Posttraumatic stress disorder (PTSD) is a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event such as a natural disaster, a serious accident, a terrorist act, war/combat, or rape or who have been threatened with death, sexual violence or serious injury.
PTSD has been known by many names in the past, such as “shell shock” during the years of World War I and “combat fatigue” after World War II, but PTSD does not just happen to combat veterans. PTSD can occur in all people, of any ethnicity, nationality or culture, and at any age. PTSD affects approximately 3.5 percent of U.S. adults every year, and an estimated one in 11 people will be diagnosed with PTSD in their lifetime. Women are twice as likely as men to have PTSD. Three ethnic groups – U.S. Latinos, African Americans, and American Indians – are disproportionately affected and have higher rates of PTSD than non-Latino whites.
People with PTSD have intense, disturbing thoughts and feelings related to their experience that last long after the traumatic event has ended. They may relive the event through flashbacks or nightmares; they may feel sadness, fear or anger; and they may feel detached or estranged from other people. People with PTSD may avoid situations or people that remind them of the traumatic event, and they may have strong negative reactions to something as ordinary as a loud noise or an accidental touch.
A diagnosis of PTSD requires exposure to an upsetting traumatic event. However, the exposure could be indirect rather than first hand. For example, PTSD could occur in an individual learning about the violent death of a close family or friend. It can also occur as a result of repeated exposure to horrible details of trauma such as police officers exposed to details of child abuse cases.
Symptoms and Diagnosis
Symptoms of PTSD fall into the following four categories. Specific symptoms can vary in severity.
- Intrusion: Intrusive thoughts such as repeated, involuntary memories; distressing dreams; or flashbacks of the traumatic event. Flashbacks may be so vivid that people feel they are re-living the traumatic experience or seeing it before their eyes.
- Avoidance: Avoiding reminders of the traumatic event may include avoiding people, places, activities, objects and situations that may trigger distressing memories. People may try to avoid remembering or thinking about the traumatic event. They may resist talking about what happened or how they feel about it.
- Alterations in cognition and mood: Inability to remember important aspects of the traumatic event, negative thoughts and feelings leading to ongoing and distorted beliefs about oneself or others (e.g., “I am bad,” “No one can be trusted”); distorted thoughts about the cause or consequences of the event leading to wrongly blaming self or other; ongoing fear, horror, anger, guilt or shame; much less interest in activities previously enjoyed; feeling detached or estranged from others; or being unable to experience positive emotions (a void of happiness or satisfaction).
- Alterations in arousal and reactivity: Arousal and reactive symptoms may include being irritable and having angry outbursts; behaving recklessly or in a self-destructive way; being overly watchful of one's surroundings in a suspecting way; being easily startled; or having problems concentrating or sleeping.
Many people who are exposed to a traumatic event experience symptoms similar to those described above in the days following the event. For a person to be diagnosed with PTSD, however, symptoms must last for more than a month and must cause significant distress or problems in the individual's daily functioning. Many individuals develop symptoms within three months of the trauma, but symptoms may appear later and often persist for months and sometimes years. PTSD often occurs with other related conditions, such as depression, substance use, memory problems and other physical and mental health problems.
(See information on Acute Stress Disorder below.)
Acute Stress Disorder
Acute stress disorder occurs in reaction to a traumatic event, just as PTSD does, and the symptoms are similar. However, the symptoms occur between three days and one month after the event. People with acute stress disorder may relive the trauma, have flashbacks or nightmares and may feel numb or detached from themselves. These symptoms cause major distress and problems in their daily lives. About half of people with acute stress disorder go on to have PTSD.
An estimated 13 to 21 percent of survivors of car accidents develop acute stress disorder and between 20 and 50 percent of survivors of assault, rape or mass shootings develop it.
Psychotherapy, including cognitive behavior therapy can help control symptoms and help prevent them from getting worse and developing into PTSD. Medication, such as SSRI antidepressants can help ease the symptoms.
Adjustment disorder occurs in response to a stressful life event (or events). The emotional or behavioral symptoms a person experiences in response to the stressor are generally more severe or more intense than what would be reasonably expected for the type of event that occurred.
Symptoms can include feeling tense, sad or hopeless; withdrawing from other people; acting defiantly or showing impulsive behavior; or physical manifestations like tremors, palpitations, and headaches. The symptoms cause significant distress or problems functioning in important areas of someone’s life, for example, at work, school or in social interactions. Symptoms of adjustment disorders begin within three months of a stressful event and last no longer than six months after the stressor or its consequences have ended.
The stressor may be a single event (such as a romantic breakup), or there may be more than one event with a cumulative effect. Stressors may be recurring or continuous (such as an ongoing painful illness with increasing disability). Stressors may affect a single individual, an entire family, or a larger group or community (for example, in the case of a natural disaster).
An estimated 5% to 20% of individuals in outpatient mental health treatment have a principal diagnosis of adjustment disorder. A recent study found that more than 15% of adults with cancer had adjustment disorder.It is typically treated with psychotherapy.
Disinhibited Social Engagement Disorder
Disinhibited social engagement disorder occurs in children who have experienced severe social neglect or deprivation before the age of 2. Similar to reactive attachment disorder, it can occur when children lack the basic emotional needs for comfort, stimulation and affection, or when repeated changes in caregivers (such as frequent foster care changes) prevent them from forming stable attachments.
Disinhibited social engagement disorder involves a child engaging in overly familiar or culturally inappropriate behavior with unfamiliar adults. For example, the child may be willing to go off with an unfamiliar adult with minimal or no hesitation. These behaviors cause problems in the child’s ability to relate to adults and peers. Moving the child to a normal caregiving environment improves the symptoms. However, even after placement in a positive environment, some children continue to have symptoms through adolescence. Developmental delays, especially cognitive and language delays, may co-occur along with the disorder.
The prevalence of disinhibited social engagement disorder is unknown, but it is thought to be rare. Most severely neglected children do not develop the disorder. Treatment involves the child and family working with a therapist to strengthen their relationship.
Reactive Attachment Disorder
Reactive attachment disorder occurs in children who have experienced severe social neglect or deprivation during their first years of life. It can occur when children lack the basic emotional needs for comfort, stimulation and affection, or when repeated changes in caregivers (such as frequent foster care changes) prevent them from forming stable attachments.
Children with reactive attachment disorder are emotionally withdrawn from their adult caregivers. They rarely turn to caregivers for comfort, support or protection or do not respond to comforting when they are distressed. During routine interactions with caregivers, they show little positive emotion and may show unexplained fear or sadness. The problems appear before age 5. Developmental delays, especially cognitive and language delays, often occur along with the disorder.
Reactive attachment disorder is uncommon, even in severely neglected children. Treatment involves the child and family working with a therapist to strengthen their relationship.
It is important to note that not everyone who experiences trauma develops PTSD, and not everyone who develops PTSD requires psychiatric treatment. For some people, symptoms of PTSD subside or disappear over time. Others get better with the help of their support system (family, friends or clergy). But many people with PTSD need professional treatment to recover from psychological distress that can be intense and disabling. It is important to remember that trauma may lead to severe distress. That distress is not the individual’s fault, and PTSD is treatable. The earlier a person gets treatment, the better chance of recovery.
Psychiatrists and other mental health professionals use various effective (research-proven) methods to help people recover from PTSD. Both talk therapy (psychotherapy) and medication provide effective evidence-based treatments for PTSD.
Cognitive Behavioral Therapy
One category of psychotherapy, cognitive behavior therapies (CBT), is very effective. Cognitive processing therapy, prolonged exposure therapy and stress inoculation therapy (described below) are among the types of CBT used to treat PTSD.
- Cognitive Processing Therapy focuses on modifying painful negative emotions (such as shame, guilt, etc.) and beliefs (such as “I have failed”; “the world is dangerous”) due to the trauma. Therapists help the person confront such distressing memories and emotions.
- Prolonged Exposure Therapy uses repeated, detailed imagining of the trauma or progressive exposures to symptom “triggers” in a safe, controlled way to help a person face and gain control of fear and distress and learn to cope. For example, virtual reality programs have been used to help war veterans with PTSD re-experience the battlefield in a controlled, therapeutic way.
- Stress Inoculation Therapy aims to arm the individual with the necessary coping skills to successfully defend against stressful triggers through the exposure of milder levels of stress, much like a vaccine is inoculated to prevent infection after exposure to an illness.
- Group therapy encourages survivors of similar traumatic events to share their experiences and reactions in a comfortable and non-judgmental setting. Group members help one another realize that many people would have responded the same way and felt the same emotions. Family therapy may also help because the behavior and distress of the person with PTSD can affect the entire family.
Other psychotherapies such as interpersonal, supportive and psychodynamic therapies focus on the emotional and interpersonal aspects of PTSD. These may be helpful for people who don’t want to expose themselves to reminders of their traumas.
Medication can help to control the symptoms of PTSD. In addition, the symptom relief that medication provides allows many people to participate more effectively in psychotherapy.
Some antidepressants such as SSRIs and SNRIs (selective serotonin re-uptake inhibitors and serotonin-norepinephrine re-uptake inhibitors), are commonly used to treat the core symptoms of PTSD. They are used either alone or in combination with psychotherapy or other treatments.
Other medications may be used to lower anxiety and physical agitation, or treat the nightmares and sleep problems that trouble many people with PTSD.
Other treatments including complementary and alternative therapies are also increasingly being used to help people with PTSD. These approaches provide treatment outside the conventional mental health clinic and may require less talking and disclosure than psychotherapy. Examples include acupuncture and animal-assisted therapy.
In addition to treatment, many people with PTSD find it very helpful to share their experiences and feelings with others who have similar experiences, such as in a peer support group.
- Bichitra Nanda Patra and Siddharth Sarkar. Adjustment Disorder: Current Diagnostic Status. Indian J Psychol Med. 2013 Jan-Mar; 35(1): 4–9.
- National Library of Medicine: MedlinePlus. Adjustment Disorder.
- American Psychiatric Association. 2013. Diagnostic and Statistical Manual of Mental Disorders, Fifth edition. (DSM-5)
- American Academy of Child and Adolescent Psychiatry. Facts for Families: Attachment Disorders.
Felix Torres, M.D., DFAPA, MBA