research essay on ptsd

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• Published: 28 September 2018

Posttraumatic stress disorder: from diagnosis to prevention

• Xue-Rong Miao   ORCID: orcid.org/0000-0002-0665-8271 1 ,
• Qian-Bo Chen 1 ,
• Kai Wei 1 ,
• Kun-Ming Tao 1 &
• Zhi-Jie Lu 1  

Military Medical Research volume  5 , Article number:  32 ( 2018 ) Cite this article

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Posttraumatic stress disorder (PTSD) is a chronic impairment disorder that occurs after exposure to traumatic events. This disorder can result in a disturbance to individual and family functioning, causing significant medical, financial, and social problems. This study is a selective review of literature aiming to provide a general outlook of the current understanding of PTSD. There are several diagnostic guidelines for PTSD, with the most recent editions of the DSM-5 and ICD-11 being best accepted. Generally, PTSD is diagnosed according to several clusters of symptoms occurring after exposure to extreme stressors. Its pathogenesis is multifactorial, including the activation of the hypothalamic–pituitary–adrenal (HPA) axis, immune response, or even genetic discrepancy. The morphological alternation of subcortical brain structures may also correlate with PTSD symptoms. Prevention and treatment methods for PTSD vary from psychological interventions to pharmacological medications. Overall, the findings of pertinent studies are difficult to generalize because of heterogeneous patient groups, different traumatic events, diagnostic criteria, and study designs. Future investigations are needed to determine which guideline or inspection method is the best for early diagnosis and which strategies might prevent the development of PTSD.

Posttraumatic stress disorder (PTSD) is a recognized clinical phenomenon that often occurs as a result of exposure to severe stressors, such as combat, natural disaster, or other events [ 1 ]. The diagnosis of PTSD was first introduced in the 3rd edition of the Diagnostic and Statistical Manual (DSM) (American Psychiatric Association) in 1980 [ 2 ].

PTSD is a potentially chronic impairing disorder that is characterized by re-experience and avoidance symptoms as well as negative alternations in cognition and arousal. This disease first raised public concerns during and after the military operations of the United States in Afghanistan and Iraq, and to date, a large number of research studies report progress in this field. However, both the underlying mechanism and specific treatment for the disease remain unclear. Considering the significant medical, social and financial problems, PTSD represents both to nations and to individuals, all persons caring for patients suffering from this disease or under traumatic exposure should know about the risks of PTSD.

The aim of this review article is to present the current understanding of PTSD related to military injury to foster interdisciplinary dialog. This article is a selective review of pertinent literature retrieved by a search in PubMed, using the following keywords: “PTSD[Mesh] AND military personnel”. The search yielded 3000 publications. The ones cited here are those that, in the authors’ view, make a substantial contribution to the interdisciplinary understanding of PTSD.

Definition and differential diagnosis

Posttraumatic stress disorder is a prevalent and typically debilitating psychiatric syndrome with a significant functional disturbance in various domains. Both the manifestation and etiology of it are complex, which has caused difficulty in defining and diagnosing the condition. The 3rd edition of the DSM introduced the diagnosis of PTSD with 17 symptoms divided into three clusters in 1980. After several decades of research, this diagnosis was refined and improved several times. In the most recent version of the DSM-5 [ 3 ], PTSD is classified into 20 symptoms within four clusters: intrusion, active avoidance, negative alterations in cognitions and mood as well as marked alterations in arousal and reactivity. The diagnosis requirement can be summarized as an exposure to a stressor that is accompanied by at least one intrusion symptom, one avoidance symptom, two negative alterations in cognitions and mood symptoms, and two arousal and reactivity turbulence symptoms, persisting for at least one month, with functional impairment. Interestingly, in the DSM-5, PTSD has been moved from the anxiety disorder group to a new category of ‘trauma- and stressor-related disorders’, which reflects the cognizance alternation of PTSD. In contrast to the DSM versions, the World Health Organization’s (WHO) International Classification of Diseases (ICD) has proposed a substantially different approach to diagnosing PTSD in the most recent ICD-11 version [ 4 ], which simplified the symptoms into six under three clusters, including constant re-experiencing of the traumatic event, avoidance of traumatic reminders and a sense of threat. The diagnosis requires at least one symptom from each cluster which persists for several weeks after exposure to extreme stressors. Both diagnostic guidelines emphasize the exposure to traumatic events and time of duration, which differentiate PTSD from some diseases with similar symptoms, including adjustment disorder, anxiety disorder, obsessive-compulsive disorder, and personality disorder. Patients with the major depressive disorder (MDD) may or may not have experienced traumatic events, but generally do not have the invasive symptoms or other typical symptoms that PTSD presents. In terms of traumatic brain injury (TBI), neurocognitive responses such as persistent disorientation and confusion are more specific symptoms. It is worth mentioning that some dissociative reactions in PTSD (e.g., flashback symptoms) should be recognized separately from the delusions, hallucinations, and other perceptual impairments that appear in psychotic disorders since they are based on actual experiences. The ICD-11 also recognizes a sibling disorder, complex PTSD (CPTSD), composed of symptoms including dysregulation, negative self-concept, and difficulties in relationships based on the diagnosis of PTSD. The core CPTSD symptom is PTSD with disturbances in self-organization (DSO).

In consideration of the practical applicability of the PTSD diagnosis, Brewin et al. conducted a study to investigate the requirement differences, prevalence, comorbidity, and validity of the DSM-5 and ICD-11 for PTSD criteria. According to their study, diagnostic standards for symptoms of re-experiencing are higher in the ICD-11 than the DSM, whereas the standards for avoidance are less strict in the ICD-11 than in the DSM-IV [ 5 ]. It seems that in adult subjects, the prevalence of PTSD using the ICD-11 is considerably lower compared to the DSM-5. Notably, evidence suggested that patients identified with the ICD-11 and DSM-5 were quite different with only partially overlapping cases; this means each diagnostic system appears to find cases that would not be diagnosed using the other. In consideration of comorbidity, research comparing these two criteria show diverse outcomes, as well as equal severity and quality of life. In terms of children, only very preliminary evidence exists suggesting no significant difference between the two. Notably, the diagnosis of young children (age ≤ 6 years) depends more on the situation in consideration of their physical and psychological development according to the DSM-5.

Despite numerous investigations and multiple revisions of the diagnostic criteria for PTSD, it remains unclear which type and what extent of stress are capable of inducing PTSD. Fear responses, especially those related to combat injury, are considered to be sufficient enough to trigger symptoms of PTSD. However, a number of other types of stressors were found to correlate with PTSD, including shame and guilt, which represent moral injury resulting from transgressions during a war in military personnel with deeply held moral and ethical beliefs. In addition, military spouses and children may be as vulnerable to moral injury as military service members [ 6 ]. A research study on Canadian Armed Forces personnel showed that exposure to moral injury during deployments is common among military personnel and represents an independent risk factor for past-year PTSD and MDD [ 7 ]. Unfortunately, it seems that pre- and post-deployment mental health education was insufficient to moderate the relationship between exposure to moral injury and adverse mental health outcomes.

In general, a large number of studies are focusing on the definition and diagnostic criteria of PTSD and provide considerable indicators for understanding and verifying the disease. However, some possible limitations or discrepancies continue to exist in current research studies. One is that although the diagnostic criteria for a thorough examination of the symptoms were explicit and accessible, the formal diagnosis of PTSD using structured clinical interviews was relatively rare. In contrast, self-rating scales, such as the Posttraumatic Diagnostic Scale (PDS) [ 8 ] and the Impact of Events Scale (IES) [ 9 ], were used frequently. It is also noteworthy that focusing on PTSD explicitly could be a limitation as well. The complexity of traumatic experiences and the responses to them urge comprehensive investigations covering all aspects of physical and psychological maladaptive changes.

Prevalence and importance

Posttraumatic stress disorder generally results in poor individual-level outcomes, including co-occurring disorders such as depression and substance use, and physical health problems. According to the DSM-5 reporting, more than 80% of PTSD patients share one or more comorbidities; for instance, the morbidity of PTSD with concurrent mild TBI is 48% [ 8 ]. Moreover, cognitive impairment has been identified frequently in PTSD. The reported incidence rate for PTSD ranges from 5.4 to 16.8% in military service members and veterans [ 10 , 11 , 12 , 13 , 14 ], which is almost double those in the general population. The estimated prevalence of PTSD varies depending on the group of patients studied, the traumatic events occurred, and the measurement method used (Table  1 ). However, it still reflects the profound effect of this mental disease, especially with the rise in global terrorism and military conflict in recent years. While PTSD can arise at any life stage in any population, most research in recent decades has focused on returned veterans; this means most knowledge regarding PTSD has come from the military population. Meanwhile, the impact of this disease on children has received scant attention.

The discrepancy of PTSD prevalence in males and females is controversial. In a large study of OEF/OIF veterans, the prevalence of PTSD in males and females was similar, although statistically more prevalent in men versus women (13% vs. 11%) [ 15 ]. Another study on the Navy and Marine Corps showed a slightly higher incidence for PTSD in the women compared to men (6.6% vs. 5.3%) [ 12 ]. However, the importance of combat exposure is unclear. Despite a lower level of combat exposure than male military personnel, females generally have considerably higher rates of military sexual trauma, which is significantly associated with the development of PTSD [ 16 ].

It is reported that 44–72% of veterans suffer high levels of stress after returning to civilian life. Many returned veterans with PTSD show emotion regulation problems, including emotion identification, expression troubles and self-control issues. Nevertheless, a meta-analytic investigation of 34 studies consistently found that the severity of PTSD symptoms was significantly associated with anger, especially in military samples [ 17 ]. Not surprisingly, high levels of PTSD and emotional regulation troubles frequently lead to poor family functioning or even domestic violence in veterans. According to some reports, parenting difficulties in veteran families were associated with three PTSD symptom clusters. Evans et al. [ 18 ] conducted a survey to evaluate the impact of PTSD symptom clusters on family functioning. According to their analysis, avoidance symptoms directly affected family functioning, whereas hyperarousal symptoms had an indirect association with family functioning. Re-experience symptoms were not found to impact family functioning. Notably, recent epidemiologic studies using data from the Veterans Health Administration (VHA) reported that veterans with PTSD were linked to suicide ideations and behaviors [ 19 ] (e.g., non-suicidal self-injury, NSSI), in which depression as well as other mood disruptions, often serve as mediating factors.

Previously, there was a controversial attitude toward the vulnerability of young children to PTSD. However, growing evidence suggests that severe and persistent trauma could result in stress responses worse than expected as well as other mental and physical sequelae in child development. The most prevalent traumatic exposures for young children above the age of 1 year were interpersonal trauma, mostly related to or derived from their caregivers, including witnessing intimate partner violence (IPV) and maltreatment [ 20 ]. Unfortunately, because of the crucial role that caregivers play in early child development, these types of traumatic events are especially harmful and have been associated with developmental maladaptation in early childhood. Maladaptation commonly represents a departure from normal development and has even been linked to more severe effects and psychopathology. In addition, the presence of psychopathology may interfere with the developmental competence of young children. Research studies have also broadened the investigation to sequelae of PTSD on family relationships. It is proposed that the children of parents with symptoms of PTSD are easily deregulated or distressed and appear to face more difficulties in their psychosocial development in later times compared to children of parents without. Meanwhile, PTSD veterans described both emotional (e.g., hurt, confusion, frustration, fear) and behavioral (e.g., withdrawal, mimicking parents’ behavior) disruption in their children [ 21 ]. Despite the increasing emphasis on the effects of PTSD on young children, only a limited number of studies examined the dominant factors that influence responses to early trauma exposures, and only a few prospective research studies have observed the internal relations between early PTSD and developmental competence. Moreover, whether exposure to both trauma types in early life is associated with more severe PTSD symptoms than exposure to one type remains an outstanding question.

Molecular mechanism and predictive factors

The mechanisms leading to posttraumatic stress disorder have not yet been fully elucidated. Recent literature suggests that both the neuroendocrine and immune systems are involved in the formulation and development of PTSD [ 22 , 23 ]. After traumatic exposures, the stress response pathways of the hypothalamic–pituitary–adrenal (HPA) axis and sympathetic nervous system are activated and lead to the abnormal release of glucocorticoids (GC) and catecholamines. GCs have downstream effects on immunosuppression, metabolism enhancement, and negative feedback inhibition of the HPA axis by binding to the GC receptor (GR), thus connecting the neuroendocrine modulation with immune disturbance and inflammatory response. A recent meta-analysis of 20 studies found increased plasma levels of proinflammatory cytokines tumor necrosis factor-alpha (TNF-a), interleukin-1beta (IL-1b), and interleukin-6 (IL-6) in individuals with PTSD compared to healthy controls [ 24 ]. In addition, some other studies speculate that there is a prospective association of C-reactive protein (CRP) and mitogen with the development of PTSD [ 25 ]. These findings suggest that neuroendocrine and inflammatory changes, rather than being a consequence of PTSD, may in fact act as a biological basis and preexisting vulnerability for developing PTSD after trauma. In addition, it is reported that elevated levels of terminally differentiated T cells and an altered Th1/Th2 balance may also predispose an individual to PTSD.

Evidence indicates that the development of PTSD is also affected by genetic factors. Research has found that genetic and epigenetic factors account for up to 70% of the individual differences in PTSD development, with PTSD heritability estimated at 30% [ 26 ]. While aiming to integrate genetic studies for PTSD and build a PTSD gene database, Zhang et al. [ 27 ] summarized the landscape and new perspective of PTSD genetic studies and increased the overall candidate genes for future investigations. Generally, the polymorphisms moderating HPA-axis reactivity and catecholamines have been extensively studied, such as FKBP5 and catechol-O-methyl-transferase (COMT). Other potential candidates for PTSD such as AKT, a critical mediator of growth factor-induced neuronal survival, were also explored. Genetic research has also made progress in other fields. For example, researchers have found that DNA methylation in multiple genes is highly correlated with PTSD development. Additional studies have found that stress exposure may even affect gene expression in offspring by epigenetic mechanisms, thus causing lasting risks. However, some existing problems in the current research of this field should be noted. In PTSD genetic studies, variations in population or gender difference, a wide range of traumatic events and diversity of diagnostic criteria all may attribute to inconsistency, thus leading to a low replication rate among similar studies. Furthermore, PTSD genes may overlap with other mental disorders such as depression, schizophrenia, and bipolar disorder. All of these factors indicate an urgent need for a large-scale genome-wide study of PTSD and its underlying epidemiologic mechanisms.

It is generally acknowledged that some mental diseases, such as major depressive disorder (MDD), bipolar disorder, and schizophrenia, are associated with massive subcortical volume change. Recently, numerous studies have examined the relationship between the morphology changes of subcortical structures and PTSD. One corrected analysis revealed that patients with PTSD show a pattern of lower white matter integrity in their brains [ 28 ]. Prior studies typically found that a reduced volume of the hippocampus, amygdala, rostral ventromedial prefrontal cortex (rvPFC), dorsal anterior cingulate cortex (dACC), and the caudate nucleus may have a relationship with PTSD patients. Logue et al. [ 29 ] conducted a large neuroimaging study of PTSD that compared eight subcortical structure volumes (nucleus accumbens, amygdala, caudate, hippocampus, pallidum, putamen, thalamus, and lateral ventricle) between PTSD patients and controls. They found that smaller hippocampi were particularly associated with PTSD, while smaller amygdalae did not show a significant correlation. Overall, rigorous and longitudinal research using new technologies, such as magnetoencephalography, functional MRI, and susceptibility-weighted imaging, are needed for further investigation and identification of morphological changes in the brain after a traumatic exposure.

Psychological and pharmacological strategies for prevention and treatment

Current approaches to PTSD prevention span a variety of psychological and pharmacological categories, which can be divided into three subgroups: primary prevention (before the traumatic event, including prevention of the event itself), secondary prevention (between the traumatic event and the development of PTSD), and tertiary prevention (after the first symptoms of PTSD become apparent). The secondary and tertiary prevention of PTSD has abundant methods, including different forms of debriefing, treatments for Acute Stress Disorder (ASD) or acute PTSD, and targeted intervention strategies. Meanwhile, the process of primary prevention is still in its infancy and faces several challenges.

Based on current research on the primary prevention of post-trauma pathology, psychological and pharmacological interventions for particular groups or individuals (e.g., military personnel, firefighters, etc.) with a high risk of traumatic event exposure were applicable and acceptable for PTSD sufferers. Of the studies that reported possible psychological prevention effects, training generally included a psychoeducational component and a skills-based component relating to stress responses, anxiety reducing and relaxation techniques, coping strategies and identifying thoughts, emotion and body tension, choosing how to act, attentional control, emotion control and regulation [ 30 , 31 , 32 ]. However, efficiency for these training has not been evaluated yet due to a lack of high-level evidence-based studies. Pharmacological options have targeted the influence of stress on memory formation, including drugs relating to the hypothalamic-pituitary-adrenal (HPA) axis, the autonomic nerve system (especially the sympathetic nerve system), and opiates. Evidence has suggested that pharmacological prevention is most effective when started before and early after the traumatic event, and it seems that sympatholytic drugs (alpha and beta-blockers) have the highest potential for primary prevention of PTSD [ 33 ]. However, one main difficulty limiting the exploration in this field is related to rigorous and complex ethical issues, as the application of pre-medication for special populations and the study of such options in hazardous circumstances possibly touches upon questions of life and death. Significantly, those drugs may have potential side effects.

There are several treatment guidelines for patients with PTSD produced by different organizations, including the American Psychiatric Association (APA), the United Kingdom’s National Institute for Health and Clinical Excellence (NICE), the International Society for Traumatic Stress Studies (ISTSS), the Institute of Medicine (IOM), the Australian National Health and Medical Research Council, and the Department of Veterans Affairs and Department of Defense (VA, DoD) [ 34 , 35 , 36 , 37 , 38 ]. Additionally, a large number of research studies are aiming to evaluate an effective treatment method for PTSD. According to these guidelines and research, treatment approaches can be classified as psychological interventions and pharmacological treatments (Fig.  1 ); most of the studies provide varying degrees of improvement in individual outcomes after standard interventions, including PTSD symptom reduction or remission, loss of diagnosis, release or reduction of comorbid medical or psychiatric conditions, quality of life, disability or functional impairment, return to work or to active duty, and adverse events.

Psychological and pharmacological strategies for treatment of PTSD. CBT. Cognitive behavioral therapy; CPT. Cognitive processing therapy; CT. Cognitive therapy; CR. Cognitive restructuring; EMDR. Eye movement desensitization and reprocessing; SSRIs. Selective serotonin reuptake inhibitors; SNRIs. Serotonin and norepinephrine reuptake inhibitors; MAO. Monoamine oxidase

Most guidelines identify trauma-focused psychological interventions as first-line treatment options [ 39 ], including cognitive behavioral therapy (CBT), cognitive processing therapy (CPT), cognitive therapy (CT), cognitive restructuring (CR), coping skills therapy (including stress inoculation therapy), exposure-based therapies, eye movement desensitization and reprocessing (EMDR), hypnosis and hypnotherapy, and brief eclectic psychotherapy. These treatments are delivered predominantly to individuals, but some can also be conducted in family or group settings. However, the recommendation of current guidelines seems to be projected empirically as research on the comparison of outcomes of different treatments is limited. Jonas et al. [ 40 ] performed a systematic review and network meta-analysis of the evidence for treatment of PTSD. The study suggested that all psychological treatments showed efficacy for improving PTSD symptoms and achieving the loss of PTSD diagnosis in the acute phase, and exposure-based treatments exhibited the strongest evidence of efficacy with high strength of evidence (SOE). Furthermore, Kline et al. [ 41 ] conducted a meta-analysis evaluating the long-term effects of in-person psychotherapy for PTSD in 32 randomized controlled trials (RCTs) including 2935 patients with long-term follow-ups of at least 6 months. The data suggested that all studied treatments led to lasting improvements in individual outcomes, and exposure therapies demonstrated a significant therapeutic effect as well with larger effect sizes compared to other treatments.

Pharmacological treatments for PTSD include antidepressants such as selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), and monoamine oxidase (MAO) inhibitors, sympatholytic drugs such as alpha-blockers, antipsychotics, anticonvulsants, and benzodiazepines. Among these medications, fluoxetine, paroxetine, sertraline, topiramate, risperidone, and venlafaxine have been identified as efficacious in treatment. Moreover, in the Jonas network meta-analysis of 28 trials (4817 subjects), they found paroxetine and topiramate to be more effective for reducing PTSD symptoms than most other medications, whereas evidence was insufficient for some other medications as research was limited [ 40 ]. It is worth mentioning that in these studies, efficacy for the outcomes, unlike the studies of psychological treatments, was mostly reported as a remission in PTSD or depression symptoms; other outcomes, including loss of PTSD diagnosis, were rarely reported in studies.

As for the comparative evidence of psychological with pharmacological treatments or combinations of psychological treatments and pharmacological treatments with other treatments, evidence was insufficient to draw any firm conclusions [ 40 ]. Additionally, reports on adverse events such as mortality, suicidal behaviors, self-harmful behaviors, and withdrawal of treatment were relatively rare.

PTSD is a high-profile clinical phenomenon with a complicated psychological and physical basis. The development of PTSD is associated with various factors, such as traumatic events and their severity, gender, genetic and epigenetic factors. Pertinent studies have shown that PTSD is a chronic impairing disorder harmful to individuals both psychologically and physically. It brings individual suffering, family functioning disorders, and social hazards. The definition and diagnostic criteria for PTSD remain complex and ambiguous to some extent, which may be attributed to the complicated nature of PTSD and insufficient research on it. The underlying mechanisms of PTSD involve changes in different levels of psychological and molecular modulations. Thus, research targeting the basic mechanisms of PTSD using standard clinical guidelines and controlled interference factors is needed. In terms of treatment, psychological and pharmacological interventions could relief PTSD symptoms to different degrees. However, it is necessary to develop systemic treatment as well as symptom-specific therapeutic methods. Future research could focus on predictive factors and physiological indicators to determine effective prevention methods for PTSD, thereby reducing its prevalence and preventing more individuals and families from struggling with this disorder.

Abbreviations

American Psychiatric Association

Acute stress disorder

Cognitive behavioral therapy

Catechol-O-methyl-transferase

Cognitive processing therapy

Complex posttraumatic stress disorder

Cognitive restructuring

C-reactive protein

Cognitive therapy

Dorsal anterior cingulate cortex

Diagnostic and Statistical Manual

Disturbances in self-organization

Eye movement desensitization and reprocessing

Glucocorticoids

Glucocorticoids receptor

Hypothalamic–pituitary–adrenal axis

International classification of diseases

Impact of events scale

Interleukin-1beta

Interleukin-6

Institute of Medicine

Intimate partner violence

International Society for Traumatic Stress Studies

Monoamine oxidase

Major depressive disorder

United Kingdom’s National Institute for Health and Clinical Excellence

Non-suicidal self-injury

Posttraumatic diagnostic scale

Posttraumatic stress disorder

Randomized controlled trials

Rostral ventromedial prefrontal cortex

Serotonin and norepinephrine reuptake inhibitors;

Strength of evidence

Selective serotonin reuptake inhibitors

Tumor necrosis factor-alpha

DoD Department of Veterans Affairs and Department of Defense

Veterans Health Administration

World Health Organization

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We thank Jamie Bono for providing professional writing suggestions.

This work was supported by the National Natural Science Foundation of China (31371084 and 31171013 by ZJL), and the National Natural Science Foundation of China (81100276 by XRM).

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ZJL and XRM conceived the project. QBC, KW and KMT conducted the article search and acquisition. XRM and QBC analyzed the data. XRM wrote the manuscript. All the authors read and discussed the manuscript. All authors read and approved the final manuscript.

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Miao, XR., Chen, QB., Wei, K. et al. Posttraumatic stress disorder: from diagnosis to prevention. Military Med Res 5 , 32 (2018). https://doi.org/10.1186/s40779-018-0179-0

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Received : 20 March 2018

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Published : 28 September 2018

DOI : https://doi.org/10.1186/s40779-018-0179-0

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Review article, treating ptsd: a review of evidence-based psychotherapy interventions.

• Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, United States

Posttraumatic stress disorder (PTSD) is a chronic, often debilitating mental health disorder that may develop after a traumatic life event. Fortunately, effective psychological treatments for PTSD exist. In 2017, the Veterans Health Administration and Department of Defense (VA/DoD) and the American Psychological Association (APA) each published treatment guidelines for PTSD, which are a set of recommendations for providers who treat individuals with PTSD. The purpose of the current review article is to briefly review the methodology used in each set of 2017 guidelines and then discuss the psychological treatments of PTSD for adults that were strongly recommended by both sets of guidelines. Both guidelines strongly recommended use of Prolonged Exposure (PE), Cognitive Processing Therapy (CPT) and trauma-focused Cognitive Behavioral Therapy (CBT). Each of these treatments has a large evidence base and is trauma-focused, which means they directly address memories of the traumatic event or thoughts and feelings related to the traumatic event. Finally, we will discuss implications and future directions.

Introduction

Posttraumatic stress disorder (PTSD) is a chronic, often debilitating mental health disorder that may develop after a traumatic life event, such as military combat, natural disaster, sexual assault, or unexpected loss of a loved one. Most of the U.S. population is exposed to a traumatic event during their lifetime ( Sledjeski et al., 2008 ) and shortly after exposure, many people experience some symptoms of PTSD. Although among most individuals these symptoms resolve within several weeks, approximately 10%–20% of individuals exposed to trauma experience PTSD symptoms that persist and are associated with impairment ( Norris and Sloane, 2007 ). Lifetime and past year prevalence rates of PTSD in community samples are 8.3% and 4.7%, respectively ( Kilpatrick et al., 2013 ), with similar rates (8.0% and 4.8%) observed in military populations ( Wisco et al., 2014 ). PTSD is associated with a wide range of problems including difficulties at work, social dysfunction and physical health problems ( Alonso et al., 2004 ; Galovski and Lyons, 2004 ; Smith et al., 2005 ). Fortunately, effective psychological treatments for PTSD exist.

Diagnostic Criteria

The diagnosis of PTSD has undergone a number of changes since it was initially included in the Diagnostic and Statistical Manual of Mental Disorders Third Edition (DSM-III; American Psychiatric Association, 1980 ), including a revision in the most recent edition released in 2013 (DSM-5; American Psychiatric Association, 2013 ). Because the majority of PTSD treatment research currently published used criteria from the DSM-Fourth Edition-Text Revision (DSM-IV-TR; American Psychiatric Association, 2000 ) or from an earlier version of the DSM, it is important to note how the DSM-5 differs from these earlier versions. The DSM-5 reclassified PTSD as a Trauma- and Stressor-Related Disorder instead of an Anxiety Disorder. In the initial formulation of PTSD, a traumatic stressor was defined as an event outside the range of usual human experience. However, with recognition that traumatic events are relatively frequent, this criterion was revised. DSM-IV and DSM-IV-TR required that intense fear, helplessness, or horror were present in the individual’s response to the traumatic event, although it became evident that this was not universal, especially in military populations. The DSM-5 increased specification as to what qualifies as a traumatic event (Criterion A) and conceptualized traumatic events as exposure to actual or threatened death, serious injury, or sexual violation, as directly experiencing traumatic events, learning of the traumatic events experienced by a close family member or close friend, or repeated exposure to aversive details of the traumatic events. DSM-5 removed the requirement that intense fear, helplessness, or horror were present in the individual’s response to the traumatic event.

The symptom clusters of PTSD also have been revised in DSM-5. DSM-III and DSM-IV included three symptom clusters (re-experiencing, avoidance/numbing and arousal). DSM-5 transitioned from the original three symptom clusters to four symptom clusters including intrusion (five symptoms, one or more required for diagnosis), avoidance (two symptoms, one or more required for diagnosis), negative alteration in cognition and mood associated with the traumatic event (seven symptoms, two or more required for diagnosis) and marked alterations in arousal and reactivity associated with traumatic events (six symptoms, two or more required for diagnosis). The increase to four symptom clusters was a result of splitting avoidance/numbing into distinct clusters (avoidance and negative alteration in mood and cognition). In addition, negative alteration in mood and cognition contains symptoms previously considered numbing symptoms as well as persistent negative emotional states. Marked alterations in arousal and reactivity maintains symptoms previously considered arousal symptoms, in addition to irritable or aggressive behavior and reckless or self-destructive behavior. Consistent with previous editions of the DSM, these symptoms must be present for more than 1 month, cause clinically significant distress or impairment, and not be attributable to substance use or another medical condition. Familiarity with the DSM symptoms of  PTSD is important for two primary reasons: diagnosing PTSD and understanding what traumatic event will be the focus of therapy. “Rape victim” or “combat veteran” is not a diagnosis. Before commencing psychological treatment for PTSD, the provider must be assured that PTSD is primary. When the patient presents with multiple traumatic events, current re-experiencing symptoms will often point towards what we refer to as the “index trauma,” which will be the focus of psychological therapy.

PTSD Treatment Guidelines

A number of psychological treatments for PTSD exist, including trauma-focused interventions and non-trauma-focused interventions. Trauma-focused treatments directly address memories of the traumatic event or thoughts and feeling related to the traumatic event. For example, both Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) are trauma-focused treatments. Non-trauma-focused treatments aim to reduce PTSD symptoms, but not by directly targeting thoughts, memories and feelings related to the traumatic event. Examples of non-trauma-focused treatments include relaxation, stress inoculation training (SIT) and interpersonal therapy. Over the last two decades, numerous organizations (e.g., American Psychiatric Association, 2004 ; National Institute for Health and Clinical Excellence, 2005 ; Institute of Medicine, 2007 ; ISTSS [ Foa et al., 2009 ]) have produced guidelines for treatment of PTSD, including guidelines by American Psychological Association (APA) and the Veterans Health Administration and Department of Defense (VA/DoD) that were both published in 2017. Guidelines are lengthy and contain a great amount of information. Thus, the purpose of the current review is to briefly review the methodology used in each set of 2017 guidelines and then discuss the psychotherapeutic treatments of PTSD for adults that were strongly recommended by both sets of guidelines. The guidelines recommended several medications for treatment of PTSD, such as Sertraline, Paroxetine, Fluoxetine, Venlafaxine (see American Psychological Association, 2017 ; VA/DoD Clinical Practice Guideline Working Group, 2017 ) however, for the purposes of this review we will focus solely on psychotherapy. The combination of psychotherapy and medication is not recommended by either these guidelines.

In 2017, the VA/DoD and APA each published a treatment guideline for PTSD. Guidelines for PTSD treatment are a set of recommendations for providers who treat individuals with PTSD. Guidelines are not standards, which are requirements or mandatory. Each of these guidelines was based on systematic reviews of the literature examining treatments for PTSD to recommend treatments with the largest and strongest evidence base. The APA guideline is specifically for treatment of PTSD among adults, while the VA/DoD guideline focuses on recommendations for general clinical management, diagnosis and assessment and treatment for providers working within the VA or DoD.

The APA guidelines ( American Psychological Association, 2017 ) are based on a systematic review conducted by the Research Triangle Institute—University of North Carolina Evidence-Based Practice Center (RTI-UNC EPC; Jonas et al., 2013 ) and fully follow the Institute of Medicine (IOM; now the National Academy of Medicine) standards for developing high quality, independent and reliable practice guidelines ( Institute of Medicine, 2011a , b ). The review conducted by RTI-UNC included trials published prior to May 2012. The APA panel consisted of individuals from a number of backgrounds, including consumers, psychologists, social workers, psychiatrists and general medicine practitioners. The APA panel considered four factors in their recommendations: (1) overall strength of the evidence for the treatment; (2) the balance of benefits vs. harms or burdens; (3) patient values and preferences for treatment; and (4) the applicability of evidence to various populations.

The VA/DoD guideline ( VA/DoD Clinical Practice Guideline Working Group, 2017 ) is an update to the 2010 PTSD clinical practice guidelines published by the VA/DoD. This update follows the Guideline for Guidelines, which is an internal document of the VA/DoD Evidence-Based Practice Working Group (2013) . Work group members had specialties and clinical areas of interest in ambulatory care, behavioral health, clinical pharmacy, clinical neuropsychology, family medicine, nursing, pharmacology, pharmacy, psychiatry and psychology. A focus group of patients was held prior to finalizing the key questions for the evidence review. The Lewin Team, including The Lewin Group, Duty First Consulting, ECRI Institute and Sigma Health Consulting, LLC, was contracted by the VA and DoD to support development of the guidelines and to conduct an evidence review. The literature review focused on interventional studies published between March 2009 and March 2016. The VA/DoD guideline used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to assess the quality of the evidence base and assign a grade for the strength of each recommendation. This system uses four domains to assess strength of each recommendation: (1) balance of desirable and undesirable outcomes; (2) confidence in the quality of the evidence; (3) patient or provider values and preferences; and (4) other implications as appropriate (e.g., resource use, equity, acceptability, feasibility, subgroup considerations).

The recommendations of these two sets of guidelines were mostly consistent. See Table 1 for an overview of the “strongly recommended” and “recommended” treatments for adults with PTSD. Both guidelines strongly recommended use of PE, CPT and trauma-focused Cognitive Behavioral Therapy (CBT). The APA strongly recommended cognitive therapy (CT). The VA/DoD recommended eye movement desensitization therapy (EMDR; APA “suggests”), brief eclectic psychotherapy (BET; APA suggests), narrative exposure therapy (NET; APA suggests) and written narrative exposure. In our discussion of PTSD treatments, we will focus on treatments that were strongly recommended by both guidelines, which includes PE, CPT and CBT. First, we will describe each treatment and evidence for its use and then we will discuss dropout, side effects and adverse effects of these treatments together.

Table 1 . Clinical practice guidelines for treatment of posttraumatic stress disorder (PTSD).

Strongly Recommended Treatments

Prolonged exposure.

PE is strongly recommended by both the APA and VA/DoD guidelines for treatment of PTSD. PE is based on emotional processing theory ( Foa and Kozak, 1985 , 1986 ), which suggests that traumatic events are not processed emotionally at the time of the event. Emotional processing theory suggests that fear is represented in memory as a cognitive structure that includes representations of the feared stimuli, the fear responses, and the meaning associated with the stimuli and responses to the stimuli. Fear structures can represent realistic threats, which is normal. However, fear structures can become dysfunctional. According to Foa and Kozak (1986) , fear structures may become problematic when the association between stimulus elements do not accurately reflect the real world, physiological and escape or avoidance responses are induced by innocuous stimuli, responses that are excessive and easily triggered interfere with adaptive behavior, and safe stimulus and response elements are incorrectly associated with threat or danger. PE focuses on altering fear structures so that they are no longer problematic. Two conditions are necessary for fear structures to be altered and for exposure to work. First, the fear structure must be activated and second, new information that is incompatible with erroneous information in the fear structure must be incorporated into the structure.

The evidence-based manual describing PE indicates that this therapy is typically completed in 8–15 sessions ( Foa et al., 2007 ). PE includes psychoeducation about PTSD and common reactions to trauma, breathing retraining, and two types of exposure: in vivo exposure and imaginal exposure. During psychoeducation, patients learn about PTSD, common reactions to trauma and exposure. Breathing retraining is a skill taught to assist patients in stressful situations but not to be used during exposure. The two main components of treatment are in vivo exposure and imaginal exposure. In vivo exposure assists patients in approaching situations, places and people they have been avoiding because of a fear response due to the traumatic event repeatedly until distress decreases. Imaginal exposure consists of patients approaching memories, thoughts and emotions surrounding the traumatic event they have been avoiding. Patients recount the narrative of the traumatic event in the present tense repeatedly and tape record this recounting to practice imaginal exposure for homework. The patient and therapist then process emotional content that emerged during the imaginal exposure. Through these two types of exposures, patients activate their fear structure and incorporate new information. PE is a particular program of exposure therapy that has been adopted for dissemination through the VA and DOD. The treatment manual has been translated into about nine different languages. A revised PE manual is due to be published in 2019. It has been shown to be helpful across survivors, in different cultures and countries, regardless of the length of time since traumatization or the number of previous traumatic events ( Powers et al., 2010 ).

As suggested by its strong recommendation by both set of guidelines, there is a large body of research evidence that indicates the effectiveness of exposure therapy and particularly PE. Individuals randomly assigned to exposure therapy have significantly greater pre- to posttreatment reductions in PTSD symptoms compared to supportive counseling ( Bryant et al., 2003 ; Schnurr et al., 2007 ), relaxation training ( Marks et al., 1998 ; Taylor et al., 2003 ) and treatment as usual including pharmacotherapy ( Asukai et al., 2010 ). In addition to the RCTs used to determine recommended treatment in the guidelines, several meta-analyses have found that exposure therapy is more effective that non-trauma focused therapies ( Bradley et al., 2005 ; Powers et al., 2010 ; Watts et al., 2013 ; Cusack et al., 2016 ). A meta-analysis on the effectiveness of PTSD found the average PE-treated patient fared better than 86% of patients in control conditions on PTSD symptoms at the end of treatment ( Powers et al., 2010 ). The effect sizes for PE were not moderated by time since trauma, publication year, dose, study quality, or type of trauma. A second meta-analysis, which examined psychological treatments for PTSD, found a high strength of evidence for the efficacy of PE ( Cusack et al., 2016 ). Regarding loss of diagnosis, rates vary across studies. Among PE participants, 41% to 95% lost their PTSD diagnosis at the end of treatment ( Jonas et al., 2013 ). In addition, 66% more participants treated with exposure therapy achieved loss of PTSD diagnosis than in waitlist control groups ( Jonas et al., 2013 ).

Cognitive Processing Therapy

In addition to PE, CPT is strongly recommended by both the APA and VA/DoD guidelines for treatment of PTSD. CPT is a trauma focused therapy drawing on social cognitive theory and informed emotional processing theory as discussed above Resick and Schnicke (1992) . CPT assumes that following a traumatic event, survivors attempt to make sense of what happened, often time leading to distorted cognitions regarding themselves, the world, and others. In an attempt to integrate the traumatic event with prior schemas, people often assimilate, accommodate, or over-accommodate. Assimilation is when incoming information is altered in order to confirm prior beliefs, which may result in self-blame for a traumatic event. An example of assimilation is “because I didn’t fight harder, it is my fault I was assaulted.” Accommodation is a result of altering beliefs enough in order to accommodate new learning (e.g., “I couldn’t have prevented them from assaulting someone”). Over-accommodation is changing ones beliefs to prevent trauma from occurring in the future, which may result in beliefs about the world being dangerous or people being untrustworthy (e.g., “because this happened, I cannot trust anyone”). CPT allows for cognitive activation of the memory, while identifying maladaptive cognitions (assimilated and over-accommodated beliefs) that have derived from the traumatic event. The main aim of CPT is to shift beliefs towards accommodation ( Resick and Schnicke, 1992 ).

Resick et al. (2017) have developed an updated treatment manual for CPT. CPT consists of 12 weekly sessions that can be delivered in either individual or group formats. Generally, CPT is composed of CT and exposure components ( Resick and Schnicke, 1992 ; Chard et al., 2012 ). Clients work to identify assimilated and over-accommodated beliefs and learn skills to challenge these cognitions through daily practice ( Resick et al., 2002 ). Initial sessions are focused on psychoeducation about the cognitive model and exploration of the patient’s conceptualization of the traumatic event. The individual considers: (1) why the traumatic event occurred; and (2) how it has changed their beliefs about themselves, the world and others regarding safety, intimacy, trust, power/control and esteem. The original version of CPT included a written trauma account where the patient described thoughts, feelings and sensory information experienced during the traumatic event. However, following evidence from recent dismantling studies, the most recent version of the protocol does not include the written trauma narrative ( Resick et al., 2008 , 2017 ; Chard et al., 2012 ). CT skills are introduced through establishing the connection between thoughts, feelings, and emotions related to the individual’s stuck points (maladaptive cognitions about the event) and learning ways to challenge cognitions that are ineffective ( Chard et al., 2012 ). These skills are used to examine and challenge their maladaptive beliefs. CPT concludes with an exploration on the shifts in how the individual conceptualizes why the traumatic event occurred, focusing on the shift to accommodation rather than assimilation and over-accommodation.

CPT has been widely supported as an effective treatment for PTSD. While CPT was developed to treat survivors of rape ( Resick and Schnicke, 1992 ), it has been researched and implemented successfully across trauma types and populations ( Chard et al., 2012 ). Research findings suggest CPT effectively treats PTSD in sexual assault survivors ( Chard, 2005 ), veterans who served in Vietnam, Iraq and Afghanistan ( Chard et al., 2010 ), and adult males with comorbid TBI and PTSD ( Chard et al., 2011 ). CPT has been found to exhibit clinically meaningful reduction in PTSD, depression and anxiety in sexual assault and Veteran samples, with results maintained at 5 and 10 year post treatment follow-up ( Resick et al., 2012 ). Meta-analyses suggest that CPT is effective in significantly reducing PTSD symptoms ( Watts et al., 2013 ; Cusack et al., 2016 ). Similar to findings for PE, the number of individuals who no longer meet criteria for PTSD after CPT varies across studies. Rates of participants who no longer met PTSD diagnosis criteria ranged from 30% to 97% and 51% more participants treated with CPT achieved loss of PTSD diagnosis, compared to waitlist, self-help booklet and usual care control groups ( Jonas et al., 2013 ).

Cognitive Behavioral Therapy for PTSD

Another strongly recommended therapy by APA and the VA/DoD is CBT for PTSD. The VA/DoD includes only trauma-focused CBT. APA included both trauma-focused and non-trauma-focused CBT in its recommendations including CBT-mixed, which included studies using cognitive behavioral techniques that did not fit in well with other categories, and CT, which included CT studies that were not specifically CPT. Brief trauma-focused CBT categorized by the VA/DoD included studies examining trauma-focused cognitive and/or behavioral techniques that were not specifically PE or CPT. Thus in this section, we will discuss brief therapies using trauma-focused behavioral and/or cognitive techniques as these are included in both sets of guidelines as strongly recommended.

Trauma-focused CBT is based on cognitive and behavioral models that tend to draw from other CBT theories, such as PE and CPT. For example, Ehlers and Clark (2000) proposed that individuals with PTSD hold excessively negative appraisals of the trauma and that their autobiographical memory of the trauma is characterized by poor contextualization, strong associative memory and strong perceptual priming, which leads to involuntary reexperiencing of the trauma. Ehlers and Clark suggest that individuals with PTSD engage in problematic behavioral and cognitive strategies that prevent them from changing negative appraisals and trauma memories. Thus, goals of this treatment include modifying negative appraisals, correcting the autobiographical memory, and removing the problematic behavioral and cognitive strategies. Kubany et al. (2004) suggest that guilt-associated appraisals may evoke negative affect and may be paired with images or thoughts of the trauma. These guilt appraisals may repeatedly recondition memories of the trauma with distress and may lead to tendencies to suppress or avoid trauma-related stimuli.

Trauma-focused CBT typically includes both behavioral techniques, such as exposure, and cognitive techniques, such as cognitive restructuring. CBT that includes exposure to the traumatic memory uses imaginal exposure, writing the traumatic narrative, or reading the traumatic memory out loud ( Marks et al., 1998 ; Kubany et al., 2004 ; Ehlers et al., 2005 ). CBT that includes exposure to trauma-related stimuli typically uses in vivo exposure ( Kubany et al., 2004 ) or teaching patients to identify triggers of re-experiencing and practice discrimination of “then vs. now” ( Ehlers et al., 2005 ). Cognitive restructuring focuses on teaching patients to identify dysfunctional thoughts and thinking errors, elicit rational alternative thoughts, and reappraise beliefs about themselves, the trauma, and the world ( Marks et al., 1998 ; Kubany et al., 2004 ; Ehlers et al., 2005 ). A CT targeting PTSD among battered women focused specifically on CT for trauma-related guilt in three phases: guilt issue assessment, guilt incident debriefings and CT ( Kubany et al., 2004 ).

Consistent with the recommendations of the guidelines, research supports the effectiveness of trauma-focused CBT for PTSD. CBT has been shown to be more effective than a waitlist ( Power et al., 2002 ), supportive therapy ( Blanchard et al., 2003 ) and a self-help booklet ( Ehlers et al., 2003 ). Researchers have compared different components of CBT (i.e., imaginal exposure, in vivo exposure, cognitive restructuring) with some mixed results. Marks et al. (1998) compared exposure therapy (that included five sessions of imaginal exposure and five sessions of in vivo exposure), cognitive restructuring, combined exposure therapy and cognitive restructuring, and relaxation in an RCT. Exposure and cognitive restructuring were each effective in reducing PTSD symptoms and were superior to relaxation. Exposure and cognitive restructuring were not mutually enhancing when combined. Bryant et al. (2008) compared imaginal exposure alone, in vivo exposure alone, imaginal and in vivo exposure, and imaginal, in vivo , and cognitive restructuring. In contrast to Marks et al. (1998) , Bryant et al. (2008) found the treatment condition with both exposure components and cognitive restructuring had the largest effect size and resulted in fewer patients with PTSD at a 6-month follow-up. Regarding loss of diagnosis, 61% to 82.4% of participants treated with CBT lost their PTSD diagnosis and 26% more CBT participants than waitlist or supportive counseling achieved loss of PTSD diagnosis ( Jonas et al., 2013 ).

Dropout, Side Effect and Adverse Effects

One common concern with trauma-focused treatment is dropout and rates of dropout appear to be similar across PE, CPT and trauma-focused CBT ( Hembree et al., 2003 ). A substantial minority of individuals drop out of PTSD treatment (e.g., Imel et al., 2013 ). Imel et al. (2013) conducted a meta-analysis of treatment dropout in PTSD treatment. The aggregate proportion of dropout across all active treatments was 18.28%, however, there was a large amount of variability across studies. The dropout rate varied between active interventions for PTSD across studies, but the differences were primarily driven by differences between studies. In addition, an increase in trauma focus did not predict an increase in the dropout rate. Imel et al. (2013) did find evidence across three relatively large trials that dropout is lower in present centered therapy (PCT; 22%) compared to trauma specific treatments (36%).

Unfortunately, few studies explicitly report on side effects and adverse effects of PTSD psychotherapy ( Cusack et al., 2016 ). The American Psychological Association (2017) guidelines recommends that research be conducted on side effects. When examining the results of large controlled trials there is no evidence that trauma-focused treatments are associated with a relative increase in adverse side effects ( American Psychological Association, 2017 ; VA/DoD Clinical Practice Guideline Working Group, 2017 ). Clearly more research should examine and report on side effects and adverse effects of PTSD treatment.

Implications and Future Directions

PE, CPT and trauma-focused CBT have been strongly recommended as treatments for PTSD in treatment guidelines by the APA and the VA/DoD. Each of these treatments have a large evidence base supporting their effectiveness in treating PTSD. Although exposure-based therapies have the largest and strongest research evidence base ( Cusack et al., 2016 ), research and meta-analyses comparing PE, CPT and trauma-focused CBT do not find that one treatment outperforms the other ( Resick et al., 2002 , 2008 ; Powers et al., 2010 ; Cusack et al., 2016 ).

The guidelines and strong research evidence suggest that PE, CPT and trauma-focused CBT should be the first line of treatment for PTSD whenever possible, considering patient preferences and values and clinician expertise. Research examining patient preferences suggests that individuals prefer PE, CPT and trauma-focused CBT to other treatments. Analog studies have demonstrated that participants have preferences for CT and exposure therapy over psychodynamic psychotherapy, EMDR, and therapies using novel technologies (e.g., virtual reality, computer-based therapy; Tarrier et al., 2006 ; Becker et al., 2007 ). In addition, results from studies examining clinical samples show that patient prefer psychotherapy, such as PE and CBT, to medication ( Angelo et al., 2008 ; Feeny et al., 2009 ; Zoellner et al., 2009 ). Findings are similar among veteran and military samples, with soldiers showing greater preference for PE and virtual reality exposure (VRE) to paroxetine or sertraline ( Reger et al., 2013 ) and veterans in a PTSD specialty clinic showing greater preference for CPT to other psychotherapies, PE to nightmare resolution therapy and PCT, and both PE and cognitive-behavioral conjoint therapy were preferred to VRE ( Schumm et al., 2015 ).

The recommendations to use these treatments by the guidelines has not been without controversy in the provider community, as evidenced by online petitions against the APA guidelines (there is also a petition supporting the guidelines). Those who petition these guidelines may be concerned that trauma-focused treatments could pose a risk to some patients because of distress elicited by focusing on the trauma memory, may limit providers’ ability to get reimbursed for other types of treatment, or they may believe that RCTs lead to false conclusions (for a rebuttal, see McKay, 2017 ; Shedler, 2017 ). However, as stated above, there is no evidence that trauma-focused treatments are associated with a relative increase in adverse side effects ( American Psychological Association, 2017 ; VA/DoD Clinical Practice Guideline Working Group, 2017 ). In addition, although RCTs cannot answer all questions in clinical psychology science, they do eliminate more sources of error (e.g., placebo effect, confirmation bias) than other research designs, such as naturalistic or observational studies. Thus, dissemination of information about effective treatments, benefits and harms related to treatment, and effective research methodology to treatment providers who work with individuals with PTSD is imperative. There is also concern that these trauma-focused treatments may not be as effective among military samples ( Steenkamp et al., 2015 ; Steenkamp, 2016 ). According to a review of trauma-focused treatment among military samples, approximately 60% to 72% of military patients retained PTSD diagnosis after treatment ( Steenkamp et al., 2015 ). However, this rate was lower than comparison groups including waitlist and PCT (range 74%–97%), within-group posttreatment effect sizes for CPT and PE were large, and 49%–70% of patients receiving CPT or PE attained clinically meaningful symptom improvement (defined as a 10–12 point decrease in interviewer or self-report symptoms ( Steenkamp et al., 2015 ). Findings from this review support the recommendation of the guidelines that PE, CPT and trauma-focused CBT should be the first line of treatment for PTSD and also suggest that outcomes from these treatments can be improved.

Future directions in PTSD treatment research include identifying ways to enhance effective treatments including among particular populations (e.g., military), further examination of treatments that are “recommended” rather than “strongly recommended”, keeping individuals engaged in treatment (i.e., reducing dropout), and determining individual factors predicting response/nonresponse. Avoidance symptoms are a core feature of  PTSD and maintain PTSD over time. Thus, it is not surprising that the dropout rate for PTSD treatment is high across treatment modalities. In addition, a portion of individuals do not respond adequately to PTSD treatment. One potential future direction is medication-enhanced psychotherapy for PTSD. Medication could potentially strengthen learning and memory, inhibit fear, and facilitate therapeutic engagement ( Dunlop et al., 2012 ). Research is beginning to examine pharmacological agents to enhance response to trauma-focused therapies such as MDMA, D-cycloserine and the neuropeptide oxytocin (e.g., Mithoefer et al., 2011 ; de Kleine et al., 2012 ; Koch et al., 2014 ; Rothbaum et al., 2014 ). Non-pharmacological enhancement of therapy is also being explored such as rTMS ( Kozel et al., 2018 ), exercise ( Rosenbaum et al., 2015 ), and other cognitive training ( Fonzo et al., 2017 ). Another potential avenue to increase engagement and reduce dropout is through use of intensive treatment programs, in which patients attend massed multiple sessions within a short period of time (e.g., one or 2 weeks) instead of weekly sessions spaced over several months. These types of programs are beginning to be evaluated with promising results (e.g., Harvey et al., 2017 ; Foa et al., 2018 ; Hendriks et al., 2018 ) and report excellent retention rates (90%–100%).

Further research on particular PTSD treatments is needed. As research continues to transition to the utilization of DSM-5 criteria, it will be essential to update the guidelines informed by the new criteria as this new conceptualization could impact the measurement and efficacy of these treatments. Examining biomarkers of PTSD, treatment response, and precision medicine, i.e., matching treatment to the individual, are the wave of the future. We need to compare interventions and determine if any treatment approaches are more or less effective for particular groups of people. Finally, further research is needed to develop new treatment approaches that are effective and acceptable to PTSD sufferers, as recommended in the 2014 IOM report ( Institute of Medicine, 2014 ).

The guidelines put forth by the VA/DoD and the APA in 2017 are recommendations for providers who treat individuals with PTSD and both strongly recommend PE, CPT and trauma-focused CBT. Each of these treatments has a large evidence base showing their effectiveness. These treatments are all trauma-focused, which means they directly address memories of the traumatic event or thoughts and feelings related to the traumatic event. Treatments with the strongest evidence should be the first line of treatment for PTSD whenever possible, with consideration of patient preferences and values and clinician expertise.

Author Contributions

LW, KS and BR discussed and conceived the topic and content of the review. LW and KS drafted the manuscript. BR wrote portions that appear throughout the manuscript. All authors provided critical revisions and approved the final manuscript.

The authors acknowledge, with gratitude, critical support from the Wounded Warrior Project, which has supported the Emory Healthcare Veterans Program in the Warrior Care Network. Dr. Rothbaum has received funding from the Wounded Warrior Project, Department of Defense, National Institute of Mental Health, Brain and Behavior Research Foundation (NARSAD), and the McCormick Foundation, and she received recent support from Transcept Pharmaceuticals.

The reviewer ED and handling editor declared their shared affiliation at the time of review.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Keywords: posttraumatic stress disorder, psychotherapy, treatment, evidence-based medicine, prolonged exposure, cognitive processing therapy, cognitive behavioral therapy

Citation: Watkins LE, Sprang KR and Rothbaum BO (2018) Treating PTSD: A Review of Evidence-Based Psychotherapy Interventions. Front. Behav. Neurosci. 12:258. doi: 10.3389/fnbeh.2018.00258

Received: 24 May 2018; Accepted: 15 October 2018; Published: 02 November 2018.

Reviewed by:

Copyright © 2018 Watkins, Sprang and Rothbaum. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Laura E. Watkins, [email protected]

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Neurobiological Models of Psychotherapy

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Get 10% off with 24start discount code, i. reactions to traumatic events, a. acute reactions, b. posttraumatic stress disorder, c. course of ptsd, ii. measures of ptsd, a. interviews, b. self-report measures, iii. prevalence of ptsd, iv. vulnerability and resiliency factors in ptsd, v. concomitant problems following trauma, vi. theories on the development and maintenance of ptsd, a. psychoanalytic theories, b. cognitive and behavioral theories, c. psychobiological approaches, vii. psychological and pharmacological interventions in ptsd, a. early interventions, b. cognitive-behavioral therapies, 1. prolonged exposure (pe), 2. stress inoculation training (sit), 3. cognitive therapy, 4. cognitive processing therapy (cpt), 5. eye movement desensitization and reprocessing (emdr), c. pharmacotherapy, d. hypnotherapy and psychodynamic psychotherapy.

VIII. Bibliography

Psychologists and physicians have long been interested in vulnerability and resilience factors in reaction to extreme stress. Earlier accounts of posttrauma reactions focused on descriptions of cases. Spurred by inclusion of Post-traumatic Stress Disorder (PTSD) in the psychiatric diagnosis nomenclature in 1980, experimental research has examined many facets of the phenomenon.

In the Diagnostic and Statistical Manual (DSM-IV) published by the American Psychiatric Association in 1994, a trauma is defined as an experienced or witnessed event that involves threat of death or serious injury, and which evokes feelings of terror, horror, or helplessness. Thus, events such as anticipated death of a loved one, job loss, or divorce would not qualify as a trauma in this formulation. The International Classification of Diseases (ICD-10), published by the World Health Organization in 1992, describes a traumatic event as having an exceptionally threatening or catastrophic nature, which would be likely to cause pervasive distress in almost anyone.

The most common traumas studied are combat, sexual assault, sexual abuse in childhood, criminal victimization, torture, accidents, and natural disasters. Larger-scale traumas, such as mass migration, refugee camp experiences, and holocausts, have not yet been thoroughly researched. Clearly, such mass traumas would be expected to have considerable impact on those individuals directly affected as well as on their children, communities, and cultures.

A number of physical and psychological symptoms are considered common reactions immediately after a traumatic experience. Many trauma victims report being disoriented and anxious after a trauma and have difficulty sleeping and concentrating. Victims are often reluctant to talk about the trauma or deliberately contemplate it; nevertheless the traumatic memory intrudes on their thoughts quite frequently. In recognition of the severe distress and psychological dysfunction that often occur immediately after a trauma, a new diagnostic classification called Acute Stress Disorder (ASD) was adopted in the DSM-IV in 1994. The focus of this disorder is on dissociative features, and, consequently, the symptom criteria include at least three of the following: a sense of numbing, detachment, or lack of emotional responsiveness, a reduction in awareness of surroundings (e.g., being in a daze), derealization, depersonalization, and dissociative amnesia. Reexperiencing of the trauma, avoidance, and arousal, as defined in the criteria for PTSD, must also exist. A diagnosis of Acute Stress Disorder is warranted when such symptoms last between 2 days and 1 month, occur within 1 month of the trauma, and interfere significantly with daily functioning.

Posttraumatic Stress Disorder, as described in DSM-IV, is a set of symptoms that begins after a trauma and persists for at least 1 month. The symptoms fall into three clusters. First, the individual must reexperience the trauma in one of the following ways: nightmares, flashbacks, or intrusive and distressing thoughts about the event; or intense emotional distress or physiological reactivity when reminded of the event. Second, the individual must have three of the following avoidance symptoms: avoidance of thoughts or feelings related to the trauma, avoidance of trauma reminders, psychogenic amnesia, emotional numbing, detachment or estrangement from others, decreased interest in leisure activities, or a sense of foreshortened future. Third, the individual must experience two of the following arousal symptoms: difficulty falling or staying asleep, difficulty concentrating, irritability or outbursts of anger, hypervigilance, or an exaggerated startle response. To meet diagnostic criteria for PTSD, the symptoms must cause significant impairment in daily functioning. These criteria provide a good operational definition of PTSD, as they describe the symptoms seen in most cases. However, the three categories of symptoms are not empirically validated as distinct symptom clusters. For instance, it is not clear that the symptoms of behavioral avoidance and emotional numbing are similar and belong in the same category.

The ICD-IO criteria for PTSD also include some reexperiencing symptoms (nightmares, flashbacks, distress on exposure to reminders), actual or preferred avoidance of trauma reminders, and either an inability to recall important aspects of the trauma or sustained psychological sensitivity and arousal (sleep disturbance, hypervigilance, difficulty concentrating). These three criteria must all be met within 6 months of the traumatic event for a diagnosis to be given.

Several differences between the two definitions can be identified. First, the DSM-IV specifies a minimal number of symptoms that need to be observed to receive the diagnosis, whereas the ICD-IO leaves more freedom for clinical judgment. The advantage of the former approach is its utility in clearly operationalizing the concept of PTSD. The disadvantage is its rigidity and the possibility that one symptom can determine diagnostic membership. Second, the ICD-IO does not recognize the numbing symptoms, which together with flashbacks and nightmares are thought to be cardinal features of PTSD. Third, arousal symptoms are optional in the ICD-IO but are required in the DSM-IE Clinical observation and theoretical accounts of PTSD support the importance of these symptoms and render the ICD-IO diagnostic criteria less satisfactory.

The course of PTSD is variable. For the majority of individuals, symptoms begin immediately after the trauma, although some appear to have a delayed reaction. During the first 3 months after the trauma, the individual is said to have acute PTSD, whereas chronic PTSD is defined as symptoms persisting beyond 3 months. Symptoms can fluctuate over time between diagnosis of PTSD, subthreshold symptoms, and few or no symptoms. Recovery is affected by a number of factors, including perception of oneself and one’s surroundings, actual social support, life stress, coping style, and personality.

A number of measures have been developed to assess PTSD, including clinical interviews and self-report instruments. These measures vary widely in terms of the target symptoms, administration time, and the samples used for ascertaining psychometric properties. Adult assessment tools are reviewed in the next section. Although some measures have also been developed for children, they are outside the scope of this paper.

The Structured Clinical Interview for DSM (SCID) is believed to be the most widely used diagnostic interview. Its major disadvantage, however, is that it does not provide a measure of symptom severity. Several other interviews that provide information of both diagnostic status and symptom severity are available. Two interviews are becoming quite widely used in PTSD research. The first is the Clinician-Administered PTSD Scale (CAPS) that yields separate scores for frequency and intensity for each symptom. Disadvantages of this interview include a long administration time and validation on military veterans only. The second interview, the PTSD Symptom Scale Interview (PSS-I), includes a combined frequency/severity rating for each of the 17 PTSD symptoms in the DSM-IV and thus yields both a diagnosis and a continuous severity rating. Unlike the CAPS, the PSS-I takes only about 15 to 20 minutes to administer and was validated on female assault victims.

Several self-report scales have been developed to assess symptoms of PTSD. The first was the Revised Impact of Events Scale (RIES), which yields two factors: intrusion and avoidance. A revised version of the RIES added hyperarousal items, but has shown mixed results in reliability studies and, like its predecessor, does not correspond fully to the DSM-IV PTSD symptoms. Two scales, the Mississippi Scale and the Penn Inventory, have excellent psychometric properties in veteran samples but do not provide information about diagnostic status because they do not fully correspond to the DSM-IV defining symptoms.

The PTSD Symptom Scale-Self-Report (PSS-SR) and its successor, the PTSD Diagnostic Scale (PDS), provide information about each of the 17 DSM-IV symptoms, yielding both diagnostic and severity information. The PDS is the only self-report instrument that assesses all DSM-IV criteria, including information about the nature of the traumatic event and the level of functional interference, in addition to information about PTSD diagnosis and symptom severity. It was validated in a sample of victims of a wide range of traumas and evidenced sound psychometric properties, and thus can be used in studies of various trauma populations.

Lifetime prevalence of PTSD in the general population is estimated at 9%, with up to a third of these cases having chronic PTSD. Among trauma victims, the rate is much higher, estimated at 24 %. However, the rates of PTSD tend to vary considerably among different types of trauma. For instance, estimates of the lifetime prevalence of PTSD in Vietnam War veterans range from 27 to 65%; in civilian populations exposed to terrorism and torture, prevalence ranges from 33 to 54%. Between 35% and 94% of victims of violent assaults manifest PTSD. In contrast, accidents and natural disasters appear to produce lower rates of PTSD, 4.6 to 59%, depending on the event studied and the degree of exposure. Even individuals with little or no direct exposure to the trauma can develop PTSD; this phenomenon has been referred to as the “ripples outward” effect. Importantly, certain occupations are at risk for PTSD by virtue of increased probability of repeated direct exposure to trauma; between 9% and 26% of professionals such as police, nurses, and firefighters develop PTSD in reaction to stressors experienced on the job.

Prevalence in certain vulnerable populations is much higher than in the general population, presumably because individuals in these groups have been exposed to more traumatic experiences. These include populations seeking outpatient psychotherapy and those in substance abuse clinics. Women appear to be somewhat more likely than men to develop PTSD after trauma, 10.4 % versus 5 %, respectively. As noted earlier, the prevalence of emotional difficulties after mass traumas, such as refugee camp experiences or holocausts, has not been systematically studied.

Factors implicated in posttrauma reactions can be divided into three categories: pretrauma variables, variables related to the trauma itself, and posttrauma variables.

Research on pretrauma demographic variables has not identified reliable predictors of who will develop chronic PTSD with one exception: women are somewhat more likely to manifest PTSD than men after experiencing a similar trauma. In contrast, it appears that poor psychological and social functioning prior to the trauma renders the individual vulnerable to developing chronic symptoms. For instance, prior hospitalization and a history of drug abuse were found to be associated with a more severe posttrauma reaction. Also, a history of traumatic events in childhood or adulthood predicts a more severe response to a new trauma.

The nature of the trauma itself also appears to affect recovery. First, traumas differ in their likelihood of producing PTSD; rape, for example, is more likely to produce persistent symptoms than a natural disaster. Second, given a specific trauma (e.g., rape), injury and perceived threat of death produce more severe and persistent reactions.

Several posttrauma factors have been found to exacerbate symptoms. It appears that dissociation (emotional numbing, amnesia, depersonalization) shortly after a trauma hinders recovery. Also, on average, assault victims who exhibit more severe initial reactions to the trauma also show more symptoms later on. Thus, individuals seem to differ in how strongly they are affected by a similar trauma, and their initial reaction is associated with later psychopathology.

Evidence on the role of social support as facilitating or hindering recovery is equivocal. It seems that negative reactions from others, such as blame, increase posttrauma psychopathology, but, unfortunately, positive reactions do not show the expected positive effects. Excessive anger or guilt after the trauma also appears to block readjustment. Additional longitudinal research on the factors that promote resilience to trauma are clearly needed.

Traumatized individuals not only exhibit ASD or PTSD symptoms, but also depression, substance abuse, anxiety, dissociation, and physical health problems.

The rate of use and abuse of drugs and alcohol, including nicotine, in traumatized individuals is higher than in the general population. There are at least two explanations for this finding. First, traumatized individuals may choose to cope with their symptoms by increasing substance use. Second, substance abuse may increase the risk of being exposed to a traumatic experience.

Many individuals report symptoms of depression after a traumatic event, such as sadness, lack of energy, diminished interest in leisure activities, hopelessness, sleeplessness, and eating disturbances. Although some of these symptoms overlap with the defining symptoms of PTSD (e.g., markedly diminished interest in activities), the two disorders are separate entities and both can develop independently as a response to a traumatic experience.

The incidence of comorbid anxiety disorders is also elevated among individuals with PTSD. For example, lifetime comorbidity of panic disorder in Vietnam veterans with PTSD was 21% in females and 8% in males, versus 1.5 to 3.5% in the general population. The lifetime prevalence of obsessive-compulsive disorder was found to be 13% in females and 10% in males, as compared with 2.5 % in the general population.

There is a greater frequency of physical health problems among trauma victims than in the general population, especially among those who develop chronic PTSD. Trauma victims have higher rates of gastrointestinal disorders and pelvic or abdominal pain, and visit the doctor more often than the general population. In the aftermath of rape and child sexual abuse, gynecological and psychosexual problems such as vaginal discharge, dysmennorhea, dyspareunia, vaginismus, and pelvic pain have also been noted.

Reactions to trauma have long captured the interest of theorists of psychopathology. Janet’s 1889 theory of reactions to trauma has influenced both early and contemporary conceptualizations. Janet proposed that when confronted with a traumatic event that besieges the victim with an overabundance of intense thoughts and feelings, too numerous or intense to integrate, some individuals selectively attend away from the trauma to trauma-irrelevant thoughts and feelings. Thus, ideas related to the trauma remain split off or dissociated from normal consciousness and become “fixed.” Although out of consciousness, these “fixed ideas” remain part of the victim’s ideational content, and therefore continue to exert influence over his or her thought, mood, and behavior in the form of fragmented reliving of the trauma such as visual images, somatic states, emotional conditions, or behavioral reenactment.

Freud wrestled with understanding the influence of traumatic experiences on the individual’s psyche. In early writings, he was influenced by Janet’s theory on the strength of the emotional reactions that are produced by a traumatic experience and that force the victim to become fixated on the trauma. Later, Freud abandoned the dissociation view and proposed that the persistence of trauma reactions reflects an association between the traumatic event and childhood repressed conflicts, ideas, or impulses, and the efforts to prevent conscious awareness of them. He also coined the concept of “repetition compulsion” to explain trauma reexperiencing, proposing that because of the need to keep it away from consciousness, the individual is forced to repeat aspects of the trauma as a contemporary experience rather than as a memory of it. Influenced by World War I experiences, Freud refocused on the external reality, and, in the spirit of Janet, viewed the emotional upheaval generated by the trauma as the source of traumatic neurosis. He suggested that the intensity of the trauma, the inability to find conscious expressions for it, and the unpreparedness of the individual cause a breach to the stimulus barrier and overwhelm the defense mechanisms. More recent theorists have proposed that the developmental level and ego resources available to the victim are central to the manner in which the trauma is experienced and to the production of symptoms. For instance, a young child, easily overwhelmed and flooded with emotion, may experience complete helplessness in the face of trauma, whereas a mature adult would be more likely to respond through emotional numbing and cognitive constriction. Psychoanalytic theorists and practitioners focus on the need to help the victim acknowledge and bear the trauma and the resulting psychic damage, and develop coping mechanisms such that the memories of the trauma are incorporated into his or her current experience.

Several schools of thought inspired cognitive-behavioral theories of PTSD. The first is learning theory, which explains PTSD symptoms in terms of instrumental and classical conditioning. The learning model that most directly influenced cognitive-behavioral treatments (CBT) aimed at anxiety reduction was Mowrer’s two-factor theory. First, Mowrer proposed that fear is acquired through classical conditioning, where a neutral stimulus comes to evoke fear through its pairing with an aversive stimulus. Applying this theory to explain PTSD symptoms, neutral stimuli (e.g., supermarket) that were present during the trauma are presumed to acquire the ability to elicit fear through their associations with the danger stimuli (e.g., gun). Through the processes of generalization and second-order conditioning, stimuli similar to those present during the trauma also come to evoke fear. For instance, the stimuli all men, being alone, and the word rape can all acquire the capacity to cause anxiety. In Mowrer’s second stage, avoidance behavior is established through the process of operant conditioning. That is, an individual learns to reduce trauma-related anxiety through avoidance of, or escape from, the feared stimuli. Escape and avoidance behaviors are negatively reinforced because avoidance diminishes the aversive fear state.

Cognitive-behavioral therapy of PTSD has also been influenced by cognitive theory. Cognitive theory assumes that the interpretation of events, rather than events themselves, underlies emotional reactions. Accordingly, an event can be interpreted in different ways and consequently can evoke different emotions. Aaron Beck and colleagues suggest that trauma victims who manifest chronic persistent anxiety are unable to discriminate between safe and unsafe signals, and consequently their thinking is dominated by the perception of danger. They also suggest that traumatic fear can be maintained through a sense of incompetence to handle stressful events.

Other cognitive theorists have postulated that cognitive schemas are disrupted after victimization. A schema is a meaning structure that guides the perception, organization, and interpretation of incoming information. Common to these theories is the supposition that a traumatic experience requires cognitive modification and that such modification is accomplished by assimilation and accommodation. Accordingly, the victim must either assimilate the traumatic experience into preexisting schemas, or, more often, change schemas to accommodate the traumatic experience. In her 1992 book, Janoff-Bulman took the position that people in general hold the assumptions: “the world is benevolent, the world is meaningful, and self is worthy,” and these assumptions are incompatible with a traumatic experience. Building on Janoff-Bulman’s ideas, other theorists suggest that the following areas are of particular relevance: safety, dependency/trust of self and others, power, esteem, intimacy, and independence.

Coming from the psychoanalytic tradition, Horowitz integrated psychoanalytical and information processing notions in his 1986 book, suggesting that people have a basic need to match trauma-related information with their “inner models based on old information.” The process of recovery entails the repeated revision of both trauma-related information and the inner models until they agree, which Horowitz referred to as the “completion tendency.”

Foa and Kozak integrated cognitive and learning theories to explain the development and maintenance of pathological anxiety in what they called emotional processing theory. In their 1986 paper, fear is conceived as a cognitive structure or a program for escaping danger which includes representations of fear stimuli, fear responses, and their meaning. Pathological fear, they suggested, is distinguished from normal fear in that it includes erroneous associations and evaluations. Emotional processing theory views anxiety disorders as representing distinctive fear structures in memory, and the persistence of anxiety symptoms is conceived as reflecting impairment in emotional processing. Accordingly, PTSD is construed as reflecting a fear memory that contains erroneous associations and evaluations, whereas a normal trauma memory reflects associations and evaluations that better match reality. First, a pathological PTSD structure contains excessive response representations that are reflected in the PTSD symptoms. Second, this structure includes erroneous stimulus-stimulus associations that do not accurately represent the world. For example, the pathological fear structure of a woman who was raped at gunpoint by a bald man would contain an association between “bald men” and “gun.” In reality, however, bald men are not more likely to carry guns or to rape than men with a full head of hair. Third, the structure also includes erroneous associations between harmless stimuli such as “bald,” “home, …. suburbs,” and the meaning of “dangerous.” Being raped one time while at home in the suburbs does not tangibly increase the chance of encountering violence in that environment. Fourth, the structure includes erroneous associations between harmless stimuli and escape or avoidance responses. For example, the victim who was raped by the bald man would tend to run away from such men. In reality, however, running away from “bald men” is not likely to enhance safety. These erroneous associations would lead to mistakenly interpreting the world as entirely dangerous.

Another set of erroneous associations and evaluations is the interpretation of the victim’s response representations. It is thought that the victim’s responses during and after the trauma, and in particular the PTSD symptoms, are interpreted to mean self-incompetence. In summary, emotional processing theory hypothesizes that two major pathological concepts underlie PTSD: the world as entirely dangerous, and the self as entirely inept.

Psychophysiological, neurohormonal, neuroanatomical, and immunological changes have been observed in animals exposed to extreme stress and in trauma victims who developed PTSD (van der Kolk, McFarlane, & Weisaeth, 1996). These changes have been hypothesized to disregulate responses to incoming information and to inhibit successful processing of traumatic memories.

The normal stress response upon exposure to a high-magnitude stressor is a complex neurohormonal response, including the release of catecholamines (e.g., epinephrine and norepinephrine), serotonin, endogenous opioids, and hormones of the hypothalamus, pituitary, or adrenal gland (e.g., cortisol, vasopressin, oxytocin). Normally, the introduction of a stressor produces intense and rapid stress responses, and these dissipate quickly after the removal of the stressor. However, after prolonged exposure to stress, the stress responses become disregulated.

Theorists propose that PTSD reflects a failure to regulate autonomic reactions to stimuli such that the individual either experiences hyperreactivity or “shutting down” and emotional numbing. Individuals with PTSD show hyperreactivity, as measured by heart rate, skin conductance, and blood pressure, in reaction to reminders of traumatic events. This disregulation of the emotional and physiological responsiveness occurs with specific reminders of the trauma as well as in reaction to intense but neutral stimuli, signifying a loss of stimulus discrimination. In addition, the individual may come to fear his or her emotional reactions because of being able to do little to control them.

Neurohormonal changes in individuals with PTSD have also been found. First, prolonged stress causes depletion of the noradrenergic system, such that receptors become hypersensitive to any new release of norepinephrine. This noradrenergic hyperreactivity is linked to the increased arousal and startle of PTSD. The high levels of norepinephrine are proposed to inhibit the release of corticotrophin-releasing hormone and thereby inhibit the entire hypothalamic-pituitaryadrenocortical axis. This inhibition, in turn, produces a deficiency in endogenous opioids. Some theories postulate that the reexperiencing symptoms of PTSD cause a burst in the release of endogenous opioids and therefore make up for this deficiency. These endogenous opioids are thought to produce an artificial numbing or calmness, another hallmark of PTSD. Additional theories propose that cortisol responses are lowered in retraumatized individuals and that serotonin levels may decrease in response to prolonged inescapable stress.

In addition to psychophysiological and neurohormonal factors, specific brain abnormalities have recently been detected in individuals with PTSD. One system that is implicated in the disorder is the limbic system, which is thought to function in memory and in emotional reactions to incoming stimuli. One area in the limbic system, the hippocampus, is presumed to record spatial and temporal aspects of experiences in memory. Researchers have noted decreased hippocampal volume in trauma victims with PTSD compared with those without PTSD. One possible explanation for this finding is that individuals with smaller hippocampuses are more likely to develop PTSD; a more likely interpretation of these results is that increased cortisol activity causes shrinkage, because cortisol is toxic to the hippocampus.

A second area in the limbic system, the amygdala, also appears to be altered in individuals with PTSD. The amygdala is thought to assign meaning to incoming stimulation by integrating memory images with emotional experiences associated with those memories, guiding emotional behavior. A single intense stimulation of the amygdala appears to alter the limbic physiology such that a “kindling” effect occurs. That is, the behavior that follows may be predominantly either “fight” or “flight,” and a pattern of conditioned behavior is set up such that there is limited processing of incoming information before the response is initiated.

Several psychological interventions have been used with trauma victims, including supportive counseling individually or in groups, brief dynamic psychotherapy, hypnotherapy, pharmacotherapy, and cognitivebehavioral therapy. As recently reviewed by Foa and Meadows, although a variety of psychological interventions are used routinely with trauma victims, controlled outcome studies have tended to focus on cognitive-behavioral treatments such as systematic desensitization, exposure, and anxiety management. Nevertheless, hypnotherapy and psychodynamic therapy have also shown promise in the few studies examining their efficacy.

The popular supposition among trauma theories is that for recovery to occur after a traumatic experience, special processing efforts should take place. This view has prompted the development of early intervention programs. These programs have focused on education, debriefing after trauma, and training professionals at risk (e.g., police). Usually, “critical incident stress debriefing” is conducted in groups, such as emergency workers, and focuses on education about common reactions to traumatic experiences, encouraging trauma victims to process their experiences in a group setting. Although such programs have become routine in many places, little is known about their efficacy. In fact, some experts have raised concerns that such programs could interfere with rather than facilitate the natural recovery process.

The recognition that victims who exhibit severe reactions immediately after the trauma are more likely to develop chronic dysfunction has prompted researchers to implement interventions that aim to prevent chronic PTSD. Foa and colleagues conducted a study to compare PTSD severity of female assault victims, who received a brief prevention program (four individual therapy sessions), to that of victims who underwent an assessment procedure. Victims who received the brief prevention program had less severe PTSD and depressive symptoms 2 months after the assault. Clearly, more studies of this type are needed before confidence in prevention efforts can be established.

Currently, five cognitive-behavioral interventions are in use for PTSD: Prolonged Exposure, cognitive therapy, Stress Inoculation Training, Cognitive Processing Therapy, and Eye Movement Desensitization and Reprocessing.

This is a set of procedures that involves confrontation with feared stimuli, either in vivo or in imagination. With PTSD, exposure therapy typically includes repeated reliving of the traumatic event in imagination and actual confrontation with feared situations and objects that have been avoided because they are reminders of the trauma but are not intrinsically dangerous.

As discussed earlier, the theoretical basis of PE lies in learning and emotional-processing theories. Foa and Kozak have proposed that successful therapy involves correcting the pathological elements of the fear structure, and that this corrective process is the essence of emotional processing. They further suggest that regardless of the type of therapeutic intervention used, two conditions are required for fear reduction. First, the fear structure must be activated through introduction of fear-relevant information. If the fear structure is not activated (fear is not evoked), the structure would not be available for modification. Second, during exposure, information that is incompatible with the existing pathological elements (e.g., fear reduction) must be provided so that the pathological fear structure can be corrected. Specifically, exposure researchers hypothesize that repeated reliving promotes several cognitive changes. First, it promotes habituation of anxiety associated with the trauma memory, and this habituation disconfirms the victim’s erroneous belief that anxiety will stay forever and therefore lead to disastrous consequences. Second, reliving promotes discrimination between “remembering” the trauma and “encountering” it again, thus reinforcing the realization that remembering itself is not dangerous. Third, repeated exposure promotes differentiation between the trauma and similar but safe situations, disconfirming the idea that the world is extremely dangerous. Fourth, it promotes the association between PTSD symptoms and a sense of mastery, rather than incompetence. Finally, repeated recounting of the trauma narrative helps to organize the narrative and thereby to facilitate the integration of the trauma memory.

Several controlled studies on exposure have shown their usefulness in treating PTSD. Whereas studies on veterans showed only modest improvement, two studies with female rape victims showed more improvement. Foa and colleagues found that exposure (imaginal and in vivo) was effective in eliminating PTSD in 55% of rape victims with chronic PTSD compared with 45% of those who received supportive counseling. Superior results were found in a second study: about 70% of victims who received Prolonged Exposure lost their PTSD diagnosis, and none of the women in a wait-list group lost their diagnosis. These treatment effects were maintained at 6-month follow-up.

This intervention consists of training victims to handle anxiety with several skills for anxiety management: relaxation, thought stopping, assertiveness, cognitive therapy, coping self-statements, and guided imagery. Although the direct goal of anxiety management techniques is to teach patients techniques to manage their anxiety, the successful acquisition of such techniques can have indirect effects on the victim’s schemas of self and the world. Specifically, the victim’s experience of being able to control the anxiety fosters a more positive self-image and thereby modifies the perception of the world as overwhelmingly dangerous. Several studies point to the efficacy of this program used alone or in combination with other techniques. For example, the two studies on rape victims reported earlier found that SIT significantly reduced PTSD, to a degree comparable to that of exposure.

Researchers believed that if PE and SIT are quite, but not completely, successful in ameliorating PTSD symptoms, a program that combined these two treatments would yield superior results. However, research does not support this view: combined programs were helpful for female assault victims, but not more than exposure or stress inoculation alone.

Cognitive techniques are often incorporated into anxiety management programs that teach patients to examine and change systematically maladaptive thoughts that can lead to negative responses. Cognitive therapy involves the use of discourse, in which the patient is taught to identify the beliefs underlying the fear, to examine whether they are distorted or accurately reflect reality, and to replace mistaken or dysfunctional beliefs with more realistic, functional ideas about the ability of the patient to cope with stress and the dangerousness of the world. One possible benefit of cognitive restructuring is that it addresses directly beliefs underlying emotions other than fear, such as anger and guilt. Early investigations of this technique revealed some promise in the use of this therapy to reduce symptoms of PTSD in rape victims.

Another cognitive-behavioral program called Cognitive Processing Therapy is described in Resick and Schnicke’s 1992 book. It involves cognitive restructuring and exposure through writing about the trauma. The cognitive therapy is geared toward correcting maladaptive cognitions associated with rape, such as power, safety, and esteem. In one study, on the average, victims who received CPT reported 40% symptom reduction, and these gains were maintained over time. More studies are needed to establish the efficacy of this relatively new treatment.

This therapy, described by Shapiro in 1995, is a form of exposure with a cognitive emphasis, accompanied by guided eye movements. The studies that have evaluated the efficacy of this treatment produced equivocal results. Some show good results, but others show no improvement. Because these studies have many methodological problems, it is difficult to determine the validity of the findings. Further well-controlled studies are needed before a definite conclusion about the value of EMDR can be made.

Many medications have been used for the treatment of PTSD, but only a few have been systematically studied. Most of these have used male combat veterans, and thus the efficacy of pharmacotherapy for other traumatized populations is largely unknown. Tricyclic antidepressants have been used in an attempt to reduce locus coeruleus overactivity and noradrenergic disregulation found in PTSD, with equivocal results. Amitriptyline and imipramine have shown modest reductions in PTSD symptoms in comparison with placebo in double-blind studies with male veterans. In contrast, desipramine failed to show efficacy. One study of fluoxetine, a selective serotonin reuptake inhibitor used to regulate serotonergic dysfunction in individuals with PTSD, found it to be effective in reducing symptoms of PTSD, especially in trauma victims other than Vietnam veterans.

Other medications that have been tested include anticonvulsants such as carbamazepine and valproic acid; but no double-blind studies have been conducted to date. Beta-adrenergic blockers such as propanolol have shown promise in reducing aggressivity and arousal symptoms in open studies, and alpha2-adrenergic agonists, such as clonidine, appear to be effective through their suppression of locus coeruleus activity.

Finally, benzodiazepines have been widely used to suppress anxiety and are believed to reduce PTSD symptoms by reducing limbic system kindling and reversing neurochemical changes in the locus coeruleus and hypothalamus. However, the rebound anxiety and withdrawal symptoms associated with benzodiazepines can be problematic.

In summary, most of our knowledge about efficacy of pharmacotherapy for PTSD is confounded by the restricted samples used in existing studies. Most were conducted on Vietnam veterans, whose symptoms are particularly resistant to all types of treatments, and therefore the present results may underestimate the efficacy of this treatment.

Hypnotherapy uses heightened concentration and focused attention to facilitate treatment related to trauma. It is based on the supposition that individuals with PTSD are unknowingly entering trance states when they reexperience the trauma and that hypnotherapy can help them learn how to control their trance states and digest the dissociated traumatic experience in a controlled manner. One study found hypnosis to be as effective as psychodynamic psychotherapy and a type of exposure called systematic desensitization. More studies of this technique are needed before conclusions can be drawn about the usefulness of hypnotherapy.

Psychodynamic psychotherapy has also been used to help individuals recover from trauma. It focuses on intrapsychic conflict about the trauma rather than on resolution of specific symptoms of PTSD. The methods used are in some respects similar to those used in cognitive-behavioral therapy, as these interventions focus on helping the victims process the traumatic experience and on teaching them how to tolerate anxiety. Both individual and group therapies have been used, and some preliminary studies suggest the utility of these interventions.

Bibliography:

• American Psychiatric Association. (1994). Diagnostic and statistical manual (4th ed.). Washington, DC: American Psychiatric Press.
• Davidson, J. R. T., & Foa, E. B. (Eds.). (1993). Post-traumatic stress disorder: DSM-IV and beyond. Washington, DC: American Psychiatric Press.
• Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99, 20-35.
• Foa, E. B., & Meadows, E. A. (1997). Psychosocial treatments for post-traumatic stress disorder: A critical review. In J. Spence (Ed.), Annual review of psychology. Palo Alto, CA: Annual Reviews, Inc.
• Foa, E. B., & Riggs, D. S. (1993). Post-traumatic stress disorder in rape victims. In J. Oldham, M. B. Riba, & A. Tasman (Eds.), American psychiatric press review of psychiatry (Vol. 12, pp. 273-303). Washington, DC: American Psychiatric Press.
• Horowitz, M. J. (1986). Stress response syndromes (2nd edition). Northvale, NJ: Jason Aronson, Inc.
• Janet, P. (1889). L’Automatisme psychologique. Paris: Felix Alcan. (Reprinted 1973, Paris, Societe Pierre Janet.)
• Janoff-Bulman, R. (1992). Shattered assumptions: Towards a new psychology of trauma. New York: Free Press.
• Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Post-traumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048-1060.
• Resick, P. A., & Schnicke, M. K. (1992). Cognitive processing therapy for sexual assault survivors: A treatment manual. Newbury Park, CA: Sage.
• Shapiro, F. (1995). Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures. New York: Guilford Press.
• van der Kolk, B. A., McFarlane, A. C., & Weisaeth, L. (Eds.). (1996). Traumatic stress: The effect of overwhelming experience on mind, body, and society. New York: Guilford Press.
• World Health Organization. (1993). ICD- I O: The ICD- IO classification of mental and behavioural disorders: Diagnostic criteria for research. Geneva, Switzerland: Author.

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Post Traumatic Stress Disorder Essay Examples

Ptsd essay topics and outline examples, essay title 1: understanding ptsd: causes, symptoms, and treatment.

Thesis Statement: This essay explores Post-Traumatic Stress Disorder (PTSD) by examining its root causes, the range of symptoms experienced by those affected, and various therapeutic approaches and treatment options available to individuals struggling with PTSD.

• Introduction
• Defining PTSD and Its Diagnostic Criteria
• Common Causes and Triggers of PTSD
• Symptoms and Psychological Effects on Individuals
• Treatment Modalities: Therapy, Medications, and Alternative Approaches

Essay Title 2: The Impact of PTSD on Veterans: Addressing the Mental Health Crisis

Thesis Statement: This essay focuses on the prevalence of PTSD among military veterans, the unique challenges they face, and the importance of providing comprehensive mental health support, including therapy, peer counseling, and community resources.

• PTSD in Military Context: Causes and Traumatic Experiences
• Challenges Faced by Veterans: Reintegration and Mental Health Stigma
• Promoting Veteran Well-Being: Accessible Mental Health Services
• Community and Government Initiatives to Support Veterans with PTSD

Essay Title 3: PTSD in Children and Adolescents: Recognizing and Healing Childhood Trauma

Thesis Statement: This essay sheds light on the prevalence of PTSD in children and adolescents exposed to trauma, emphasizing the importance of early intervention, trauma-informed care, and support systems for young individuals experiencing post-traumatic stress.

• Childhood Trauma and Its Impact on Mental Health
• Signs and Symptoms of PTSD in Children and Adolescents
• Treatment Approaches: Play Therapy, Counseling, and Family Support
• Educational and Community Resources to Address Childhood PTSD

Ptsd and Its Implications Among Law Enforcement Officers

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Analysis of The Cognitive Impacts of Ptsd

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Post-traumatic Stress Disorder in The Novel Comfort Woman

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112 PTSD Essay Topic Ideas & Examples

🏆 best ptsd topic ideas & essay examples, 👍 good essay topics on ptsd, ⭐ simple & easy ptsd essay titles, ❓ ptsd research questions examples.

• PTSD in Charlie of “The Perks of Being a Wallflower” As an example of the latter, this paper focuses on the analysis of Charlie Kelmeckis, the protagonist of Stephen Chbosky’s novel The Perks of Being a Wallflower, and his PTSD.
• Post Traumatic Stress Disorder: History and Symptoms This essay looks into the history, the symptoms of posttraumatic stress disorder, and the individuals who are likely to suffer from this condition, psychological problems associated with this condition and the treatment of the disorder.
• Post-Traumatic Stress Disorder and Substance Use Disorder The hypothesis of self-medication is one of the mechanisms that can expound the comorbidity between post-traumatic stress disorder and anxiety illness.
• Post Traumatic Stress Disorder (PTSD) as a Health Issue in the Society The treatment is aimed at relieving the symptoms that the patient seems to be experiencing so that the individual can be able to deal with the traumatic experience.
• Aspects of the Posttraumatic Stress Disorder They include direct or indirect exposure to stressors, intrusion symptoms, the persistent avoidance of trauma-related stressors, negative alterations in mood and the development of mental health comorbidities, aggression, and self-destructive behavior, the duration for not […]
• The Importance of PTSD for Master Leaders Course in the Army The multiplicity of this manifestation and presentation of PTSD creates a research question focusing on the need for research into the main types of disorder and the support.
• Self-Reported PTSD (Posttraumatic Stress) Symptoms and Social Support At the same time, multiple authors prove that social support and connectedness with family members, relatives, friends, and other members of the community contribute to PTG and the minimization of the signs of PTSD in […]
• The Traumas from Post Traumatic Stress Disorder Measuring the prevalence and incidence of PTSD requires excellent knowledge of epidemiology and biostatistics. The prevalence and incidence of PTSD have increased since 2000.
• Post-Traumatic Stress Disorder: Preliminary Care Coordination The personal character of trauma and how the patient reacts to it justifies the need to design patient-centered interventions to address this healthcare problem.
• Post-Traumatic Stress Disorder: Causes and Symptoms The article by Smith entitled Posttraumatic Stress Disorder is valuable because it offers important information on the causes and symptoms of PTSD and ways of recognizing and treating the condition.
• Major Depressive Disorder and Post-Traumatic Stress Disorder Her sleep is turbulent, she has rape nightmares, her mood is depressed, and her affect is congruent and constrained. Her mental process is rational and linear, and her mental faculties are largely intact.
• Posttraumatic Stress Disorder: Case Presentation Report Date of initial assessment: N/A PSEUDO Name: Ana Ana is a self-referred and re-occurring client who entered counseling after the case of domestic violence. As a result, Ana expressed feelings of anxiety and fear […]
• The DSM-5 Criteria for Posttraumatic Stress Disorder The inference is backed by the fact that Victor’s traumatic situation is persistently manifesting intrusion symptoms such as nightmares, flashbacks, unwanted upsetting memories, and a lack of willingness to share previous hurtful events. Victor displays […]
• Posttraumatic Stress Disorder Treatment Research Therefore, the advantage of qualitative research, in this case, relates to the ability to investigate patients’ PTSD treatment experiences and uncover their meanings.
• Post-Traumatic Stress Disorder Misapprehension A significant proportion of civilians are affected by post-traumatic stress but ignore the symptoms and fail to seek early interventions influenced by misconceptions about how PTSD develops and its symptoms.
• Post-Traumatic Stress Disorder and Opioid Use in Veterans This study examined the proportion of United States veterans who had PTSD and engaged in the use of illegal opioids to cope with it or had done so in the past.
• Post Traumatic Stress Disorder in A Journal for Jordan Considering the loss of her husband in the war, Dana had not recovered, and the expression of irate reaction is a symptom of PTSD.
• Post-Traumatic Stress Disorder Development Avoidance of objects that remind you of the traumatic incident is another symptom of PTSD. Identifying erroneous and unreasonable beliefs about the incident and replacing them with a more balanced image is also part of […]
• Sexual Aversion and Post-Traumatic Stress Disorder This aspect causes difficulties in prescribing therapy, since the latter requires a thorough study of the psychological nature of the problems. In the treatment of sexual aversion disorder, a doctor needs to investigate a complex […]
• Zaccari et al. (2020). “Yoga for Veterans With PTSD”: Content, Strength, and Weaknesses This discussion reviews the strengths and weaknesses of the method, sampling, and validity of Zaccari et al.research. The assertions reported in the article are supported by cited and referenced scientific studies, which enhances the validity […]
• Secondary Post Traumatic Stress Disorder in Children The relationship between parents’ experiences and interactions with the onset of PTSD in children will be explored. There is vast information on the management of treatment and prevention of PTSD in children.
• Aspects of Secondary PTSD in Children They constantly contact and interact with each other, and the latter inadvertently affects the mental health of the former, which leads to the development of secondary PTSD.
• Post-Traumatic Stress Disorder and Parenting Style On a scale of 1 to 10, with 1 being lowest and 10 being highest, how much do you believe that kids need to learn early who the boss is in the family?
• Psychiatry: PTSD Following Refugee Trauma The psychiatrists finally recognized PTSD in the first version of the Diagnostic and Statistical Manual of Mental Disorders after the mass occurrence of similar symptoms in Vietnam veterans.
• 35-Year-Old Man With PTSD: Case Study In such a case, it is recommended this is precisely a recommendation, not a requirement to do an MRI, which would allow a better study of the patient’s body.
• PTSD Dual Representation Theory Use in Military Personnel However, it is the position of this paper that this is mere gender stereotyping and the real cause of trauma among women veterans has to do with sexual harassment.
• Substance Abuse Disorders and PTSD The concept indicates that people who have PTSD are at higher risk of substance abuse and consequently substance disorders due to the tendency to consume alcohol and use drugs to deal with stress.
• “Mindfulness Interventions in the Treatment of PTSD” by Williston The primary purpose of that article is to conduct a survey of meta-analyses related to the efficiency of cognitive behavioral therapy.
• “Experiences of Military Spouses of Veterans With Combat-Related PTSD” by Yambo Spouses living with PTSD veterans are unprepared and struggling to deal with issues that their husbands experience.
• Post-Traumatic Stress Disorder Pathophysiology Sakellariou and Stefanatou, further link threat responsiveness and fear regulation with the signalling of 5-HT within the amygdala; this is an area within the brain deemed essential in comprehending the reaction to fear and aetiology […]
• The Fiction Character`s PTSD Diagnosis: Rambo According to the American Psychiatric Association, experiencing traumatic events, witnessing the events, learning that a traumatic event occurred to a close person, and is exposed to aversive details of events are the triggers of PTSD.
• IL-6: Predicting the Development of PTSD Therefore, it is important to understand and define the biological underpinnings of immune dysregulation in PTSD as it also plays a crucial role in helping us to understand the nature of the associations between PTSD […]
• Cognitive Processing Therapy and Evidence Based Interventions for Veterans Diagnosed With PTSD According to the evidence attained, comprehensive and extensive evidence is crucial in providing a clear correlation of the benefits accrued from CPT in comparison to other forms of treatment.
• Effective Use of Prazosin for Posttraumatic Stress Disorder All the traditional agents have shown to have several side effects and cannot be fully relied on in treatment of PTSD.
• Post-Traumatic Stress Disorder Diagnostics and Screening Do you observe a headache from the early morning? Do you have a headache when you sleep well?
• PTSD Mental Disorder: Triggers, Clinical Manifestations, and Treatment PTSD is normally characterized as a mental disorder that is a direct result of anxiety-related syndromes that came about as a direct result of a traumatic event.
• Posttraumatic Stress Disorder The study seeks to find out the prevalence of TBI/PTSD and the variations in the prevalence based on the severity of TBI, as well as other related variables.
• Post-Traumatic Stress Disorder (PTSD) Among Vets One of the integral components of this concept is the problem of traumatic stressors, as is customary in international classifications, the issue of post-traumatic stress disorder.
• Post-Traumatic Stress Disorder: Overview The overall process of evaluation and analysis of the film was done correctly and adhered to the standard principles of counseling.
• Post-Traumatic Stress Disorder Treatment in Intellectually Disabled Patients: The Promise of Eye Movement Desensitization and Reprocessing Therapy The use and application of findings that shed light on current research gaps related to the effectiveness of EMDR in PTSD patients with IDs may contribute to improvements in this population’s quality of life and […]
• Client Diagnosis: Posttraumatic Stress Disorder As for the PTSD itself, the client meets criterion A because she reported car accident involving death of the other passenger.
• Disaster Crisis: Post-Traumatic Stress Disorder Symptoms Since the account of the incidence, almost a month, she lost interest in work and concentration on activities relating to work at her place of work.
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• Posttraumatic Stress Disorder After Rape Attempt During the treatment of the patient, the Target Memory is the day the girl was attacked. In her treatment, it is necessary to eliminate the feeling of guilt for the accident.
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• Post Traumatic Stress Disorder: German Researches The other objective of the study was to identify the specific features a traumatic event could influence PTSP in the solders.
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• Post-Traumatic Stress Disorder and Treatment Effectiveness In the final section, the effectiveness of all the explored interventions will be discussed to summarize the results of the present literature review.
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• Posttraumatic Stress Disorder Treatment in Soldier Within the framework of the reviewed case, one of the key needs of the soldier is to be able to cope with anger and irritation.
• Cognitive Behavioral Therapy in Treating PTSD The chosen case is the case of Ivan S, who is a war veteran who suffers from a variety of psychological symptoms that affect his relationships with his family and loved ones. Secondly, Ivan shows […]
• Posttraumatic Stress Disorder: Modality Treatment Plan With the problem of nightmares and the related lack of sleep, the unmet need of psychological stability results in the interruption of sleep because of traumatic thoughts and nightmares.
• Post-Traumatic Stress Disorder and Its Theories The study by Bandelow et al.showed that the development of PTSD is associated with the dysregulation of the hypothalamic-pituitary-adrenal axis and the impaired sympathoadrenal medullary system as part of immunity.
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• Post-Traumatic Stress Disorder in Soldiers With the help of the course materials, I was able to understand that Huerta had a panic attack just from its description. It is critical to be honest with oneself and to accept the problem.
• Post-Traumatic Stress Disorder: Gender Variations In this regard, the aim of the current research is to provide evidence that women have the same probability of getting PTSD as men.
• Post Traumatic Stress Disorder: Joseph Wolpe Treatment Theory This is similar to the concept of phobias wherein a person is presented with an animal that he is irrationally afraid of and the result is fear or in the case of an inanimate object […]
• SNOMED-CT and PTSD Terminologies Based on the research questions described in the foregoing discussions, the researchers mapped a total of 153 PTSD-specific concepts and terms to the SNOMED-CT controlled medical terminologies and concept codes.
• Post-Traumatic Stress Disorder – Psychology Post-traumatic stress disorder is thought to be as a result of either corporeal disturbance or emotional disturbance, or more often a mishmash of both.
• Post Traumatic Stress Disorder Principles and Types The affected areas of the body include the nervous system, the brain and hormonal system. A number of issues are to be taken into consideration as for the treatment of the PDST.
• Post-Traumatic Stress Disorder in Veterans Patient education is important in order to eradicate any form of misconception that the patients may have about PTSD, and enhance the levels of understanding of the patients, along with an improvement on their ability […]
• Post-Traumatic Stress Disorder: Causes, Symptoms and Treatments One who is trying to numb and avoid remembrance of the event is likely to avoid thoughts, activities, places and even feelings that may associate with the trauma, have a feeling of detachment from others […]
• Critical Review of a Mental Disorder: The Post Traumatic Stress Disorder in DSM-IV-TR However, the risk to contracting the condition is always determined by the resilience of the personnel to these exposures, past unsettled concerns in their life history, and the quantity as well as intensity of depiction […]
• Post Traumatic Stress Disorder and Its Treatment In this case a person constantly relieves the event through any of the following exposure to a situation that is similar to the event, vivid memories of the event, perceptions, and sometimes through dreams.
• Comparison of the Etiology, Diagnosis, and Treatment of DID and PTSD Individuals who were exposed to acts of violence in the past are likely to try and expose others to similar conditions. The inability to diagnose is attributed to the fact that the effects of these […]
• Post-Traumatic Stress Disorder and Abused Women In most cases, these incidences of women abuse occur within the confine of a family set up or relationship where one partner tends to mistreat, mishandle, abuse and assaults the other partner and in most […]
• Earthquakes as a Cause of the Post Traumatic Stress Disorder Although earthquake is a major cause of the post traumatic stress disorder, there are other factors that determine the development of the same.
• Post Traumatic Stress Disorder Developed in Repeated War Zones Deployment Most of the combatants, usually, tailored a war awareness state to manage the consistent pressure of battle duty. Majority of the combat soldiers that were repeatedly deployed to war zones suffered post traumatic stress disorders.
• Effects of PTSD and Correlation between Diagnosis and Violence It is also worth noting that there is a correlation between PTSD and violence, though this has been cited to be of minimal significance.
• Abnormal Psychology: Posttraumatic Stress Disorder In addition, some of this research indicates that the differences in the degree of the disorder are due to the varying nature of the trauma experienced by that individual.
• Post Traumatic Stress Disorder: Assessment and Treatment Strategies If PTSD is ignored and fails to be treated, it can lead to disturbing consequences which widely affects not only the PTSD victim but also the relationships of the victim with his family and the […]
• The Effects of PTSD on Families of Veterans Drug abuse may result from the inadequacies in the coping abilities of family members as they try to come into terms with the suffering of their fellow family member.
• Post Traumatic Stress Disorder in Veterans and How Family Relationships Are Affected Both qualitative and quantitative data shall be used with numbers being used to provide evidence of the occurrence and magnitude of the effects of the condition on the population.
• Characteristics and Treatments of Post Traumatic Stress Disorder For in-depth understanding of the background of PTSD is, this paper will adopt a specific definition of abnormality that relates to the disorder itself. The category of the syndrome will also determine the type of […]
• Analysis of Posttraumatic Stress Disorder in Military Personnel The experiences that military personnel undergo determine the nature and extent of the posttraumatic stress disorder they develop during and after their deployment. However, Ramirez had resilience factors that helped him to cope and manage […]
• How PTSD Affects Veteran Soldiers’ Families The effects are even worse to the partner who is left behind; whether wife or husband because they are required to care for the children and the thought of being the sole bread winner makes […]
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Why people with PTSD should have hope for recovery

June 6, 2024 – Effective treatments are available to help people recover from post-traumatic stress disorder (PTSD) , according to Karestan Koenen , professor of psychiatric epidemiology at Harvard T.H. Chan School of Public Health.

In a May 23 interview on WBUR, Koenen shared her personal experience with PTSD and how it motivated her to become a trauma researcher. After being sexually assaulted and becoming severely depressed, she found that therapy helped her to get better.

“Something everyone should know is that we do have treatments for PTSD that work. They’re called trauma-informed therapies. And you can get better,” she said. In addition to therapy, she recommended reaching out to national hotlines to talk with people who are trained to listen and can help find further resources.

Koenen currently conducts research on why people who experience the same type of traumatic experience can have different mental health symptoms. She has found that some people may suffer more because of a genetic link to previous generations of family members who also experienced trauma.

“In the long run, what we can learn from this genetic research is that it will help us identify biological pathways that can be used to develop new treatments, interventions, perhaps that can even prevent PTSD after trauma,” she said.

Listen to or read the WBUR story: ‘You can get better’: A trauma specialist’s advice for starting the recovery process

PTSD’s genetic component validated in new study (Harvard Chan School news)

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PTSD is rising among college students, recent studies find — here’s how to manage it

The covid-19 pandemic, among other factors, could be contributing to the rise of mental health disorders among young adults.

By Caroline McDonald

Recent studies have shown that post-traumatic stress disorder and anxiety are on the rise in college students.

The research, published on JAMA Network , indicated that PTSD among college students increased from 3.4% to 7.5% between 2017 and 2022. Over 390,000 participants were involved in the study.

The study also analyzed the rise in ASD, acute stress disorder. The data revealed a “notable increase” in both PTSD and ASD, which “highlight the escalating mental health challenges among college students.”

Experts are now seeking to understand why these disorders are increasing among young adults.

Why are college students struggling with PTSD?

According to The New York Times , the disorder diagnoses peaked during the COVID-19 pandemic, when campuses across the nation shut down and “upended young adults’ lives.”

The research pointed to contributing factors such as “pandemic-related stressors (e.g., loss of loved ones) and the effect of traumatic events (e.g., campus shootings, racial trauma).”

About six out of every 100 people will experience PTSD in their lifetime, according to the National Center for PTSD . The disorder occurs after an individual has “been through a traumatic event.” The likeliness of developing the disorder is higher in women than it is in men.

The symptoms of PTSD can include flashbacks, intrusive thoughts and sensitivity to reminders of a traumatic event, according to The New York Times , with the symptoms continuing more than a month after the event occurs.

Academic researcher Shannon E. Cusack told The New York Times that some are skeptical about whether the “profound disruptions” caused by the pandemic connote the kinds of “triggering events” linked to PTSD.

“They’re causing symptoms that are consistent with the PTSD diagnosis,” Cusack said. “Am I not going to treat them because their stressor doesn’t count as a trauma?”

According to the study , “these findings suggest the need for targeted, trauma-informed prevention and intervention strategies by mental health professionals and policy makers to support the affected student population.”

How can I cope with PTSD in college?

“It is important for anyone with PTSD symptoms to work with a mental health professional who has experience treating PTSD,” according to the National Institute of Mental Health . Professionals are equipped with the knowledge and expertise necessary to help people with treatment plans.

The National Institute of Mental Health provided further methods to help those struggling with symptoms of PTSD:

• Create realistic, manageable goals.
• Practice activities, like exercise, that reduce stress.
• Avoid drugs and alcohol.
• Have routines for meals, sleep and exercise.
• Understand that your symptoms will “improve gradually, not immediately.”
• Talk with a trusted friend or member of your family.

Harvard Health provided some ways college students can manage symptoms of anxiety:

• Work on self-care. Self-care is a critical way to ease stress. A self-care routine can consist of healthy eating habits, exercise and proper sleep.
• Utilize campus resources. Campuses have resources to help students cope with stress and adapt to new situations. Search for mental health counseling, academic advising and student groups.
• Don’t avoid others. Some students try to combat intense stress by skipping class or avoiding stressors. But this will make anxiety worse. Try introducing yourself to someone new or emailing a professor or TA. Practice the small steps.

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PTSD Has Surged Among College Students

The prevalence of post-traumatic stress disorder among college students rose to 7.5 percent in 2022, more than double the rate five years earlier, researchers found.

By Ellen Barry

Post-traumatic stress disorder diagnoses among college students more than doubled between 2017 and 2022, climbing most sharply as the coronavirus pandemic shut down campuses and upended young adults’ lives, according to new research published on Thursday.

The prevalence of PTSD rose to 7.5 percent from 3.4 percent during that period, according to the findings . Researchers analyzed responses from more than 390,000 participants in the Healthy Minds Study, an annual web-based survey.

“The magnitude of this rise is indeed shocking,” said Yusen Zhai, the paper’s lead author, who heads the community counseling clinic at the University of Alabama at Birmingham. His clinic had seen more young people struggling in the aftermath of traumatic events. So he expected an increase, but not such a large one.

Dr. Zhai, an assistant professor in the Department of Human Studies, attributed the rise to “broader societal stressors” on college students, such as campus shootings, social unrest and the sudden loss of loved ones from the coronavirus.

PTSD is a mental health disorder characterized by intrusive thoughts, flashbacks and heightened sensitivity to reminders of an event, continuing more than a month after it occurs.

It is a relatively common disorder , with an estimated 5 percent of adults in the United States experiencing it in any given year, according to the most recent epidemiological survey conducted by the Department of Health and Human Services. Lifetime prevalence is 8 percent in women and 4 percent in men, the survey found.

The new research also found a sharp rise in the prevalence of a similar condition, acute stress disorder, which is diagnosed less than a month after a trauma. Diagnoses rose to 0.7 percent among college students in 2022, up from 0.2 percent five years earlier.

Use of mental health care increased nationally during the pandemic, as teletherapy made it far easier to see clinicians. Treatment for anxiety disorders increased most steeply, followed by PTSD, bipolar disorder and depression, according to economists who analyzed more than 1.5 million insurance claims for clinician visits between 2020 and 2022.

PTSD was introduced as an official diagnosis in 1980, as it became clear that combat experiences had imprinted on many Vietnam veterans, making it difficult for them to work or participate in family life. Over the decades that followed, the definition was revised to encompass a larger range of injury, violence and abuse, as well as indirect exposure to traumatic events.

However, the diagnosis still requires exposure to a Criterion A trauma, defined in the Diagnostic and Statistical Manual of Mental Disorders as “death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence.”

It is not uncommon for young adults to experience traumatic events. A 1996 study of Detroit residents found that exposure to traumatic events — such as violent assaults, injuries or unexpected death — peaked sharply between the ages of 16 and 20. It then declined precipitously after age 20.

Research suggests that less than one-third of people exposed to traumatic events go on to develop PTSD.

Shannon E. Cusack, an academic researcher who has studied PTSD in college students, said there was division within the field about whether the profound disruptions that young adults experienced during the pandemic — abrupt loss of housing and income, social isolation and fear about infections — amount to triggering events.

“They’re causing symptoms that are consistent with the PTSD diagnosis,” said Dr. Cusack, a clinical psychologist and an assistant professor of psychiatry at Virginia Commonwealth University. “Am I not going to treat them because their stressor doesn’t count as a trauma?”

The prevalence data, she said, points to a pressing need for PTSD treatment on college campuses. Short-term treatments developed for veterans, such as prolonged exposure therapy and cognitive processing therapy, have proved effective in managing PTSD symptoms.

Stephen P. Hinshaw, a professor of psychology at the University of California, Berkeley, said that the disruptions of the pandemic might have left college students emotionally depleted and less resilient when faced with traumatic events.

“Midway through this study, there may have been legitimately more trauma and death,” he said, adding that the lockdowns may have caused more general despair among young people. “With the general mental health deterioration, is it harder to cope with traumatic stressors if you do get exposed to them?”

Some changes to the diagnostic manual may have blurred the line between PTSD and disorders like depression or anxiety, Dr. Hinshaw said. In 2013, the committee overseeing revisions to the manual expanded the list of potential PTSD symptoms to include dysphoria, or a deep sense of unease, and a negative worldview, which could also be caused by depression, he said. But the changes, he added, do not account for the sharp increase in diagnoses.

Ellen Barry is a reporter covering mental health for The Times. More about Ellen Barry

Understand Post-Traumatic Stress Disorder

Psychedelic Drugs: As the F.D.A. weighs whether to approve the use of MDMA for treatment  of post-traumatic stress disorder, an advisory panel overwhelmingly decided against endorsing it .

College Students: PTSD diagnoses among college students more than doubled between 2017 and 2022 , climbing most sharply as the coronavirus pandemic shut down campuses, according to new research.

Falling Short: The treatments for PTSD — including several forms of psychotherapy and medication — are effective for many patients, but they don’t work for everyone .

E.M.D.R.: The once-experimental trauma treatment might look bizarre, but some clinicians say it’s highly effective against PTSD. Here’s how the therapy works .

Removing the Stigma: Misconceptions about how PTSD develops and its symptoms can prevent people from seeking treatment .

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Posttraumatic Stress Disorder: Overview of Evidence-Based Assessment and Treatment

Cynthia l. lancaster.

1 Ralph H. Johnson Veterans Affairs Medical Center, 109 Bee Street, Charleston, SC 29401, USA; ude.csum@ycsacnal (C.L.L.); ude.csum@sreteet (J.B.T.); ude.csum@dsorg (D.F.G.)

2 Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 5 Charleston Center Drive, Suite 151, Charleston, SC 29401, USA

Jenni B. Teeters

Daniel f. gros, sudie e. back.

Posttraumatic stress disorder (PTSD) is a chronic psychological disorder that can develop after exposure to a traumatic event. This review summarizes the literature on the epidemiology, assessment, and treatment of PTSD. We provide a review of the characteristics of PTSD along with associated risk factors, and describe brief, evidence-based measures that can be used to screen for PTSD and monitor symptom changes over time. In regard to treatment, we highlight commonly used, evidence-based psychotherapies and pharmacotherapies for PTSD. Among psychotherapeutic approaches, evidence-based approaches include cognitive-behavioral therapies (e.g., Prolonged Exposure and Cognitive Processing Therapy) and Eye Movement Desensitization and Reprocessing. A wide variety of pharmacotherapies have received some level of research support for PTSD symptom alleviation, although selective serotonin reuptake inhibitors have the largest evidence base to date. However, relapse may occur after the discontinuation of pharmacotherapy, whereas PTSD symptoms typically remain stable or continue to improve after completion of evidence-based psychotherapy. After reviewing treatment recommendations, we conclude by describing critical areas for future research.

1. Introduction

Posttraumatic stress disorder (PTSD) is among the most common mental health disorders in the United States [ 1 ]. PTSD is associated with a chronic course and debilitating symptoms. This manuscript reviews the epidemiology and clinical characteristics of PTSD, current options for screening and treatment, and describes more recent directions in treatment research.

1.1. Epidemiology

PTSD develops after exposure to a potentially traumatic event. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM; [ 2 ]), the traumatic event must involve exposure to actual or threatened death, serious injury, or sexual violence. Exposure is defined as directly experiencing or witnessing a traumatic event, or learning that a trauma occurred to a close family member or friend. PTSD can also develop from repeated or extreme exposure to aversive details of traumatic events, such as military photographers whose job it is to photograph the details of wartime atrocities, first responders who are charged with collecting human remains, and police officers who are repeatedly exposed to details of child abuse. The fifth edition of the diagnostic manual explicitly excludes exposure to traumas via television, movies, pictures, or electronic mediums, possibly due to concerns that the definition of trauma was enlarging to a construct too broad to be useful [ 2 ]. Even so, nearly 90% of the general population endorses experiencing one or more traumatic events (with the modal number of trauma exposures being three), such as sexual or physical assault, combat, motor vehicle accidents, and natural disasters [ 3 ].

Although most individuals experience a traumatic event during their lifetime, the majority of trauma-exposed individuals do not develop PTSD. The lifetime prevalence of PTSD is estimated at 8.3% [ 3 ]. During the weeks following a traumatic event, the vast majority of individuals exhibit normative acute reactions, such as intrusive thoughts or dreams about the event, hyper-alertness, irritability, and problems with sleep, memory, and/or concentration [ 4 , 5 , 6 , 7 , 8 ]. For approximately two-thirds of individuals exposed to a traumatic event, these symptoms resolve on their own with time [ 7 , 9 , 10 ]. PTSD thus is characterized by a failure to follow the normative trajectory of recovery after exposure to a traumatic event. A key to understanding this disorder is therefore investigating predictors of the trajectory of recovery or non-recovery.

Researchers have identified a dose-response relation between exposure to traumatic events and the subsequent development of PTSD, such that the prevalence of PTSD increases as the number of traumatic events increase [ 3 , 11 , 12 ]. PTSD is also more likely to occur after more severe types of trauma, such as rape, childhood sexual abuse, or military combat [ 13 ]. Furthermore, the population trajectory seems to differ by trauma type. In comparing intentional to non-intentional traumas (as distinguished by whether harm was inflicted deliberately), Santiago and colleagues [ 10 ] found that PTSD prevalence increases over time among survivors of intentional trauma, whereas the opposite is true among survivors of non-intentional traumas.

Higher risk for PTSD has also been associated with numerous pre-trauma variables, including female gender, disadvantaged social, intellectual, and educational status, history of trauma exposure prior to the index event, negative emotional attentional bias, anxiety sensitivity, genetic subtypes implicated in serotonin or cortisol regulation, as well as personal and family history of psychopathology [ 11 , 12 , 14 , 15 , 16 , 17 ]. PTSD risk factors related to peri-traumatic and post-traumatic variables include perceived life threat during the trauma, more intense negative emotions during or after the trauma (e.g., fear, helplessness, shame, guilt, and horror), dissociation during or after the trauma, lower levels of social support after the trauma, and generally more severe symptoms during the first week following the traumatic event [ 12 , 18 ].

1.2. Clinical Characteristics

In addition to a history of trauma exposure, PTSD is characterized by four clusters of symptoms: (1) re-experiencing symptoms (e.g., recurrent intrusive memories, traumatic nightmares, and flashbacks); (2) avoidance symptoms (e.g., avoiding trauma-related thoughts and feelings and/or objects, people, or places associated with the trauma); (3) negative changes in cognitions and mood (e.g., distorted beliefs about oneself or the world, persistent shame or guilt, emotional numbing, feelings of alienation, inability to recall key details of the trauma); and (4) alterations in arousal or reactivity symptoms (e.g., irritability, hypervigilance, reckless behavior, sleep disturbance, difficulty concentrating). In order to qualify for a diagnosis of PTSD, these symptoms must be present for more than one month, lead to significant distress or functional impairment, and must not be due to medications, substance use, or a medical condition.

2. Assessment of PTSD

The thorough assessment of symptoms is an essential component in the effective treatment of PTSD. The primary goals of assessment include the detection of trauma exposure, evaluation of DSM-5 PTSD criteria, and ongoing assessment of symptom severity during treatment [ 19 ]. Assessment procedures may involve several steps, ranging from the initial screening typically conducted in non-specialty clinics (e.g., primary care offices) to lengthy diagnostic interviews, and self-report symptom questionnaires. Together, the data gathered through these various methods provides invaluable information that can be used to inform treatment planning and monitor treatment progress. Numerous assessment tools have been developed and investigated for PTSD. The following sections focus on the most common and empirically supported measures relevant to diagnostics, treatment planning, and treatment monitoring for PTSD (see Table 1 for overview).

Commonly used screening and self-report measures for trauma exposure and PTSD symptom severity.

2.1. Initial Screening

Several brief tools have been developed to screen for exposure to a Criterion A traumatic event, which allows for rapid identification of persons at-risk for PTSD. These screening tools are especially relevant to busy settings that necessitate that a large amount of data be collected in a short period of time, such as primary care clinics [ 20 ]. Although there is no gold-standard trauma-exposure screener [ 19 ], several options with growing support in the literature exist [ 21 , 22 ]. Questionnaires such as the Trauma Assessment of Adults [ 21 ], the Brief Trauma Questionnaire [ 23 ], the Life Events Checklist [ 24 ], and the Trauma Life Events Questionnaire [ 22 ] all have psychometric support for evaluating exposure to potentiality traumatic events. In addition to trauma exposure screeners, abbreviated PTSD symptom screeners are frequently used to determine the need for more in depth clinical interviews. These include the Primary Care PTSD Screen (PC-PTSD; [ 25 ]), the Short Form of the PTSD Checklist-Civilian Version [ 26 ], the Trauma Screening Questionnaire (TSQ [ 11 ]), and the Short Post-Traumatic Stress Disorder Rating Interview (SPRINT [ 27 ]).

2.2. Diagnosis

After initial screening, more advanced assessment procedures should be conducted to establish clinical diagnosis of PTSD based on the DSM-5 diagnostic criteria. In general, these diagnostic assessments can take up to several hours to complete and require significant training to administer. Although excellent disorder-specific interviews exist for PTSD (Clinician Administered PTSD Scale [ 28 ], PTSD Symptom Scale—Interview Version [ 29 ]), interviews designed to assess the full spectrum of psychiatric disorders may be better suited for treatment planning due to high rates of psychiatric comorbidity among PTSD patients (e.g., major depressive disorder, substance use disorders, etc.). One of the best examples of this is the Structured Clinical Interview of DSM-5 Disorders (SCID [ 30 ]). The SCID has been shown to provide valid and reliable diagnostics for PTSD as well as most other psychiatric disorders. Additional structured clinical interviews include the Anxiety Disorder Interview Schedule for DSM-5 [ 31 ], which, unlike the SCID, provides an index to quantify symptom severity, and the Mini International Neuropsychiatric Interview [ 32 ], which also provides the DSM diagnoses but takes approximately half the time to administer relative to the SCID.

2.3. Symptom Severity and Treatment Tracking

Once a PTSD diagnosis has been established, symptom frequency and severity are the next essential components to treatment planning and monitoring. A number of measures have been developed for monitoring PTSD symptoms. These measures are generally brief, self-report assessments of the 20 symptoms associated with PTSD. Some of the most widely used measures include the PTSD Checklist for DSM-5 [ 28 ] and the Posttraumatic Diagnostic Scale for DSM-5 [ 29 ]. These provide quick feedback regarding symptom severity and include cutoff scores to inform diagnostic status [ 19 , 29 , 33 ]. Separate trauma-specific versions of symptom severity measures have also been developed (e.g., military vs. civilian [ 33 ]). In addition, more brief versions have been proposed to further reduce the time demands, but not the accuracy, of symptom severity questionnaires such as the Primary Care PTSD screen (PC-PTSD [ 25 , 34 ]).

3. Evidence-Based Treatments

Is PTSD primarily a biological or psychological phenomenon, and relatedly, are psychosocial or pharmacological treatments more appropriate? This question sets up a false dichotomy, as PTSD is rooted in both biological and psychological factors with regard to onset of symptoms, development of PTSD diagnosis, and maintenance of the disorder. Studies demonstrate that biological differences [ 36 ] and psychosocial differences [ 14 , 37 ] contribute to the risk for developing PTSD. Experimental research additionally provides evidence that both biological and psychological interventions delivered relatively soon after trauma exposure have the potential to mitigate or even prevent (in the case of psychotherapy for Acute Stress Disorder) the development of PTSD [ 38 , 39 ]. Furthermore, across several controlled clinical trials, both pharmacological [ 40 ] and psychological [ 41 ] interventions have been shown to significantly reduce PTSD symptoms. Altogether, the extant literature provides a strong case that PTSD is rooted in both biological and psychological underpinnings. The more pressing question, then, is which intervention pathway provides the most potent and persistent symptom reduction, and for which patients? The following section reviews evidence-based psychological and pharmacological treatments.

3.1. Psychosocial Interventions for PTSD

Exposure-Based Interventions. Exposure-based interventions are the most empirically supported treatment modalities for PTSD [ 41 , 42 ]. The early roots of exposure-based therapies rest in the development of behaviorism in the 1920s, when Pavlov [ 42 ] demonstrated that fear could be both conditioned and extinguished through learning experiences. For example, repeatedly pairing the presentation of a tone with an uncomfortable shock eventually led to an automatic fear response to the tone (even in the absence of a shock). Furthermore, repeatedly playing the same feared tone without the shock eventually reduced (or extinguished) the fear response to the tone. Exposure-based behavioral therapies for PTSD are rooted in these same straightforward principles. The therapist helps the patient to systematically approach, instead of avoid, safe but feared stimuli (e.g., the memory of the trauma or situations that remind the patient of the traumatic event) in the absence of the feared consequences (such as bodily harm or unending anxiety), until the feared consequences are disconfirmed and the automatic fear response to trauma-related stimuli subsides. Though this basic principle is common to all exposure-based therapies across anxiety disorders, the necessity of defining the therapy provided in the context of clinical trials led to the development of specific, session-by-session exposure therapy protocols for the treatment for PTSD.

One of the most commonly investigated and empirically-supported exposure-based protocols for PTSD is Prolonged Exposure therapy (PE; [ 41 , 43 ]). PE is an 8-to-15-session protocol, typically provided in weekly or bi-weekly, 60-to-90 minute sessions [ 43 , 44 ]. The majority of patients who complete PE evidence significant and reliable reductions in PTSD symptoms [ 45 ]. In the beginning of PE, patients are taught a brief relaxation breathing exercise, and they receive psycho-education about PTSD symptoms and factors that contribute to the maintenance of PTSD (e.g., avoidance of the memory and related reminders). Over the next several sessions, the patient revisits and describes the trauma memory aloud for a prolonged time (e.g., 30–45 min) in order to extinguish the fear response associated with the memory. This is called imaginal exposure. In addition, the patient is taught to approach safe, trauma-related situations that have been avoided because they remind the patient of the trauma. This is called in vivo exposure. As “homework” between sessions, patients listen to recordings of the therapy sessions and practice the in vivo exposures.

In randomized clinical trials, dropout rates from PE have ranged from 10%–38% [ 44 ]. Notably, researchers have found that dropout can be higher in community settings ([ 46 , 47 ] although dropout rates do not differ between exposure and non-exposure therapies for PTSD [ 47 ]. A meta-analysis pooled across 13 studies found large effect sizes of PE relative to control groups at post-treatment, and medium to large effects at follow up time points [ 41 ]. Evidence also suggests that PE can produce further symptom reduction among patients with only partial response to pharmacotherapy [ 48 ].

3.2. Cognitive-Based Therapies

Over time, the field of psychotherapy has expanded to include cognitive-based treatment techniques in addition to exposure-based techniques. Though PE is categorized as a cognitive-behavioral therapy, and its exposure-based protocol does produce changes in negative thinking patterns associated with PTSD [ 49 ], the intervention strategies themselves are primarily behavioral rather than cognitive. Cognitive Processing Therapy (CPT; [ 50 , 51 ]) on the other hand, relies more heavily on interventions that directly target maladaptive thinking patterns. CPT, alongside other cognitive-based therapies for PTSD, emphasizes the role that maladaptive or inaccurate interpretation of a situation plays in maintaining disorders such as PTSD, and intervenes directly with the thoughts rather than the resulting behaviors.

Similar to PE, the initial sessions of CPT include psycho-education about PTSD symptomatology and the role of avoidance in maintaining PTSD, but CPT provides much stronger emphasis on the role of maladaptive thinking patterns in maintaining PTSD symptoms. Early in therapy, the patient writes a statement of impact that the traumatic event had on their life, specifically including details about how the trauma affected the patient’s beliefs about self, others, and the world. This is read aloud and discussed with the therapist. The therapist begins to gently question any potential maladaptive thinking patterns, thereby helping the patient discover over-generalized or unhelpful automatic thoughts. Over time, the therapist works with the patient to develop strategies for generating more useful or accurate thinking patterns. In the standard CPT protocol, the patient additionally writes one to two detailed accounts of the trauma and reads this account aloud in session. The last several sessions focus on specific areas of one’s life that are likely affected by maladaptive trauma-related thought patterns, including the areas of safety, trust, power/control, esteem, and intimacy. At the end of treatment, the patient re-writes the impact statement, which is used to evaluate treatment gains.

The 12-session CPT protocol can be disseminated effectively in either a group or individual format [ 51 ]. Elements of CPT have also been disseminated effectively in a dyadic format in the context of Cognitive Behavioral Conjoint Therapy (CBCT) for PTSD [ 52 ]. Dropout rates are approximately 20% in CPT [ 53 ] and no different than other active psychotherapies for PTSD [ 54 , 55 ]. Numerous trials have found CPT to be superior to a wait-list control group [ 53 , 55 , 56 ] and one study has demonstrated its equivalence to PE [ 55 ]. One dismantling study suggests that CPT may be equally efficacious with and without the written account of the trauma [ 57 ]. Subsequent analyses of this data qualified these results, demonstrating that those with higher levels of dissociation (especially depersonalization) responded best to the full protocol, and those with lower dissociation responded more rapidly to CPT without the trauma account [ 58 ]. Of note, other cognitive therapy protocols [ 59 , 60 , 61 , 62 ] or combined exposure and cognitive therapy protocols [ 63 , 64 ] have shown promising results [ 41 ].

3.3. Eye Movement Desensitization and Reprocessing.

Eye movement desensitization and reprocessing (EMDR) therapy had also received empirical support for the treatment of PTSD [ 65 , 66 ]. The model used to explain PTSD in EMDR is similar to cognitive-behavioral therapies in that PTSD is viewed as a result of insufficient processing of the traumatic memory. EMDR hypothesizes that the trauma memory, if not fully processed, is stored in its initial state, preserving any misperceptions or distorted thinking patterns that occurred at the time of the trauma.

At the outset of EMDR, patients are trained in strategies for managing negative emotions. The length of this treatment phase varies in accordance with the patient’s skill level in this area. To prepare for “reprocessing,” patients generate a list of traumatic (or other emotionally significant) experiences, along with distorted beliefs related to the experience (e.g., “I am a failure”) and desired beliefs (e.g., “I can handle tough situations”). During the reprocessing phase, the therapist asks the patient to bring to mind a vivid visual representation of the traumatic memory, along with the distorted belief (i.e., cognitive exposure), and to focus on the physical sensations related to the traumatic memory (i.e., interoceptive/visceral exposure). The patient is then instructed to engage in bilateral/saccadic eye movements, following the clinician’s finger from left to right for several repetitions. The patient visualizes the memory while continuing to engage in the bilateral stimulation. The patient is asked what experiences emerge next (e.g., thoughts, images, emotions, or sensations), and the cycle is repeated. The patient later practices thinking the desired thought (e.g., “I can handle tough situations”) with the visual image of the trauma brought to mind.

The bilateral eye movements in EMDR are somewhat controversial. In support of the use of this strategy, van den Hout and colleagues [ 67 ] found that bilateral eye movements during autobiographical memory recall reduce vividness and emotions attached to the memory (though their research was conducted in healthy controls rather than in PTSD patients). Developers of EMDR hypothesize that bilateral eye movements therefore reduce distress attached to the trauma memory, thereby reducing avoidance, and allowing for increased attention to more adaptive thinking patterns that are then attached to the traumatic memory [ 65 ]. A recent meta-analysis further supports that bilateral stimulation (eye movements are not the only potential form of bilateral stimulation used in EMDR) impacts memory in ways that might facilitate PTSD treatment [ 68 ]. Other researchers have hypothesized, however, that the exposure-based components of EMDR are all that is required, and a review of dismantling studies has demonstrated that the EMDR protocol works just as well without the bilateral stimulation component [ 69 ]. Regardless of the validity of its theoretical underpinnings, EMDR has empirical support in that it consistently outperforms no-treatment controls and demonstrates similar outcomes to exposure- and cognitive-based psychotherapies for PTSD [ 41 , 70 ].

3.4. Relaxation-Based Psychotherapies

Although less frequently studied and supported in the more recent literature, relaxation-based psychotherapies are another type of psychotherapy for PTSD. One of the most commonly investigated relaxation-based therapies for PTSD is Stress Inoculation Training (SIT; [ 71 , 72 ]). The treatment model is based on Lazarus & Folkman’s [ 73 ] conceptualization of stress resulting from perceived situational demands outweighing perceived resources to meet demands [ 74 ]. In this model, PTSD and other anxiety/stress disorders are maintained by ongoing perceptions of situational demands outweighing the available coping resources. The primary goal in SIT is to increase the patient’s sense of mastery over their anxiety, and to “inoculate” patients against future episodes of pervasive anxiety and stress. Treatment therefore focuses primarily on skills training in a vast array of anxiety-management strategies such as breathing retraining, muscle relaxation, negative-thought stopping, and restructuring/challenging maladaptive cognitions. Relaxation skills are trained and practiced in sessions using techniques such as behavioral rehearsal and imagery, modeling, and role-play. As treatment progresses, anxiety management strategies are practiced in the context of increasingly challenging and anxiety-provoking situations, including during graduated in vivo/situational exposures. Mastering the use of anxiety management skills in stressful situations is viewed as producing “inoculation” against future problems.

In clinical trials for PTSD treatment, SIT outperforms wait-list and supportive counseling [ 75 , 76 ]. However, evidence suggests that PE is superior to both SIT and SIT combined with exposure [ 75 ]. The reduced efficacy of PE+SIT in comparison to PE could be due to the reduced dosage of therapeutic exposure to feared situations in the combined treatment, or perhaps could be due to a “kitchen sink” effect (i.e., rapid training in too many strategies rather than focused mastery of one strategy).

4. Evidence-Based Pharmacological Treatments

Although psychotherapeutic interventions are the first and most supported option for the treatment of PTSD, there are several evidence-based pharmacological treatments available. In contrast to psychological interventions, pharmacotherapies can be provided in most clinical settings and require much less time and effort on the part of the patient (e.g., fewer and shorter appointments, no homework between visits). The foundation of pharmacological treatments is supported by a growing literature for the association between PTSD and dysregulations in neurotransmitter and neuroendocrine systems [ 77 , 78 , 79 , 80 ]. For the purposes of this review, we have focused on the current medication options with the most evidence, and therefore omitted older (e.g., monoamine oxidase inhibitors) and less studied options (e.g., mood stabilizers).

4.1. Selective Serotonin Reuptake Inhibitors

Most of the current research on pharmacotherapy for PTSD is focused on the selective serotonin reuptake inhibitors (SSRIs) to treat PTSD [ 40 ]. SSRIs have a broad effect on PTSD symptoms, including improvements in re-experiencing, avoidance, numbing, and hyper-arousal symptoms, and related quality of life improvements associated with the symptom reductions [ 81 ]. In terms of specific SSRIs, both sertraline and paroxetine have received FDA support for PTSD treatment and were superior to placebo in multisite clinical trials [ 81 , 82 , 83 , 84 , 85 ]. Other agents, such as fluvoxamine and citalopram, also have received support for the treatment of PTSD [ 86 , 87 ]. Interestingly, paroxetine also has been shown to potentially address cognitive deficits associated with PTSD, in addition to the clinical symptoms [ 88 ]. Longer trials of SSRIs (36 weeks) have been associated with a higher percentage of treatment response compared to the standard 12-week trials [ 89 ]. Unfortunately, independent of the duration of the trial, the discontinuation of SSRIs is associated with the relapse of PTSD symptoms [ 81 , 83 , 90 ]. In contrast, symptoms typically remain stable or continue to improve after completion of evidence-based psychotherapy for PTSD [ 91 ].

4.2. Other Promising Agents

There are several other agents that have received support in the pharmacological treatment of PTSD. These agents tend to effect specific sets of symptoms within PTSD, and are often studied in conjunction with an SSRI [ 81 ]. Two common examples are trazadone, an antidepressant serotonergic agent with a sedating side effect, and prazosin, an antiadrenergic agent that has been studied in the treatment of sleep and nightmares in PTSD. Prazosin has received increased attention as of late after randomized clinical trials demonstrating its effectiveness for PTSD-related sleep disruptions and nightmares, as well as global functioning and PTSD symptoms [ 92 ]. While these medications have shown some promise in reducing PTSD symptoms, they are not FDA approved for the treatment of PTSD and further research on their efficacy for PTSD is needed.

5. Summary and Future Directions

In summary, PTSD is a relatively common and highly debilitating psychiatric disorder affecting approximately 8% of the U.S. population [ 2 ]. Potent evidence-based psychosocial interventions are available, and several medications have FDA approval for the treatment of PTSD. While pharmacological treatments have shown some promise, more investigation and advancement in this area is needed. One of the most important concerns with the sole use of pharmacotherapy for PTSD treatment is the evidence that discontinuing treatment can be associated with relapse [ 81 , 83 , 90 ]. Although relapse is relatively infrequent after one responds to an evidence-based psychotherapy for PTSD [ 91 ], a proportion of patients either drop out of therapy prematurely or do not respond to therapy [ 46 , 47 , 54 ]. It is therefore critical to continue to investigate new strategies to improve upon the available treatments for PTSD.

One novel line of research has investigated the potential to enhance mechanisms of learning during cognitive behavioral therapies (such as those used for PTSD) by administering medications that could facilitate fear extinction, for example, d -cycloserine, yohimbine, methylene blue, MDMA, and oxytocin [ 93 , 94 ]. However, pharmacological augmentation of learning mechanisms is still in its infancy and will require much further exploration before these strategies can be recommended as standard treatment techniques for PTSD. Another line of cutting edge research involves priming the trauma memory through a reminder, and then preventing reconsolidation of the primed memory through pharmacological blockade [ 95 ]. Although some evidence suggests that this technique reduces emotional reactivity to the trauma memory [ 95 ], findings in this newer area of research are very preliminary and somewhat conflicted [ 39 ]. Innovative treatments outside the realms of psychotherapy and pharmacotherapy, such as neuronal feedback and brain stimulation techniques [ 96 ], are also being explored and may help reduce PTSD symptoms, particularly in treatment-resistant patients.

Acknowledgments

This research was supported by NIDA grant R01 DA030143 (PI: Back), NIDA grant K02 DA039229 (PI: Back), and Department of Veteran Affairs CSR&D Career Development Award CX000845 (PI: Gros). The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of NIDA, Department of Veterans Affairs, or the United States government.

Conflicts of Interest

There are no conflicts of interest to disclose.

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How To Treat Post-Traumatic Stress Disorder (PTSD)

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Post-traumatic stress disorder is a type of anxiety disorder that can develop after you experience a traumatic event. People without PTSD usually experience stress after a disturbing event, but they recover. People with PTSD, however, continue to feel prolonged stress after the traumatic event has ended. Their bodies continue to release stress hormones (such as cortisol), which can cause lasting effects.

Living with PTSD can be a challenging or debilitating experience. Fortunately, treatment is available to help you process your trauma, manage stress, and improve your overall well-being. The goal of treatment is not only to make you feel better but to instill a sense of safety in your daily life. Mental healthcare providers (such as psychologists or psychiatrists ) may recommend therapy, medications, or a combination of both to help offset symptoms.

It's worth noting that treatment for PTSD doesn't always work overnight. It may take some trial and error, which can be frustrating. However, it's important to be patient with yourself and your journey and continue trying methods that work for you. With proper treatment, you can become better equipped to deal with future stressors, set attainable life goals, and reconnect with the people in your life to build a robust support system.

The first line of treatment for PTSD is therapy . These therapy sessions will usually last anywhere from five to 16 weeks, depending on your symptoms and needs. Your healthcare team—which may include your primary care provider, psychologist, psychiatrist, or social worker—can offer several trauma-focused therapy options, such as:

• Cognitive processing therapy (CPT): A type of cognitive behavioral therapy (CBT) that teaches you how to re-evaluate your thoughts surrounding your traumatic event. Your mental health provider will work with you to help you consider new ways of thinking. This, in turn, may help you cope with your emotions surrounding the event.
• Prolonged exposure therapy: Another form of CBT that helps you engage with situations or feelings you typically avoid due to previous trauma. Your therapist will discuss real-life and imaginary scenarios to address the fear around the trauma you experienced to re-expose to the situation. Through slow and gradual exposure, you may be able to experience the activities you may have been unable to enjoy since your traumatic experience.
• Writing exposure therapy (WET): This type of trauma therapy lasts for about five sessions, making it shorter than some of the other therapy options. During these sessions, you will write about your feelings surrounding the traumatic event. Then, you will discuss your writing with a mental health provider to help process the information. This may help you become more comfortable with the traumatic memory.
• Present-centered therapy: A type of talk therapy that isn’t based on recounting your traumatic event. Instead, you focus on solving some of the real-life issues that your PTSD may have caused. Your sessions will focus on using your strengths to face daily problems or stressors. This may be more appealing to those who don’t want to recall their traumatic experiences.
• Eye movement desensitization and reprocessing (EMDR) therapy : This talk therapy uses motion or sound to help you process your emotions. While you think about the traumatic event, you will focus on a repetitive sound or movement. Your mental health provider may use a blinking light, beeping tone, or move their finger back and forth for you to focus on. People usually see an improvement in their symptoms after a few sessions.

Medications

In some cases, healthcare providers may also recommend medications to help treat PTSD. You may take medications alone, but research suggests that a combination of therapy and medication is most effective.

SSRIs and SNRIs

There are two major classes of medications that can treat PTSD long-term: SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin-norepinephrine reuptake inhibitors). Keep in mind: these medications also require a prescription from a healthcare provider.

Generally, you'll need to take these medications daily, which can take up to six weeks to reach their full effect. It's also essential that you take your medication as prescribed at the same time every day.

While effective, SSRIs and SNRIs may come with some mild to moderate side effects, including:

• Upset stomach
• Decreased libido (sex drive)
• Trouble sleeping
• Nausea and vomiting
• Higher risk of serotonin syndrome (excess serotonin in your body)

Benzodiazepines

Your healthcare provider may opt to prescribe you benzodiazepines—a class of medications that can help calm your mind before going to sleep. Some examples of these medications include:

• Xanax (alprazolam)
• Klonopin (clonazepam)
• Ativan (lorazepam)

Your provider will likely only recommend these medications for a short period because the medication can cause some adverse effects if you use them for too long. These side effects include physical dependence on the drug, irritability, and worsening depression . In some cases, these medications can also affect your breathing, so it's best to ask your provider if the drug is safe for you, especially if you live with conditions like sleep apnea or chronic obstructive pulmonary disease (COPD).

Complementary and Alternative Medicine

Your mental healthcare provider may also recommend alternative options to aid your treatment journey. One of the most common complementary treatments for PTSD is mindfulness . This approach focuses on accepting your emotions and thoughts as they are and being present in the moment.

Mindfulness-based stress reduction (MBSR) is the most common mindfulness approach. This treatment involves about eight weeks of group mindfulness sessions and a full-day silent retreat. During the course of this treatment, you may also learn yoga, meditation, and coping mechanisms for dealing with stress.

A Quick Review

PTSD can be a difficult condition to live with, but fortunately, treatment is available to help you improve your quality of life. The first line of treatment for PTSD is therapy that focuses on addressing the traumatic experience. But, your provider may also recommend medications, such as SSRIs, SNRIs, or benzodiazepines. Mindfulness is also an approach you can try to complement your treatment journey.

MedlinePlus. Post-traumatic stress disorder .

U.S. Department of Veterans Affairs. PTSD Treatment Basics .

U.S. Department of Veterans Affairs. Why get treatment.

Miao XR, Chen QB, Wei K, Tao KM, Lu ZJ. Posttraumatic stress disorder: from diagnosis to prevention . Mil Med Res . 2018;5(1):32. doi:10.1186/s40779-018-0179-0

U.S. Department of Veterans Affairs. Cognitive Processing Therapy.

U.S. Department of Veterans Affairs. Prolonged Exposure for PTSD.

U.S. Department of Veterans Affairs. Written Exposure Therapy (WET) for PTSD.

U.S. Department of Veterans Affairs. Present-Centered Therapy (PCT) for PTSD.

U.S. Department of Veterans Affairs. Eye Movement Desensitization and Reprocessing (EMDR) for PTSD .

Edinoff AN, Akuly HA, Hanna TA, et al. Selective Serotonin Reuptake Inhibitors and Adverse Effects: A Narrative Review .  Neurol Int . 2021;13(3):387-401. doi:10.3390/neurolint13030038

National Institute of Mental Health. Post-traumatic stress disorder.

American Psychological Association. Medications for PTSD .

U.S. Department of Veterans Affairs. Medications for PTSD .

U.S. Department of Veterans Affairs. Benzodiazepines and PTSD .

Boyd JE, Lanius RA, McKinnon MC. Mindfulness-based treatments for posttraumatic stress disorder: a review of the treatment literature and neurobiological evidence . J Psychiatry Neurosci . 2018;43(1):7-25. doi:10.1503/jpn.170021

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