PTSD (Post-Traumatic Stress Disorder)

Post-traumatic stress disorder is a mental health condition that sometimes occurs following a traumatic event. Not everyone who experiences one of these events will develop PTSD, but it can be debilitating for those who do. Finding the right support and treatment can help people with PTSD overcome their symptoms.

Key takeaways

• PTSD is a serious mental health condition that some people will experience following a traumatic event

• Symptoms of PTSD can be debilitating and can include flashbacks, nightmares, and hypervigilance

• PTSD can be treated, usually through a combination of talk therapies and medication. Specialized treatments such as EMDR can be particularly effective for many people

Understanding PTSD

It is normal to experience distress and upset after experiencing or witnessing a deeply stressful or traumatic event. Nightmares, anxiety, and repeatedly thinking about the event are all common in the first few days or weeks afterwards. These symptoms will usually diminish on their own and don’t signal a mental health condition.^[1]

For people with PTSD, these feelings don’t go away. They might remain constant or even become worse over time. They continue for more than a month, and they make it difficult to continue with normal activities.^[2]

Complex PTSD

More recently, complex PTSD (cPTSD) has been put forward as a subtype of PTSD or an adjacent disorder. People with cPTSD might not have experienced a single event that is as extreme as those with PTSD, but they have experienced many traumatic events over a sustained period.

Common experiences leading to cPTSD include child abuse, domestic violence, frequent community violence, repeated sexual abuse, or being in a war zone. They are characterized by a sustained period of trauma and helplessness.^[3]Symptoms of cPTSD are typically more severe than those for PTSD.

Complex PTSD is not included in DSM-5, but it is included in the World Health Organization (WHO) listings of disorders, known as ICD-11.^[4]

Causes of PTSD

The main trigger for PTSD is a serious or life-threatening traumatic event, but not everyone who experiences these events goes on to develop PTSD. Scientists are still trying to understand what makes some people more vulnerable to PTSD than others. A combination of factors likely influences whether someone develops PTSD after experiencing trauma.

There is a high degree of overlap between PTSD and ADHD, which has prompted some researchers to explore whether there is a causal connection. Differences in how attention is directed in someone with ADHD may make it difficult for them to fully consolidate and process traumatic memories.^[5]There is also some evidence that people with ADHD may experience more traumatic events in their lifetimes than those without, which could also explain some of the co-occurrence.^[6]

Other researchers have looked at how facing certain kinds of difficulties as a child (known as early life adversity or ELA) can cause changes to the hypothalamic-pituitary-adrenal (HPA) axis in the brain. This is an area of the brain associated with integrating thoughts, emotions, and behaviors, and the changes produced by ELA may increase someone’s vulnerability to PTSD.^[7]

This suggestion is supported by the observation that people with PTSD have altered levels of certain hormones in their bloodstream, including reduced cortisol, which is usually associated with stress.^[8]It’s not yet clear how these hormonal changes could produce the symptoms of PTSD.^[7]

PTSD and veterans

PTSD is especially common in military veterans, with some estimates suggesting that 3-17% experience PTSD following deployment.^[9][10]Overall, more than 500,000 US veterans have received treatment for PTSD at a cost of over three billion dollars.^[11]

Evidence suggests that veterans may benefit less from psychotherapy for PTSD than other patients.^[12]This may be because traumatic combat scenarios are typically longer-lasting than many other non-combat traumatic events, such as a traffic accident. If so, PTSD in veterans may incorporate aspects of cPTSD, which can be challenging to treat.

Alcohol and substance use disorders are common amongst veterans, especially those with PTSD.^[13][14]The combination of these disorders can also make treatment more difficult.

While the experiences and challenges veterans face can make the treatment of PTSD or cPTSD more complex, recovery is possible.

PTSD symptoms

PTSD symptoms vary widely between individuals. There are several main categories of symptoms, however.^[15]

Re-experiencing symptoms

One of the symptoms most people recognize as being characteristic of PTSD is flashbacks. Flashbacks are an example of a re-experiencing symptom. People with PTSD re-experience their traumatic event(s). This isn’t the same as having a memory. Instead, these re-experiencing symptoms are intrusive, uncontrolled, and cause extreme distress.

Re-experiencing or intrusive symptoms of PTSD include

• Flashbacks

• Intrusive thoughts or memories

• Nightmares

• Intense distress towards things that relate to the trauma

Avoidance symptoms

Another key category of PTSD symptoms is avoidance. People with PTSD avoid external stimuli that remind them of their traumatic event or are somehow closely linked to it. They may also avoid stimuli that are symbolically linked to the event. These symbolic connections may not be apparent to others.

Avoidance symptoms of PTSD can refer to external stimuli, such as avoiding places, and internal ones, such as avoiding thoughts or memories.

If someone with PTSD cannot avoid stimuli that remind them of their trauma, they may become intensely distressed or angry, increase their efforts to escape, or feel paralyzed. These responses are known as fight, flight, or freeze responses.

Common avoidance symptoms include

• Behavioral avoidance

• Cognitive avoidance

• Emotional numbing

• Substance use

• Distraction techniques

Hyperarousal symptoms

PTSD leads to a perception that the world is profoundly unsafe, which probably contributes to people living with the condition experiencing a higher state of alertness and fear. This is known as hyperarousal.

Hyperarousal symptoms can include

• Hypervigilance (constantly being on alert)

• Exaggerated startle response

• Difficulty concentrating

• Issues with sleep, such as insomnia, restless sleep, or disturbed sleep

• Irritable behavior with angry outbursts

Dissociative symptoms

Dissociation involves feeling a loss of connection between parts of the self, or between the self and reality. People who are experiencing dissociation can feel as though they are not fully centered in their body, as though they or the people around them are not entirely real, or as though the things that are happening are happening to someone else.

Dissociative symptoms of PTSD include

• Dissociation

• Depersonalization (feeling outside of your own body)

• Derealization (feeling as though the world isn’t real)

• Amnesia

Mood and cognitive symptoms

PTSD is also associated with changes in mood, thoughts, and beliefs. Someone with PTSD may have strong or unpredictable emotional outbursts. They may also believe that the world is an inherently threatening and unsafe place or that they deserve the bad things that have happened to them.

The main types of mood and cognitive symptoms of PTSD are

• Difficulty controlling emotions (emotional dysregulation)

• Distorted self-perception

• Trouble remembering aspects of the traumatic event

• Difficulty experiencing positive emotions

• Lack of interest in activities

• Feelings of shame, fear, or guilt

Diagnosing PTSD

The first question a doctor, licensed therapist, psychologist, or psychiatrist will ask when diagnosing PTSD is whether you have experienced trauma. To qualify for PTSD, you must have either directly experienced or been closely associated with an event involving the risk of death, violence, serious injury, or sexual violence.^[2]

Being closely involved includes witnessing the event, hearing that it happened to someone close to you, or being exposed to the aftermath repeatedly, for example, as a first responder or war correspondent. While distressing, watching reports of serious events on news channels or social media does not count as a traumatic event for a PTSD diagnosis.

The criteria for diagnosing PTSD include experiencing all of hyperarousal, re-experiencing, avoidance, and mood or cognitive symptoms. Although dissociative symptoms are common, they are not required for a diagnosis. These symptoms must have lasted for at least a month and caused difficulties in work, social interactions, or other important aspects of your life.

If you have dissociative symptoms without re-experiencing or hyperarousal, you may be offered an alternative diagnosis of a dissociative disorder.

When to see a doctor

It can be difficult to know whether your symptoms are a natural response to a traumatic event or early signs of PTSD. For example, it is extremely common to feel unsafe or have difficulty sleeping following any traumatic event.

In most people, these symptoms will fade over time. If you are still experiencing symptoms a few weeks after a traumatic event or if your symptoms feel especially severe or unmanageable, speak to your doctor. It’s never too early to start the conversation with your provider.

If you experience any thoughts of self-harm or suicide, reach out for support immediately. This could include contacting your doctor, specific helplines such as 988, the Crisis Text Line, Samaritans USA, or emergency services.

Treatment for PTSD

When talking about treatment for PTSD, it’s essential to be clear about what can and can’t be achieved. If someone has PTSD, they’ve experienced a serious traumatic event. No treatment will take away the memory of that event or events. Treatment for PTSD aims to help people with PTSD process that trauma and minimize the effect it has on their lives.

Treating PTSD isn’t about returning to who you were before the trauma. It’s about moving forward toward a place of greater stability, resilience, and self-agency. Effective treatment can help reduce symptoms, build coping tools, and improve your daily functioning. The goal is to feel more connected, in control, and capable of navigating your life.

Therapeutic treatment for PTSD

Cognitive behavioral therapy

The main therapy suggested for PTSD is cognitive behavioral therapy (CBT).^[16]This is a type of talk therapy that helps people with PTSD recognize times when their experiences lead them to have inaccurate and unhelpful thoughts and beliefs about the world.

CBT can also be useful as a first-line treatment to help a patient learn to self-manage their symptoms enough to then find the mental and emotional resources for more exploratory therapies.^[17]This allows it to fulfill the first stage of Herman’s 3 stages of recovery from trauma; making yourself safe in the present moment.^[18]This stage should then be followed by stage 2 (remembrance and mourning) and stage 3 (reconnection). These latter stages are less suitable for CBT therapy.

Eye movement desensitization and reprocessing

Another common treatment for PTSD is eye movement desensitization and reprocessing (EMDR). In this type of therapy, someone managing PTSD is encouraged to talk about the traumatic events while their eyes are being directed to different points in space. Sometimes, sounds located on different sides of the head are used instead of eye movements.^[19]

Although EMDR is also offered to people living with cPTSD, it is not always as effective. Someone with cPTSD may have tens, or even hundreds, of traumatic events to work through. Carrying out EMDR with just some of the traumatic events can still be helpful, however.^[20]

Exposure therapy

Exposure therapy can be offered to people living with PTSD to help them overcome avoidance symptoms. This type of therapy involves working with a trained therapist who provides support while the patient gradually increases their tolerance for the stimuli they are trying to avoid.^[21]

Medication treatment for PTSD

Antidepressants are commonly offered to people living with PTSD to help manage their symptoms. These can be taken for short periods or prescribed in the longer term, depending on the patient’s needs.

The most common medications prescribed for PTSD are selective serotonin reuptake inhibitors (SSRIs) and Venlafaxine.^[22]

Alternative treatment for PTSD

Although mainstream treatments for PTSD are well-established, there are still a large number of patients who do not find them effective. Researchers are currently investigating novel treatment options, such as using psychoactive substances to help patients process traumatic events.

Medications currently under investigation include MDMA, ketamine, LSD, and psilocybin. Evidence appears to be developing for MDMA, in combination with psychotherapy, as a potentially effective option. More research will be needed, however, before these substances could become widely available.^[23]

Self-management for PTSD

Many people experiencing PTSD attempt to self-manage their condition. For some, this is due to a lack of available support specific to their needs, while others may believe that their symptoms are something they should be able to ‘get over’.

It is important to be careful when self-managing PTSD. Many people living with PTSD attempt to manage their feelings with alcohol or other substances, leading to high rates of substance use disorder (SUD).^[24]SUD rates are estimated to be 16-80% in people with PTSD.^[17]

Similarly, avoidance symptoms can become stronger in people self-managing PTSD. Avoiding locations and circumstances that remind you of the traumatic event offers temporary relief and prevents the condition from being debilitating daily, but it also reinforces the perception that those locations and circumstances are threatening.^[25]This can be even more problematic if you are avoiding thoughts and memories.

Writing and mindfulness practices can be safe and helpful for managing feelings that feel too overwhelming to share.^[26]It can also be valuable to find places, situations, and people who help you feel safe and reduce the impression that the world is always threatening. Prioritising normal healthy living, including a good diet, exercise, and sleep, can all help people deal with the symptoms of PTSD, but they don’t make the underlying condition go away.

Final thought

PTSD is a serious acquired mental disorder that can be effectively treated. Working with a licensed and trained mental health professional can help you determine the best care approach. It’s helpful to seek support early, before symptoms are deeply entrenched.