Post-Traumatic Stress Disorder (PTSD)
What is PTSD?
PTSD (posttraumatic stress disorder) is a mental health problem that some people develop after experiencing or witnessing a life-threatening event, like combat, a natural disaster, a car accident, or sexual assault.
It’s normal to have upsetting memories, feel on edge, or have trouble sleeping after this type of event. At first, it may be hard to do normal daily activities, like go to work, go to school, or spend time with people you care about. But most people start to feel better after a few weeks or months.
If it’s been longer than a few months and you’re still having symptoms, you may have PTSD. For some people, PTSD symptoms may start later on, or they may come and go over time.
What are the symptoms of PTSD?
It is normal to have stress reactions after a traumatic event. Your emotions and behavior can change in ways that are upsetting to you. Even though most people have stress reactions following a trauma, they get better in time. But, you should seek help if symptoms:
• Last longer than three months
• Cause you great distress
• Disrupt your work or home life
Symptoms of PTSD may disrupt your life and make it hard to continue with your daily activities. You may find it hard just to get through the day.
There are four types of PTSD symptoms:
1. Reliving the event (also called re-experiencing symptoms). Memories of the traumatic event can come back at any time. You may feel the same fear and horror you did when the event took place. For example:
a. You may have nightmares.
b. You may feel like you are going through the event again. This is called a flashback.
c. You may see, hear, or smell something that causes you to relive the event. This is called a trigger. News reports, seeing an accident, or hearing a car backfire are examples of triggers.
2. Avoiding situations that remind you of the event. You may try to avoid situations or people that trigger memories of the traumatic event. You may even avoid talking or thinking about the event. For example:
a. You may avoid crowds, because they feel dangerous.
b. You may avoid driving if you were in a car accident or if your military convoy was bombed.
c. If you were in an earthquake, you may avoid watching movies about earthquakes.
d. You may keep very busy or avoid seeking help because it keeps you from having to think or talk about the event.
3. Negative changes in beliefs and feelings. The way you think about yourself and others changes because of the trauma. This symptom has many aspects, including the following:
a. You may not have positive or loving feelings toward other people and may stay away from relationships
b. You may forget about parts of the traumatic event or not be able to talk about them.
c. You may think the world is completely dangerous, and no one can be trusted.
4. Feeling keyed up (also called hyperarousal). You may be jittery, or always alert and on the lookout for danger. You might suddenly become angry or irritable. This is known as hyperarousal. For example:
a. You may have a hard time sleeping
b. You may have trouble concentrating
c. You may be started by a loud noise or surprise
d. You might want to have your back to a wall in a restaurant or waiting room.
What should I do if I have symptoms of PTSD?
PTSD symptoms usually start soon after the traumatic event. But for some people, they may not happen until months or years after the trauma. Symptoms may come and go over many years. So you should keep track of your symptoms and talk to someone you trust about them.
If you have symptoms that last longer than four weeks, cause you great distress, or disrupt your work or home life, you probably have PTSD. You should seek professional help from a doctor or counselor.
How common is PTSD?
Posttraumatic stress disorder (PTSD) can occur after you have been through a trauma. A trauma is a shocking and dangerous event that you see or that happens to you. During this type of event, you think that your life or others’ lives are in danger.
Going through trauma is not rare. About 6 out of every 10 min (or 60%) and 5 out of every 10 women (or 50%) experience at least one trauma in their lives. Women are more likely to experience sexual assault and child sexual abuse. Men are more likely to experience accidents, physical assault, combat, disaster, or to witness death or injury.
PTSD can happen to anyone. It is not a sign of weakness. A number of factors can increase the chance that someone will develop PTSD, many of which are not under that person’s control. For example, if you were directly exposed to the trauma or injured, you are more likely to develop PTSD.
Here are some facts (based on the U.S. population):
• About 7 or 8 out of every 100 people (or 7-8% of the population) will have PTSD at some point in their lives.
• About 8 million adults have PTSD during a given year. This is only a small portion of those who have gone through a trauma.
• About 10 of every 100 women (or 10%) develop PTSD sometime in their lives compared with about 4 of every 100 men (or 4%).
PTSD and the Military
When you are in the military, you may see combat. You may have been on missions that exposed you to horrible and life-threatening experiences. These types of events can lead to PTSD.
The number of Veterans with PTSD varies by service era:
• Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF): About 11-20 out of every 100 Veterans (or between 11-20%) who served in OIF and OEF have PTSD in a given year.
• Gulf War (Desert Storm): About 12 out of every 100 Gulf War Veterans (or 12%) have PTSD in a given year.
• Vietnam War: About 15 out of every 100 Vietnam Veterans (or 15%) were currently diagnosed with PTSD at the time of the most recent study in the late 1980s, the National Vietnam Veterans Readjustment Study (NVVRS). It is estimated that about 30 out of every 100 (or 30%) of Vietnam Veterans have had PTSD in their lifetime.
Other factors in a combat situations can add more stress to an already stressful situation. This may contribute to PTSD and other mental health problems these factors include what you do in the war, the politics around the war, where the war is fought, and the type of enemy you face.
Another cause of PTSD in the military can be military sexual trauma (MST). This is any sexual harassment or sexual assault that occurs while you are in the military. MST can happen to both men and women and can occur during peacetime, training, or war.
Among Veterans who use VA health care, about:
• 23% reported sexual assault when in the military
• 55% of women and 38% of men have experienced sexual harassment when in the military
There are many more male Veterans than there are female Veterans. So, even though military sexual trauma is more common in women Veterans, over half of all Veterans with military sexual trauma are men.
What Can I Do If I Think I Have PTSD?
The only way to know for sure if you have PTSD is to talk to a mental health care provider.
The provider will ask you about your trauma, your symptoms and any other problems you have.
Talk to someone you trust
After a traumatic event, it’s normal to think, act, and feel differently than usual. Most people will start to feel better after a few weeks. If you symptoms last longer than a few months, are very upsetting, and disrupt your daily life, you should get help. Whether or not you have PTSD, treatment can help if thoughts and feelings from the trauma are bothering you. Talk to:
• Your family doctor
• A mental health professional, such as therapist
• Your local VA facility or Vet Center, if you are a Veteran
• A close friend or family member who can support you while finding help
• A clergy member
• Fill out a PTSD questionnaire or screen
Talk a self-screen for PTSD
A screen is a brief set of questions to tell you if it is likely you might have PTSD. Below is the Primary Care PTSD Checklist for DSM-5, or the PC-PTSD-5 Screen.
Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example:
• A serious accident or fire
• A physical or sexual assault or abuse
• An earthquake or flood
• A war seeing someone be killed or seriously injured
• Having a loved one die through homicide or suicide
Have you ever experienced this kind of event? YES/NO
If no, screen total = 0. Please stop here.
If yes, please answer the questions below:
In the past month, have you…
• Had nightmares about the event(s) or thought about the event(s) when you did not want to? YES/NO
• Tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)? YES/NO
• Been constantly on guard, watchful, or easily startled? YES/NO
• Felt numb or detached from people, activities, or your surroundings? YES/NO
• Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused? YES/NO
If you answer “yes” to any three items (items 1 to 5 above), you should talk to a mental health care provider to learn more about PTSD and PTSD treatment.
Answering “yes” to 3 or more questions on the PC-PTSD-5 does not mean you have PTSD. Only a mental health care provider can tell you for sure. And, if you do not answer “yes” to 3 or more questions, you may still want to talk to a mental health care provider. If you have symptoms that last following a trauma, treatment can help- whether or not you have PTSD.
It’s common to think that your PTSD symptoms will just go away over time. But this is unlikely, especially if you’ve had symptoms for longer than a year. Here are some of the reason why you should seek help.
Early treatment is better
Symptoms of PTSD may get worse. Dealing with them now might help stop symptoms from getting worse in the future and lead to a better quality of life for you.
It’s never too late to get PTSD treatment
Treatment can help even if your trauma happened years ago. And treatment for PTSD has gotten much better over the years. If you tried treatment before and you’re still having symptoms, it’s a good idea to try again.
PTSD symptoms can affect those you love
PTSD symptoms can get in the way of your family life. You may even find that you pull away from loved ones are not able to get along with people, or that you are angry or even violent. Getting help for your PTSD can help improve your relationships.
PTSD can be related to other health problems
PTSD symptoms can affect physical health problems. For example, a few studies have shown a relationships between PTSD and heart trouble. By getting help for your PTSD, you could also improve your physical health.
It may not be PTSD
Having some symptoms does not always mean you have PTSD. Some of the symptoms of PTSD are also symptoms of other mental health problems. For example, trouble concentrating or feeling less interested in things you used to enjoy can be symptoms of depression and PTSD. And, different problems have different treatments.
When you seek help, your mental health care provider can determine whether you need treatment for PTSD, or another type of treatment.
Find the best treatment for you
Today, there are several treatment options for PTSD. For some people, these treatments can get rid of symptoms altogether. Others find they have fewer symptoms or feel that that their symptoms are less intense.
Helping a family member who has PTSD
When someone has PTSD, it can change family life. The person with PTSD may act differently and get angry easily. He or she may not want to do things you used to enjoy together.
You may feel scared and frustrated about the changes you see in your loved one. You also may feel angry about what’s happening to your family, or wonder if things will ever go back to the way they were. These feelings and worries are common in people who have a family member with PTSD.
IT is important to learn about PTSD so you can understand why it happened, how it is treated, and what you can do to help. But you also need to take care of yourself. Changes in family life are stressful, and taking care of yourself will make it easier to cope.
How can I help?
You may feel helpless, but there are many things you can do. Nobody expects you to have all the answers.
Here are ways you can help:
• Learn as much as you can about PTSD. Knowing how PTSD affects people may help you understand what your family member is going through. The more you know, the better you and your family can handle PTSD.
• Offer to go to doctor visits with your family member. You can help keep track of medicine and therapy, and you can be there for support.
• Tell your loved one you want to listen and that you also understand if he or she doesn’t feel like talking
• Plan family activities together, like having dinner or going to a movie
• Talk a walk, go for a bike ride, or do some other physical activity together. Exercise is important for health and helps clear your mind
• Encourage contact with family and close friends. A support system will help your family member get through difficult changes and stressful times.
Your family member may not want your help. If this happens, keep in mind that withdrawal can be a symptom of PTSD. A person who withdraws may not feel like talking, taking part in group activities, or being around other people. Give your loved one space, but tell him or her that you will always be ready to help.
How can I deal with anger or violent behavior?
Your family member may feel angry about many things. Anger is a normal reaction to trauma, but it can hurt relationships and make it hard to think clearly. Anger also can be frightening.
If anger leads to violent behavior or abuse, it’s dangerous. Go to a safe place and call for help right away. Make sure children are in a safe place as well.
It’s hard to talk to someone who is angry. One thing you can do is set up a time-out system. This helps you find a way to talk even while angry. Here’s one way to do this.
• Agree that either of you can call a time-out at any time.
• Agree that when someone calls a time-out, the discussion must stop right then
• Decide on a signal you will use to call a time-out. The signal can be a word that you say or a hand signal.
• Agree to tell each other where you will be and what you will be doing during the time-out. Tell each other what time you will come back.
While you are taking a time-out, don’t focus on how angry you feel. Instead, think calmly about how you will talk things over and solve the problem.
After you come back:
• Take turns talking about solutions to the problem. Listen without interrupting
• Use statements starting with “I,” such as “I think” or “I feel.” Using “you” statements can sound accusing
• Be open to each other’s ideas. Don’t criticize each other.
• Focus on things you both think will work. It’s likely you will both have good ideas
• Together, agree which solutions you will use.
How can I communicate better?
You and your family may have trouble talking about feelings, worries and everyday problems. Here are some ways to communicate better:
• Be clear and to the point
• Be positive. Blame and negative talk won’t help the situation.
• Be a good listener. Don’t argue or interrupt. Repeat what you hear to make sure you understand, and ask questions if you need to know more.
• Put your feelings into words. Your loved one may not know you are sad or frustrated unless you are clear about your feelings
• Help your family member put feelings into words. Ask, “Are you feeling angry? Sad? Worried?”
• Ask how you can help
• Don’t give advice unless you are asked.
If your family is having a lot of trouble talking things over, consider trying family therapy. Family therapy is a type of counseling that involves your whole family. A therapist helps you and your family communicate, maintain good relationships, and cope with tough emotions.
During therapy, each person can talk about how a problem is affecting the family. Family therapy can help family members understand and cope with tough emotions.
During therapy, each person can talk about how a problem is affecting the family. Family therapy can help family members understand and cope with PTSD.
Your health professional or a religious or social services organization can help you find a family therapist who specializes in PTSD.
How can I take care of myself?
Helping a person with PTSD can be hard on you. You may have your own feelings of fear and anger about the trauma. You may feel guilty because you wish your family member would just forget his or her problems and get on with life. You may feel confused or frustrated because your loved one has changed, and you may worry that your family life will never get back to normal.
All of this can drain you. It can affect your health and make it hard for you to help your loved one. If you’re not careful, you may get sick yourself, become depressed, or burn out and stop helping your loved one.
To help yourself, you need to take care of yourself and have other people help you.
Care for yourself
• Don’t feel guilty or feel that you have to know it all. Remind yourself that nobody has all the answers. It’s normal to feel helpless at times.
• Don’t feel bad if things change slowly. You cannot change anyone. People have to change themselves.
• Take care of your physical and mental health. If you feel yourself getting sick or often feel sad and hopeless, see your doctor.
• Don’t give up your outside life. Make time for activities and hobbies you enjoy. Continue to see your friends. Take time to be by yourself. Find a quiet place to gather your thoughts and “recharge.”
• Get regular exercise, even just a few minutes a day. Exercise is a healthy way to deal with stress.
• Eat healthy foods. When you are busy, it may seem easier to eat fast food than to prepare healthy meals. But healthy foods will give you more energy to carry you through the day.
• Remember the good things. It’s easy to get weighed down by worry and stress. But don’t forget to see and celebrate the good things that happen to you and your family
During difficult times, it is important to have people in your life who you can depend on. These people are your support network. They can help you with everyday jobs, like taking a child to school, or by giving you love and understanding.
You may get support from:
• Family members
• Friends, coworkers and neighbors
• Members of your religious or spiritual group
• Support groups
• Doctors and other health professionals
Treatment of PTSD
Recommended treatments: Treatments with the most research support
Trauma-focused psychotherapies are the most highly recommended type of treatment for PTSD. “Trauma-focused” means that the treatment focuses on the memory of the traumatic event or its meaning. These treatments use different techniques to help you process your traumatic experience. Some involve visualizing, talking, or thinking about the traumatic memory. Others focus on changing unhelpful beliefs about the trauma. They usually last about 8-16 sessions. The trauma-focused psychotherapies with the strongest evidence are:
• Prolonged Exposure (PE). Teaches you how to gain control by facing your negative feelings. It involves talking about your trauma with a provider and doing some of the things you have avoided since the trauma.
• Cognitive Processing Therapy (CPT). Teaches you to reframe negative thoughts about the trauma. It involves talking with your provider about your negative thoughts and doing short writing assignments.
• Eye-Movement Desensitization and Reprocessing (EMDR). Helps you process and make sense of your trauma. It involves calling the trauma to mind while paying attention to a back-and-forth movement or sound (like a finger waving side to side, a light, or a tone).
There are other types of trauma-focused psychotherapy that are also recommended for people with PTSD. These include:
• Brief Eclectic Psychotherapy (BEP). A therapy in which you practice relaxation skills, recall details of the traumatic memory, reframe negative thoughts about the trauma, write a letter about the traumatic event, and hold a farewell ritual to leave trauma in the past.
• Narrative Exposure Therapy (NET). Developed for people who have experienced trauma from ongoing war, conflict, and organized violence. You talk through stressful life events in order (from birth to the present day) and put them together into a story.
• Written Narrative Exposure. Involved writing about the trauma during sessions. Your provider gives instructions on the writing assignment, allows you to complete the writing alone, and then returns at the end of the session to briefly discuss any reactions to the writing assignment.
• Specific cognitive behavioral therapies (CBTs) for PTSD. Include a limited number of psychotherapies shown to work for PTSD where the provider helps you learn how to change unhelpful behaviors or thoughts.
Antidepressants (SSRIs and SNRIs)
Medications that have been shown to be helpful in treating PTSD symptoms are some of the same medications also used for symptoms of depression and anxiety. These are antidepressant medications called SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin-norepinephrine reuptake inhibitors). SSRIs and SNRIs affect the level of naturally occurring chemicals in the brain called serotonin and/or norepinephrine. These chemicals play a role in brain cell communication and affect how you feel.
There are four antidepressant medications that are recommended for PTSD:
• Sertraline (Zoloft)
• Paroxetine (Paxil)
• Fluoxetine (Prozac)
• Venlafaxine (Effexor)
There are other types of antidepressant medications, but these four medications listed above are the ones that are most effective for PTSD.
If you decide to try one of these medications, your provider will give you a prescription. Once you fill your prescription, you will begin taking a pill at regular time(s) each day. You will meet with your provider every few months or so. Your provider will monitor your response to the medication (include side effects) and change your dose, if needed.
Suggested Treatments: Treatments with Some Research Support
Some psychotherapies do not focus on the traumatic event, but do help you process your reactions to the trauma and manage symptoms related to PTSD. The research behind these treatments not as strong as the research supporting trauma-focused psychotherapies (listed above). However, these psychotherapies may be a good option if you are not interested in trauma-focused psychotherapy, or if it is not available:
• Stress Inoculation Training (SIT). A cognitive-behavioral therapy that teaches skills and techniques to manage stress and reduce anxiety.
• Present-Centered Therapy (PCT). Focuses on current life problems that are related to PTSD.
• Interpersonal Psychotherapy (IPT). Focuses on the impact of trauma on interpersonal relationships.
There are also other medications that may be helpful, although the evidence behind them is not as strong as for SSRIs and SNRIs (listed above). These include:
• Nefazodone (serzone). A serotonin reuptake inhibitor (SRI) that works by changing the levels and activity of naturally occurring chemical signals in the brain.
• Imipramine (Tofranil). A tricyclic antidepressant (TCA) which acts by altering naturally occurring chemicals which help brain cells communicate and can lift mood.
• Phenelzine (Nardil). A monoamine oxidase inhibitor (MAOI) which inactivates a naturally-occurring enzyme which breaks down the neurotransmitters serotonin, norepinephrine and dopamine.
Other treatments: Treatments that do not yet have research support
There may be other options available such as certain complementary and integrative medicine approaches (like yoga, meditation, or acupuncture), biological treatments (like hyperbaric oxygen therapy or transcranial magnetic stimulation), or online treatment programs. These treatments do not have strong research behind them at this time, but you and your doctor can discuss the benefits and risks of these options to determine whether or not they are right for you.
Choosing a treatment
No one treatment is right for everyone. You can discuss treatment options with your health care provider, and determine which ones are best for you based on the benefits, risks, and side effects of each treatment. Some people are uncomfortable with the idea of seeking treatment because of concerns with stigma or worries about having to talk about difficult life experiences. However, treatment provides the opportunity to improve symptoms, personal and professional relationships, and quality of life.