CHAPTER 1

What is Posttraumatic Stress Disorder (PTSD)?

Posttraumatic stress disorder (PTSD) is a psychiatric disorder that may occur in people who have experienced or witnessed a
traumatic event, series of events or set of circumstances. An individual may experience this as emotionally or physically harmful
or life-threatening and may affect mental, physical, social, and/or spiritual well-being. Examples include natural disasters,
serious accidents, terrorist acts, war/combat, rape/sexual assault, historical trauma, intimate partner violence and bullying,

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. The lifetime prevalence of PTSD in
adolescents ages 13 -18 is 8%. An estimate 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 Native Americans/Alaska Natives – 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. Exposure includes directly experiencing an event,
witnessing a traumatic event happening to others, or learning that a traumatic event happened to a close family member 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.

HISTORY OF POST-TRAUMATIC STRESS DISORDER (PTSD)

Post-traumatic stress disorder (PTSD) has perhaps existed as long as mankind has experienced trauma. It was finally recognized
as a diagnosable condition in 1980, when the American Psychological Association included it in its Diagnostic and Statistical
Manual for mental health practitioners.1

Despite the length of time it took for medical practitioners to formally recognize the condition, the disorder has been evidenced
throughout history. As a result of all types of trauma, from natural disasters, to assault, or soldiers in battle, PTSD has been
recognized as a human response to trauma and has been known by a number of explanations throughout history.

Early Recognition of PTSD: Combat and Beyond

Mentions of combat stress can be found over 2,000 years ago in historical literature, and one of the first mentions can be found
in a story of the battle of Marathon by Herodotus in fifth century Ancient Greece. Ancient tales of battle trauma and flashback-
like dreams were documented by Hippocrates (4607-377 BC), and Lucretius in the poem De Rerum Natura, which was written in
50 BC.2

Later, PTSD flashbacks and nightmares that were related to battle experience could be found in documentation of the Hundred
Years’ War between England and France (1337 to 1453). Even Shakespeare alluded to it in various plays, including his play
Romeo and Juliet, in which Mercutio tells a lengthy account of Queen Mab, a character who creates dreams in the minds of
men; who would wake men through dreams of battle and death.2

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PTSD in the 1800s

By the 1800s, mentions of PTSD in relation to combat and war zone participation were merely characterized as “battle
exhaustion” or “soldier’s fatigue” — a reference to the repeated forays into battle by traumatized soldiers, resulting in
exhaustion of the body’s adrenaline-fueled responses, particularly during long engagements with daily fire. In fact, PTSD was
often referred to as the “thousand-yard stare,” a reference to the blank look and dissociated demeanor of traumatized soldiers.2

In 1887 at the Salpêtrière Hospital in Paris, physician Jean-Martin Charcot documented that traumatic experience could later
lead to “hysterical attacks” that might happen years after the trauma.3

U.S. soldiers who fought in the gruesome battles of the Civil War were no exception. Today, the National Museum of Civil War
Medicine is still curating and uncovering information about PTSD related to the U.S. Civil War through an exhibit on PTSD and
suicide in the 1860s and beyond.4

PTSD did not only occur in combat. Difficult living conditions gave way to trauma through other experiences. PTSD symptoms
became recognized in history under a host of different names was also referred to as “railway spine” during the late 19th and
early 20th centuries to describe psychological responses in those who witnessed or endured graphic railroad accidents.

By the late 1800s and early 1900s, the “talking cure,” as popularized by Sigmund Freud, began as a method to treat symptoms
that may have been caused by PTSD. These early therapeutic interventions were the first step toward helping people who had
survived traumatic events.3

PTSD in the 1900s and Modern Day

WWI brought a new awareness of traumatic effects of war. In 1915, the term “shell shock” was introduced to medical literature.
This condition described the same symptoms as PTSD and went on to become the predecessor of the official diagnosis.
Treatments for shell shock ranged from psychoanalysis to drastic and unproven “treatments” of electric shocks.

By the 1950s, treatments became more humane, but many people would not admit to any trauma symptoms due to the stigma
surrounding mental illness. Treatments improved through the advent of group therapy and newly created psychotropic
medications.3

Modern definitions of PTSD gained national spotlight in the 1970s, as countless Vietnam veterans began experiencing a host of
psychological problems, many persisting upon their return home.

Social movements in the 1970s began to study Holocaust survivors, Vietnam veterans, and survivors of domestic abuse. In 1974,
a two-person team of psychologist Ann Wolbert Burgess and sociologist Lynda Lytle Holmstrom coined the term, “Rape Trauma
Syndrome” to describe a variant of PTSD experienced by women who had undergone the harrowing experience of sexual assault
— marked by three phases of stress responses.

This research was a pioneering force in drawing attention to the effects of trauma. These research and social efforts gave way to
further understanding and the official description of PTSD in 1980. At that time, post-traumatic stress disorder was finally
adopted into the Diagnostic and Statistical Manual of Mental Disorders (DSM), considered the definitive text for diagnosis
among those in the psychological professions.

In the 1990s, new treatments for PTSD began to crop up. Eye-movement desensitization and reprocessing (EMDR), newer
generations of medications, and new approaches to therapy have all been continually developing in the last 20-30 years.
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 reliving 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.

Related Conditions

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. Acute stress disorder has been
diagnosed in 19%-50% of individuals that experience interpersonal violence (e.g., rape, assault, intimate partner violence).

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

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 key 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 two. 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.
Developmental delays including cognitive and language delays often co-occur with this disorder. Caregiving quality has been
shown to mediate the course of this illness. Yet even with improvements in the caregiving environment some children may have
symptoms that persist through adolescence.

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. The most important treatment modality is to work with caregivers to ensure the child has
an emotionally available attachment figure.

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 a therapist working with a
child and their family in order to strengthen the relationship between the child and their primary caregivers.
 CHAPTER 2

TYPES OF POST-TRAUMATIC STRESS DISORDER (PTSD)

[ ] NORMAL STRESS RESPONSE

PTSD might begin with a normal stress response, but not all stress responses develop into PTSD.

Normal stress responses affect the nervous, endocrine, and immune systems. The physiological effect of the stress response
activates the fight-or-freeze response in the body.

This response allows the body to either fight or leave the situation and activates adrenaline. Events that may trigger a normal
stress response include:

• accidents

• illnesses

• injuries

• high amounts of stress and tension

After the threat is over, the body turns to pre-arousal levels. Normal stress responses do not often have long-term affects or
disrupt day-to-day life.

[ ] ACUTE STRESS DISORDER

Similar to PTSD, acute stress disorder can also develop after a traumatic event. However, symptoms can start between 3 days
and 1 month after the event.

According to the Department of Veterans Affairs, approximately 6-33% of individuals can develop acute stress disorder within 1
month of a traumatic event. This rate is different for each type of trauma.

For example, after a car accident, approximately 13-21% of individuals have a chance of developing acute stress disorder,
compared to 20-50% of individuals after a rape, assault, or mass shooting.

Symptoms of acute stress disorder are similar to PTSD and can occur after you have:

• directly experienced a trauma

• witnessed an event as it occurred to someone close to you

• learned that an event happened to someone close to you

• have repeated exposure to extreme or repeated details of a traumatic event

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Types of PTSD

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• Normal stress response

• Acute stress disorder

• Dissociative PTSD

• Uncomplicated PTSD

• Complex PTSD

• Co-morbid PTSD

• Resources and support

• Recap

Post-traumatic stress disorder – aka PTSD – is one condition but has different subtypes depending on an individual’s symptoms.

Not everyone reacts to traumatic events in the same way or experiences the same symptoms. Each person’s response is unique.

Also, not everyone who experiences trauma will develop post-traumatic stress disorder (PTSD). You might have experienced the
same type of trauma as someone else and be affected differently.

PTSD often begins with a normal stress response that may develop into PTSD. Some people might not even be aware they are
having symptoms of PTSD.
Stress disorders and PTSD can have similar symptoms and even present in the same way. But there are some differences in the
way each type is managed.

Normal stress response

PTSD might begin with a normal stress response, but not all stress responses develop into PTSD.

Normal stress responses affect the nervous, endocrine, and immune systems. The physiological effect of the stress response
activates the fight-or-freeze response in the body.

This response allows the body to either fight or leave the situation and activates adrenaline. Events that may trigger a normal
stress response include:

• accidents

• illnesses

• injuries

• high amounts of stress and tension

After the threat is over, the body turns to pre-arousal levels. Normal stress responses do not often have long-term affects or
disrupt day-to-day life.

The best treatment for normal stress response is psychotherapy (talk therapy) and support from loved ones. Having someone to
talk with or vent to can help ease stress and anxiety.

Group therapy might also be helpful.

Acute stress disorder

Similar to PTSD, acute stress disorder can also develop after a traumatic event. However, symptoms can start between 3 days
and 1 month after the event.

According to the Department of Veterans Affairs, approximately 6-33% of individuals can develop acute stress disorder within 1
month of a traumatic event. This rate is different for each type of trauma.

For example, after a car accident, approximately 13-21% of individuals have a chance of developing acute stress disorder,
compared to 20-50% of individuals after a rape, assault, or mass shooting.

Symptoms of acute stress disorder are similar to PTSD and can occur after you have:

• directly experienced a trauma

• witnessed an event as it occurred to someone close to you

• learned that an event happened to someone close to you

• have repeated exposure to extreme or repeated details of a traumatic event

Treatment for acute stress disorder often includes psychotherapy, including cognitive behavioral therapy (CBT).
Older studies show that CBT helps to reduce symptoms and decreases the likelihood that symptoms will develop into PTSD.

[ ] DISSOCIATIVE PTSD

Dissociative PTSD was added to the new version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013. A
key feature of this form of PTSD is dissociative symptoms (depersonalization or derealization) and emotional detachment.

Other characteristics of dissociative PTSD include:

• higher levels of co-occurrence with other mental health conditions

• dissociative flashbacks and dissociative amnesia

• more significant history of early life trauma

• more severe PTSD symptoms

ResearchTrusted Source suggests that those with re-experiencing symptoms – such as flashbacks after trauma – are more likely
to experience disassociation.

There is still ongoing research on treatment for this type of PTSD. However, experts believe that exposure-based therapy might
be helpful for managing these symptoms. These include:

• cognitive processing therapy (CPT)

• prolonged exposure (PE)

• eye movement desensitization and reprocessing (EMDR)

• narrative exposure therapy (NET)

• prolonged exposure (PE)

• eye movement desensitization and reprocessing (EMDR)

• narrative exposure therapy (NET)

[ ] UNCOMPLICATED PTSD

Individuals with this type have similar symptoms to other types of PTSD, such as re-experiencing the trauma and avoiding places
or people related to the trauma.
But the main difference between this one and others is that it does not coexist with other mental health conditions such as
depression.
Uncomplicated PTSD is also one of the most commonly diagnosed and is highly responsive to treatment.

[ ] COMPLEX PTSD

Complex PTSD occurs when repeated, or multiple, traumas happen over a period of months, or even years, instead of a
traumatic event that happens once and is over – such as a violent attack or car accident.
Chronic trauma associated with complex PTSD symptoms can occur in childhood or adulthood and can cause issues in
relationships and behaviors.
Complex PTSD can also present through physical health symptoms such as fatigue and chronic pain.
Co-morbid PTSD

Individuals with co-morbid PTSD also have at least one co-occurring mental health condition. Some common co-
occurring conditions include:

• anxiety disorder

• panic disorder

• major depressive disorder

• substance use disorder

What can cause PTSD?

The situations we find traumatic can vary from person to person. There are many different harmful or life-threatening events
that might cause someone to develop PTSD. For example:

• being involved in a car crash

• being raped or sexually assaulted

• being abused, harassed or bullied - including racism, sexism, homophobia, biphobia or transphobia, and other types of abuse
targeting your identity

• being kidnapped, held hostage or any event in which you fear for your life

• experiencing violence, including military combat, a terrorist attack, or any violent assault

• seeing other people hurt or killed, including in the course of your job (sometimes called secondary trauma)

• doing a job where you repeatedly see or hear distressing things, such as working in the emergency services or armed forces

• surviving a natural disaster, such as flooding, earthquakes or pandemics, such as the coronavirus pandemic

• traumatic childbirth as a mother, or as a partner witnessing a traumatic birth

• losing someone close to you in particularly upsetting circumstances

Treatment
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 is an evidence-based, cognitive behavioral therapy designed specifically to treat PTSD and
comorbid symptoms. It focuses on changing 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.

• Trauma Focused Cognitive Behavioral Therapy is an evidence-based treatment model for children and adolescents that
incorporates trauma-sensitive interventions with cognitive behavioral, family, and humanistic principles and techniques.

• Eye Movement Desensitization and Reprocessing for PTSD is a trauma-focused psychotherapy which is administered over
approximately 3 months. This therapy helps a person to reprocess the memory of the trauma so that it is experienced in a
different way. After a thorough history is taken and a treatment plan developed the therapist guides the patient through
questions about the traumatic memory. Eye movements similar to those in REM sleep is recreated during a session by having
the patient watch the therapist’s fingers go back and forth or by watching a light bar. The eye movements last for a brief time
period and then stop. Experiences during a session may include changes in thoughts, images, and feelings. After repeated
sessions the memory tends to change and is experienced in a less negative manner.

• 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 do not want to expose themselves to reminders of their
traumas.

Medication
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.

References

• American Psychiatric Association. (2022). Trauma- and Stressor-Related Disorders. In Diagnostic and Statistical Manual of
Mental Disorders (5th ed., text rev.).

• Bichitra Nanda Patra and Siddharth Sarkar. Adjustment Disorder: Current Diagnostic Status. Indian J Psychol Med. 2013 Jan-
Mar; 35(1): 4–9.

• Harvard Medical School. (2007). National Comorbidity Survey (NCS). (2017, August 21). Data Table 2: 12-month prevalence
DSM-IV/WMH-CIDI disorders by sex and cohort.

• National Library of Medicine: MedlinePlus. Adjustment Disorder.

• American Academy of Child and Adolescent Psychiatry. Facts for Families: Attachment Disorders.

• Merikangas KR, He JP, Burstein M, et al. Lifetime prevalence of mental disorders in U.S. adolescents: results from the National
Comorbidity Survey Replication–Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2010 Oct;49(10):980-9.>

• Substance Abuse and Mental Health Services Administration. SAMHSA’s Concept of Trauma and Guidance for a Trauma-
Informed Approach. HHS Publication No. (SMA) 14-4884. Rockville, MD: Substance Abuse and Mental Health Services
Administration, 2014.