturally.
The word “trauma” comes from the Greek word meaning “to wound.” Therefore, PTSD can be understood as a disorder that occurs when that wound does not heal correctly. In other words, post-traumatic stress disorder is a problem of recovery.
How Common is Trauma?
In a 1997 landmark study, the CDC and Kaiser Permanente examined the relationship between adverse childhood experience (ACE) and health outcomes in a sample of 17,000 adults.
The study defined an ACE to include not only events more commonly associated with trauma such as physical and emotional abuse and neglect but also household substance abuse and family mental illness.
The study found that ACEs are quite common. In fact, researchers found that 70% of adults will experience at least one ACE in their lifetime. Many adults will also experience interpersonal trauma—28% of study participants reported physical abuse and 21% reported sexual abuse.
Researchers also found that ACEs had a “dose-response” relationship to negative healthcare outcomes—i.e., the more ACEs a person experienced the more likely he or she was to experience adverse effects on physical health and well-being.
For example, a child with four or more ACEs was 390% more likely to develop COPD, 460% more likely to suffer from depression, and had a 1,220% increased risk of suicide attempts.
Researchers believe that ACEs lead to a variety of functional impairments that cause individuals to adopt risky behaviors that led to disease, disability, social problems, and ultimately, early death.
What Makes Some People More Likely to Develop Post-Traumatic Stress Disorder?
Many factors can influence whether someone develops PTSD or not. If a person develops PTSD, it does not mean that they are weak or flawed. It likely means that something got in the way of their recovery, so the wound could not heal. Likely, the person had more risk than protective factors.
Some of the risk factors for PTSD relate to the traumatic event such as the severity and immediacy of the trauma. Some relate to the person’s prior history such as prior exposure to trauma, neglect, or childhood adversity.
One of the biggest risk factors for PTSD is the experience of cumulative trauma. Given that PTSD is a problem of recovery, it makes sense that the more trauma a person experiences, the less likely they are to heal and recover.
Protective factors promote resiliency. One important protective factor for PTSD is social support after a traumatic event.
The National Institute of Mental Health lists some risk and protective factors relating to Post-Traumatic Stress Disorder.
Risk Factors of PTSD:
- Living through dangerous events and traumas.
- Seeing another person hurt, or seeing a dead body.
- Feeling horror, helplessness, or extreme fear.
- Dealing with extra stress after the event, such as loss of a loved one, pain, injury, or loss of a job or home.
- Having little or no social support after the event.
- Having a history of mental illness or substance abuse.
- Childhood trauma.
Protective Factors of PTSD:
- Seeking out support from other people, such as friends or family.
- Learning to feel good about one’s own actions in the face of danger.
- Being able to act and respond effectively despite feeling fear.
- Finding a support group after a traumatic event.
- Having a positive coping strategy, or a way of getting through the bad event and learning from it.
What is a Traumatic Event?
To be diagnosed with PTSD, a person must first have been exposed to a traumatic event. It is extremely important to distinguish the experience of “trauma” in the general sense from the experience of a “traumatic event” that qualifies under Criterion A of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
If a person experiences a traumatic event that does not qualify under the DSM-5, this does not mean that they do not have symptoms or impairment. It just means that their condition does not satisfy the DSM-5 criteria for PTSD.
Specifically, Criterion A of the DSM-5 requires that a person must be exposed to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, in at least one of the following ways:
- Direct exposure.
- Witnessing the trauma.
- Learning that a relative or close friend was exposed to trauma.
- Indirect exposure to aversive details of the trauma, usually in the course of professional duties (e.g., first responders, medics, etc.).
What Are the Symptoms of PTSD?
Under the DSM, if the person has experienced a qualifying traumatic event, to meet criteria for PTSD, he or she must have all of the following symptoms for at least one month.
Re-Experiencing Symptoms (Criterion B)
The traumatic event must be re-experienced in one of the following ways:
- Frequent thoughts, memories, and nightmares about the traumatic events.
- Being physically responsive to reminders of the traumatic event.
- Strong feelings of stress or anxiety when reminded of the traumatic event.
- Experiencing flashbacks – having the sensation that the traumatic event is happening all over again.
These symptoms can interfere with a person’s day-to-day functioning. Words, images, situations, or places that are reminders of the event may trigger these symptoms.
For example, a song or sound (e.g., car backfiring) that the person heard at the time of the event may trigger these symptoms. A person’s thoughts or feelings may cause them to feel as if they are back at the time of the event.
Whatever the cause, these are memories that the person has not tried to and likely does not want to remember. In children, you may see a behavioral reenactment of the traumatic event in play.
For example, children who have lived through a tornado may later act this out in play by running to seek shelter.
Avoidance Symptoms (Criterion C)
The person must avoid trauma-related stimuli in one of the following ways:
- Avoidance of internal trauma-related reminders (e.g. thoughts and feelings)
- Avoidance of external trauma-related reminders (e.g. situations and places)
Either internal or external reminders of the traumatic event can trigger avoidance symptoms. Experiential avoidance occurs when a person avoids internal reminders about the traumatic event.
An assault survivor may try to force himself to think about other things whenever thoughts or feelings about the assault arises. He may try to suppress thoughts or feelings telling himself, “Stop worrying about this” or “Past is past.”
When a person avoids places or situations that remind her of the trauma, it is sometimes called behavioral avoidance. For example, a combat veteran may stop watching the news or reading the newspaper because of coverage of the war.
Negative Thoughts and Feelings (Criterion D)
The person must experience negative thoughts or feelings that began or worsened after the trauma, in at least two of the following ways:
- Overly negative thoughts and assumptions about oneself or the world.
- Exaggerated blame of self or others for causing the trauma.
- Decreased interest in activities.
- Difficulty experiencing positive affects.
- Negative affect.
- Feeling isolated.
A person processes a traumatic event within the context of his or her existing beliefs. When a traumatic event occurs, it can directly challenge people’s beliefs about themselves, others, and the world.
For example, many people have a “just-world belief” that a person’s actions should bring about morally fair and just consequences. Sadly, this belief can also lead people to blame themselves (i.e., “if this horrible thing happened to me and bad things only happen to bad people, then I must have done something to deserve this.”)
A person may also change his or her belief to incorporate the event. For instance, instead of blaming herself, a rape victim may have distorted beliefs about others such as “all men are violent” or the world “it is not safe to leave the house.”
If persistent and rigid, such beliefs could cut her off from meaningful relationships and interactions with people who care about her.
Hyperarousal and Reactivity Symptoms (Criterion E)
The person must experience trauma-related arousal and reactivity that began or worsened after the trauma, in at least two of the following ways:
- Irritability or aggression.
- Difficulty concentrating.
- Risky or destructive behavior.
- Heightened startle reaction.
- Difficulty sleeping.
These symptoms are often challenging to differentiate the behavior that arises due to the anger, irritability, hypervigilance, and sleep difficulties of PTSD from non-trauma related behaviors or disorders that mimic these symptoms.
In many children and adolescents, this group of PTSD symptoms looks very much like the impulsivity and hyperarousal present in attention-deficit hyperactivity disorder (ADHD). For example, many youth presenting these symptoms are often misdiagnosed with ADHD or other disruptive behavior disorders and never treated for PTSD.
This group of symptoms can be difficult to effectively treat because they reflect the effects of overactivation of the sympathetic nervous system (SNS).
This overactivation of the SNS can shrink the hippocampus, enlarge the amygdala, and affect other areas of the cortex. In this sense, effective treatment for PTSD involves rewiring or the brain.
- About 7 or 8 out of every 100 people (or 7-8% of the population) will have PTSD at some point in their lives.
- About 8 million adults have PTSD during a given year. This is only a small portion of those who have gone through a trauma.
- About 10 of every 100 women (or 10%) develop PTSD sometime in their lives compared with about 4 of every 100 men (or 4%). Learn more about women, trauma and PTSD.
- Among adolescents age 12 – 17, about 6 of every 100 girls (6.3%) or 4 of every 100 boys (3.7%) had PTSD.
Treatments for Post-Traumatic Stress Disorder
Treatment for PTSD typically involves a combination of psychotherapy, pharmacotherapy, or a combination of the two.
There is a great deal of information available online about how to choose the best treatment option for PTSD. It is important that you consult with a mental health professional with experience in treating PTSD to choose the treatment that is right for you.
Cognitive Behavioral Therapy (CBT)
Cognitive Behavioral Therapy (CBT) for PTSD has the same underlying components as regular CBT but is trauma-focused. It focuses on identifying, understanding, and restructuring thinking and behavior patterns relating to the trauma.
Cognitive Therapy (CT)
Derived from CBT, cognitive therapy focuses on restructuring the maladaptive thoughts and beliefs that have developed around the traumatic event. CPT-C is a variation of CPT that omits the written trauma account and focuses more on cognitive techniques and is considered a cognitive therapy.
Cognitive Processing Therapy (CPT)
Cognitive Processing Therapy (CPT) is a 12-session treatment that involves the following psychoeducation, cognitive therapy around trauma-related thoughts, a detailed written trauma account, and cognitive restructuring around five core concepts that are often impacted in PTSD (safety, trust, power/control, esteem, and intimacy). The VA has a CPT Coach app that may be helpful for clients completing CPT.
Prolonged Exposure (PE)
Prolonged Exposure (PE) typically lasts 8 – 15 weekly sessions. Like CPT, PE treatment involves psychoeducation regarding the thoughts, feelings, and behaviors relating to the trauma. Unlike CPT, however, PE includes a comprehensive gradual exposure component. The VA also has the PE Coach app that may be helpful for clients completing PE.
Eye Movement Desensitization and Reprocessing Therapy (EMDR)
Eye Movement Desensitization and Reprocessing Therapy (EMDR) is another recommended treatment for PTSD. According to the APA Practice Guidelines, EMDR “encourages the patient to briefly focus on the trauma memory while simultaneously experiencing bilateral stimulation (typically eye movements).” This intervention is associated with a reduction in the vividness and emotion associated with the trauma memories.
The National Center for PTSD has also developed a helpful decision aid that discusses the different treatment options for PTSD.
Treatments for Children and Adolescents
According to the California Evidence-Based Clearing House, the EBTs for PTSD in children and adolescents with the strongest evidentiary report include:
- EMDR for Children and Adolescents: This version of EMDR treatment is a downward extension of EMDR for children and adolescents.
- Prolonged Exposure Therapy for Adolescents (PE-A): PE-A is an adaptation of PE designed to be used with adolescents ages 12 – 18.
- Trauma-Focused Cognitive Behavioral Therapy (TF-CBT): TF-CBT is a comprehensive treatment for PTSD in children ages 3 – 18 that typically takes 12-16 sessions. TF-CBT includes child-only, parent-only, and conjoint sessions. TF-CBT includes the following “PPRACTICE” components:
- Psychoeducation and Parenting skills
- Affective Expression and Regulation
- Cognitive Coping
- Trauma Narrative Development and Processing
- In Vivo Gradual Exposure
- Conjoint Parent-Child sessions
- Enhancing Safety and Future Development
For more information on Post-Traumatic Stress Disorder and available treatments, you can visit the following websites:
- National Center for PTSD: 1-844-698-2311
- National Institute of Mental Health: 1-866-615-6464
- National Child Traumatic Stress Network: 1-310-235-2633
- International Society for Traumatic Stress Studies: 1-847-686-2234
- National Child Traumatic Stress Initiative: 1-800-662-4357
- American Professional Society on the Abuse of Children: 1-877-402-7722