Difference between revisions of "Post-traumatic stress disorder" - New World Encyclopedia

	Post-traumatic stress disorder
Symptoms	Disturbing thoughts, feelings, or dreams related to the event; mental or physical distress to trauma-related cues; efforts to avoid trauma-related situations; increased fight-or-flight response
Complications	Self-harm, suicide
Duration	> 1 month
Causes	Exposure to a traumatic event
Diagnostic method	Based on symptoms
Treatment	Counseling, medication
Medication	Selective serotonin reuptake inhibitor
Frequency	8.7% (lifetime risk); 3.5% (12-month risk) (US)

Latest revision as of 21:38, 13 October 2023

Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that can develop because of exposure to a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a person's life. Symptoms may include disturbing thoughts, feelings, or dreams related to the events, mental or physical distress to trauma-related cues, attempts to avoid trauma-related cues, alterations in the way a person thinks and feels, and an increase in the fight-or-flight response. These symptoms last for more than a month after the event.

A person with PTSD is at a higher risk of suicide and intentional self-harm. Their ability to function successfully in their work environment and to maintain family relationships may be severely impaired.

Fortunately, most people who experience traumatic events do not develop PTSD. However, especially among military personnel who experienced combat during war time, the rate of PTSD occurrence is sufficiently high to be detrimental to society as a whole. If the occurrence of traumatic events is not reduced, then their effects need to be better understand and efforts to improve treatment options continue to be necessary.

Terminology

Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that can develop because of exposure to a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a person's life.^[1]

The Diagnostic and Statistical Manual of Mental Disorders (DSM) does not hyphenate "post" and "traumatic," thus, the DSM-5 lists the disorder as posttraumatic stress disorder. However, the ICD-10 does hyphenate the name of the disorder, viz., "post-traumatic stress disorder,"^[3] as do many scientific journal articles and other scholarly publications.

Classification

PTSD was classified as an anxiety disorder in the DSM-IV. It has since been reclassified as a "trauma and stressor-related disorder" in the DSM-5.^[1]

ICD-10 classifies PTSD under "Reaction to severe stress, and adjustment disorders (F43)."^[3]

History of the terminology

Symptoms of trauma-related mental disorders have been documented since at least the time of the ancient Greeks.^[4] Several instances of post-traumatic illness have been noted in the seventeenth and eighteenth centuries, such as Samuel Pepys's description of intrusive and distressing symptoms following the 1666 Fire of London.^[5] In a similar vein, psychiatrist Jonathan Shay has proposed that Lady Percy's soliloquy in William Shakespeare's play Henry IV, Part 1 (act 2, scene 3, lines 40–62), written around 1597, represents an unusually accurate description of the symptom constellation of PTSD.^[6]

The 1952 edition of the DSM-I includes a diagnosis of "gross stress reaction," which has similarities to the modern definition and understanding of PTSD. Gross stress reaction is defined as a normal personality using established patterns of reaction to deal with overwhelming fear as a response to conditions of great stress. The diagnosis includes language which relates the condition to combat as well as to "civilian catastrophe."^[7]

Early in 1978, the diagnosis term "post-traumatic stress disorder" was first recommended in a working group finding presented to the Committee of Reactive Disorders.^[8] The condition was officially recognized by the American Psychiatric Association in 1980 in DSM-III as "posttraumatic stress disorder."^[9]

The term "post-traumatic stress disorder" came into use in the 1970s in large part due to the diagnoses of U.S. military veterans of the Vietnam War.^[10] Owing to its association with the war in Vietnam, PTSD has become synonymous with many historical war-time diagnoses such as "railway spine," stress syndrome, nostalgia, "soldier's heart," shell shock, battle fatigue, combat stress reaction, traumatic war neurosis, "war nerves," neurasthenia, and "combat neurosis."^[11]^[12]

Statue, Three Servicemen, Vietnam Veterans Memorial

The correlations between combat and PTSD are undeniable:

It is now known that soldiers on a battlefield can hope to preserve their psychological equilibrium for only several months at best; the strict selection process notwithstanding, one-tenth of mobilized American men were hospitalized for mental disturbances between 1942 and 1945, and after thirty-five days of uninterrupted combat, 98 percent of them manifested psychiatric disturbances in varying degrees.^[13]

A study based on personal letters from soldiers of the eighteenth-century Prussian Army concludes that combatants may have had PTSD.^[14] Aspects of PTSD in soldiers of ancient Assyria have been identified using written sources from 1300 to 600 B.C.E. These Assyrian soldiers would undergo a three-year rotation of combat before being allowed to return home, and were reported to have faced immense challenges in reconciling their past actions in war with their civilian lives.^[15] Connections between the actions of Viking berserkers and the hyper-arousal of post-traumatic stress disorder have also been drawn.^[16]

The initial overt focus on PTSD was as a combat related disorder when it was first fleshed out in the years following the war in Vietnam. However, other traumas may also result in similar psychological disturbance. For example, Ann Wolbert Burgess and Lynda Lytle Holmstrom defined Rape Trauma Syndrome (RTS) in order to draw attention to the striking similarities between the experiences of soldiers returning from war and of victims of rape.^[17]

Complex PTSD

Complex post-traumatic stress disorder (C-PTSD or CPTSD; also known as complex trauma disorder)^[18] is a psychological disorder that may develop in response to exposure to a series of traumatic events in a context in which the individual perceives little or no chance of escape, and particularly where the exposure is prolonged or repetitive. It is not yet recognized by the American Psychiatric Association or the DSM-5 as a valid disorder. However, the DSM-5 does list a sub-type of post-traumatic stress disorder (PTSD) called dissociative PTSD that seems to encompass C-PTSD symptoms.^[19] C-PTSD was added to the eleventh revision of the International Classification of Diseases (ICD-11).^[20] Complex PTSD is also recognized by the United States Department of Veterans Affairs (VA), Healthdirect Australia (HDA), and the British National Health Service (NHS).

C-PTSD was first described in 1992 by American psychiatrist and scholar Judith Lewis Herman in her book Trauma & Recovery, in which she described C-PTSD as distinct from, but similar to, PTSD, somatization disorder, dissociative identity disorder, and borderline personality disorder.^[11]

Children can suffer chronic trauma such as maltreatment, family violence, dysfunction, or a disruption in attachment to their primary caregiver.^[21] The term Developmental Trauma Disorder (DTD) has been proposed as the childhood equivalent of C-PTSD. This developmental form of trauma places children at risk for developing psychiatric and medical disorders.^[21] Bessel van der Kolk explains DTD as numerous encounters with interpersonal trauma such as physical assault, sexual assault, violence or death. It can also be brought on by subjective events such as abandonment, betrayal, defeat or shame.^[22]

Symptoms

Symptoms of PTSD generally begin within the first three months after the inciting traumatic event, but may not begin until years later.^[1] A person with PTSD is at a higher risk of suicide and intentional self-harm.^[2]

Symptoms may include disturbing thoughts, feelings, or dreams related to the events, mental or physical distress to trauma-related cues, attempts to avoid trauma-related cues, alterations in the way a person thinks and feels, and an increase in the fight-or-flight response. The DSM-5 diagnostic criteria for PTSD include four symptom clusters: re-experiencing, avoidance, negative alterations in cognition/mood, and alterations in arousal and reactivity.^[1] Young children are less likely to show distress but instead may express their memories through play.^[1]

In the typical case, the individual with PTSD persistently avoids either trauma-related thoughts and emotions or discussion of the traumatic event and may even have amnesia of the event.^[1] However, the event is commonly relived by the individual through intrusive, recurrent recollections, dissociative episodes of reliving the trauma ("flashbacks"), and nightmares.^[23] While it is common to have symptoms after any traumatic event, these must persist to a sufficient degree, causing dysfunction in life or clinical levels of distress, for longer than one month after the trauma to be classified as PTSD (clinically significant dysfunction or distress for less than one month after the trauma may be acute stress disorder).^[1]

The ICD-10 criteria for PTSD include re-experiencing, avoidance, and either increased reactivity or inability to recall certain details related to the event.

The ICD-11 diagnostic description for PTSD contains three components or symptom groups (1) re-experiencing, (2) avoidance, and (3) heightened sense of threat; ICD-11 no longer includes verbal thoughts about the traumatic event as a symptom.^[24]

ICD-11 also proposes identifying a distinct group with complex post-traumatic stress disorder (C-PTSD), who have more often experienced several or sustained traumas and have greater functional impairment than those with PTSD.^[24]

In addition to the symptoms of PTSD, an individual with C-PTSD experiences emotional dysregulation, negative self-beliefs and feelings of shame, guilt, or failure regarding the trauma, and interpersonal difficulties.^[20] C-PTSD relates to the trauma model of mental disorders and is associated with chronic sexual, psychological, and physical abuse or neglect, or chronic intimate partner violence, bullying, victims of kidnapping and hostage situations, indentured servants, victims of slavery and human trafficking, sweatshop workers, prisoners of war, concentration camp survivors, and prisoners kept in solitary confinement for a long period of time, or defectors from authoritarian religions. Situations involving captivity/entrapment (a situation lacking a viable escape route for the victim or a perception of such) can lead to C-PTSD-like symptoms, which can include prolonged feelings of terror, worthlessness, helplessness, and deformation of one's identity and sense of self.^[11]

Risk factors

Persons considered at risk include combat military personnel, victims of natural disasters, concentration camp survivors, and victims of violent crime. Persons employed in occupations that expose them to violence (such as soldiers) or disasters (such as emergency service workers) are also at risk.

Trauma

PTSD has been associated with a wide range of traumatic events. The risk of developing PTSD after a traumatic event varies by trauma type, and most people who experience traumatic events do not develop PTSD.^[2]

People who experience interpersonal violence such as rape, other sexual assaults, being kidnapped, stalking, physical abuse by an intimate partner, and incest or other forms of childhood sexual abuse are more likely to develop PTSD than those who experience non-assault based trauma, such as accidents and natural disasters.^[25] Those who experience prolonged trauma, such as slavery, concentration camps, or chronic domestic abuse, may develop complex post-traumatic stress disorder (C-PTSD).

Intimate partner violence

An individual that has been exposed to domestic violence is predisposed to the development of PTSD. However, being exposed to a traumatic experience does not automatically indicate that an individual will develop PTSD.^[26]

PTSD symptoms include re-experiencing the assault, avoiding things associated with the assault, numbness, and increased anxiety and an increased startle response. The likelihood of sustained symptoms of PTSD is higher if the rapist confined or restrained the person, if the person being raped believed the rapist would kill them, the person who was raped was very young or very old, and if the rapist was someone they knew. The likelihood of sustained severe symptoms is also higher if people around the survivor ignore (or are ignorant of) the rape or blame the rape survivor.^[27]

War-related trauma

While active military service is a serious risk factor for developing PTSD, refugees are also at an increased risk for PTSD due to their exposure to war, hardships, and traumatic events. While the stresses of war affect everyone involved, displaced persons have been shown to be more so than others.^[28]

Unexpected death of a loved one

Sudden, unexpected death of a loved one is the most common traumatic event type reported in cross-national studies.^[25]^[22] However, the majority of people who experience this type of event will not develop PTSD. An analysis from the WHO World Mental Health Surveys found a 5.2 percent risk of developing PTSD after learning of the unexpected death of a loved one.^[22] Because of the high prevalence of this type of traumatic event, unexpected death of a loved one accounts for approximately 20 percent of PTSD cases worldwide.^[25]

Medical trauma

Medical conditions associated with an increased risk of PTSD include cancer,^[29] heart attack, and stroke. Intensive-care unit (ICU) hospitalization is also a risk factor for PTSD.^[30] Some women experience PTSD from their experiences related to breast cancer and mastectomy.^[29] Loved ones of those who experience life-threatening illnesses are also at risk for developing PTSD, such as parents of child with chronic illnesses.^[31]

Women who experience miscarriage are at risk of PTSD, and those who experience subsequent miscarriages have an increased risk of PTSD compared to those experiencing only one.^[32]

Genetics

There is evidence that susceptibility to PTSD is hereditary. Approximately 30 percent of the variance in PTSD is caused from genetics alone.^[33] Research has also found that PTSD shares many genetic influences common to other psychiatric disorders. Panic and generalized anxiety disorders and PTSD share 60 percent of the same genetic variance. Alcohol, nicotine, and drug dependence share greater than 40 percent genetic similarities.^[33]

Diagnosis

Evidence-based assessment principles, including a multimethod assessment approach, form the foundation of PTSD assessment.^[34] There are a number of PTSD screening instruments for adults, such as the PTSD Checklist for DSM-5 (PCL-5).^[35]

There are also several screening and assessment instruments for use with children and adolescents, such as the Child PTSD Symptom Scale (CPSS) and the Child Trauma Screening Questionnaire. In addition, there are also screening and assessment instruments for caregivers of very young children (six years of age and younger), including the Young Child PTSD Screen, the Young Child PTSD Checklist, and the Diagnostic Infant and Preschool Assessment.

PTSD can be difficult to diagnose, for several reasons:

the subjective nature of most of the diagnostic criteria (although this is true for many mental disorders);
the potential for over-reporting, such as while seeking disability benefits, or when PTSD could be a mitigating factor at criminal sentencing
the potential for under-reporting, due to stigma, pride, or fear that a PTSD diagnosis might preclude certain employment opportunities;
symptom overlap with other mental disorders such as obsessive compulsive disorder and generalized anxiety disorder;^[36]
association with other mental disorders such as major depressive disorder and generalized anxiety disorder;
substance use disorders, which often produce some of the same signs and symptoms as PTSD; and
substance use disorders can increase vulnerability to PTSD or exacerbate PTSD symptoms or both; and
PTSD increases the risk for developing substance use disorders.
the differential expression of symptoms culturally (specifically with respect to avoidance and numbing symptoms, distressing dreams, and somatic symptoms)^[1]

Differential diagnosis

A diagnosis of PTSD requires that the person has been exposed to an extreme stressor. Any stressor can result in a diagnosis of adjustment disorder and it is an appropriate diagnosis for a stressor and a symptom pattern that does not meet the criteria for PTSD.

The symptom pattern for acute stress disorder must occur and be resolved within four weeks of the trauma. If it lasts longer, and the symptom pattern fits that characteristic of PTSD, the diagnosis may be changed.^[23]

Obsessive compulsive disorder may be diagnosed for intrusive thoughts that are recurring but not related to a specific traumatic event.^[23]

In extreme cases of prolonged, repeated traumatization where there is no viable chance of escape, survivors may develop complex post-traumatic stress disorder. This occurs as a result of layers of trauma rather than a single traumatic event, and includes additional symptomatology, such as the loss of a coherent sense of self.^[11]

Pathophysiology

Neuroendocrinology

PTSD symptoms may result when a traumatic event causes an over-reactive adrenaline response, which creates deep neurological patterns in the brain. These patterns can persist long after the event that triggered the fear, making an individual hyper-responsive to future fearful situations.^[26] During traumatic experiences, the high levels of stress hormones secreted suppress hypothalamic activity that may be a major factor toward the development of PTSD.^[37]

PTSD causes biochemical changes in the brain and body, that differ from other psychiatric disorders such as major depression. Most people with PTSD show a low secretion of cortisol and high secretion of catecholamines in urine, with a norepinephrine/cortisol ratio consequently higher than comparable non-diagnosed individuals.^[38] This is in contrast to the normative fight-or-flight response, in which both catecholamine and cortisol levels are elevated after exposure to a stressor.^[39]

Brain catecholamine levels are high, and corticotropin-releasing factor (CRF) concentrations are high.^[40] Together, these findings suggest abnormality in the hypothalamic-pituitary-adrenal (HPA) axis.

Hyperresponsiveness in the norepinephrine system can also be caused by continued exposure to high stress. Overactivation of norepinephrine receptors in the prefrontal cortex can be connected to the flashbacks and nightmares frequently experienced by those with PTSD. A decrease in other norepinephrine functions (awareness of the current environment) prevents the memory mechanisms in the brain from processing the experience, and emotions the person is experiencing during a flashback are not associated with the current environment.^[41]

Neuroanatomy

Regions of the brain associated with stress and post-traumatic stress disorder

Structural MRI studies have found an association with reduced total brain volume, intracranial volume, and volumes of the hippocampus, insula cortex, and anterior cingulate in PTSD in those exposed to the Vietnam War.^[40] People with PTSD have decreased brain activity in the dorsal and rostral anterior cingulate cortices and the ventromedial prefrontal cortex, areas linked to the experience and regulation of emotion.^[42]

The amygdala is strongly involved in forming emotional memories, especially fear-related memories. During high stress, the hippocampus, which is associated with placing memories in the correct context of space and time and memory recall, is suppressed. According to one theory this suppression may be the cause of the flashbacks that can affect people with PTSD. When someone with PTSD undergoes stimuli similar to the traumatic event, the body perceives the event as occurring again because the memory was never properly recorded in the person's memory.^[33]

The amygdalocentric model of PTSD proposes that the amygdala is very much aroused and insufficiently controlled by the medial prefrontal cortex and the hippocampus, in particular during extinction. This is consistent with an interpretation of PTSD as a syndrome of deficient extinction ability.^[43]

Associated medical conditions

Trauma survivors often develop depression, anxiety disorders, and mood disorders in addition to PTSD.^[44]

Substance use disorder, such as alcohol use disorder, commonly co-occur with PTSD.^[45] Recovery from post-traumatic stress disorder or other anxiety disorders may be hindered, or the condition worsened, when substance use disorders are comorbid with PTSD.

In children and adolescents, there is a strong association between emotional regulation difficulties (such as mood swings, anger outbursts, temper tantrums) and post-traumatic stress symptoms, independent of age, gender, or type of trauma.^[46]

Prevention

Prevention may be possible when counseling (psychotherapy) is targeted at those with early symptoms but has not been shown to be effective when provided to all trauma-exposed individuals whether or not symptoms are present.^[2] Modest benefits have been seen from early access to cognitive behavioral therapy.

Trauma-exposed individuals often receive treatment called psychological debriefing in an effort to prevent PTSD, which consists of interviews that are meant to allow individuals to directly confront the event and share their feelings with the counselor and to help structure their memories of the event. However, several meta-analyses find that psychological debriefing is unhelpful and is potentially harmful.^[47]

Management

The main treatments for people with PTSD are counseling (psychotherapy) and medication.^[48] Four interventions are strongly recommended, all of which are variations of cognitive behavioral therapy (CBT): Cognitive Behavioral Therapy (CBT), Cognitive Processing Therapy (CPT), Cognitive Therapy, and Prolonged Exposure. Additionally, three psychotherapies and four medications are conditionally recommended: Brief Eclectic Psychotherapy, Eye Movement Desensitization and Reprocessing (EMDR) Therapy, Narrative Exposure Therapy (NET), and the four medications sertraline, paroxetine, fluoxetine, and venlafaxine.^[49]

Benefits from medication are less than those seen with counseling; it is not known whether using medications and counseling together has greater benefit than either method separately.^[2]

Psychotherapy

Trauma-focused psychotherapies for PTSD (also known as "exposure-based" or "exposure" psychotherapies), such as prolonged exposure therapy (PE), eye movement desensitization and reprocessing (EMDR), and cognitive-reprocessing therapy (CPT) have the most evidence for efficacy and are recommended as first-line treatment for PTSD by almost all clinical practice guidelines.^[50] Exposure-based psychotherapies demonstrate efficacy for PTSD caused by different trauma "types," such as combat, sexual-assault, or natural disasters.^[51]

Counseling

The approaches with the strongest evidence include behavioral and cognitive-behavioral therapies such as prolonged exposure therapy, cognitive processing therapy, and eye movement desensitization and reprocessing (EMDR).^[49]^[52] There is some evidence for brief eclectic psychotherapy (BEP), narrative exposure therapy (NET), and written exposure therapy.^[53]

Children with PTSD are far more likely to pursue treatment at school (because of its proximity and ease) than at a free clinic.^[54]

Cognitive behavioral therapy

The diagram depicts how emotions, thoughts, and behaviors all influence each other. The triangle in the middle represents CBT's tenet that all humans' core beliefs can be summed up in three categories: self, others, future.

Cognitive behavioral therapy (CBT) seeks to change the way a person feels and acts by changing the patterns of thinking or behavior, or both, responsible for negative emotions. Results from a 2018 systematic review found high strength of evidence that supports CBT-exposure therapy efficacious for a reduction in PTSD and depression symptoms, as well as the loss of PTSD diagnosis.^[55]

In CBT, individuals learn to identify thoughts that make them feel afraid or upset and replace them with less distressing thoughts. The goal is to understand how certain thoughts about events cause PTSD-related stress.^[56]

EMDR

Eye movement desensitization and reprocessing (EMDR) is a form of psychotherapy which controls eye movements while thinking about disturbing memories.^[57] This theory proposes that eye movement can be used to facilitate emotional processing of memories, changing the person's memory to attend to more adaptive information. The therapist initiates voluntary rapid eye movements while the person focuses on memories, feelings or thoughts about a particular trauma.^[58]

EMDR closely resembles cognitive behavior therapy as it combines exposure (re-visiting the traumatic event), working on cognitive processes and relaxation/self-monitoring.^[58] However, exposure by way of being asked to think about the experience rather than talk about it has been highlighted as one of the more important distinguishing elements of EMDR.^[59]

There is moderate strength of evidence to support the efficacy of EMDR "for reduction in PTSD symptoms, loss of diagnosis, and reduction in depressive symptoms" according to a 2018 systematic review update.^[55]

Medication

While many medications do not have enough evidence to support their use, four antidepressants of the SSRI or SNRI type (sertraline, fluoxetine, paroxetine, and venlafaxine) have been shown to have a small to modest benefit over placebo.^[60]

With many medications, residual PTSD symptoms following treatment is the rule rather than the exception.^[61]

Prazosin, an alpha-1 adrenergic antagonist, has been used in veterans with PTSD to reduce nightmares. Studies show variability in the symptom improvement, appropriate dosages, and efficacy in this population.^[62]

Other

Exercise, sport, and physical activity

Physical activity, including sports and exercise, can enhance people's psychological and physical well-being. The U.S. National Center for PTSD recommends moderate exercise as a way to distract from disturbing emotions, build self-esteem, and increase feelings of being in control again. They recommend a discussion with a doctor before starting an exercise program.^[63]

Play therapy for children

Play is thought to help children link their inner thoughts with their outer world, connecting real experiences with abstract thought. Repetitive play can be one way a child relives traumatic events, and that can be a symptom of trauma in a child or young person.^[64] Play therapy is a form of psychotherapy which uses play to help overcome challenges andto reduce psychological harm from traumatic events.

Military programs

Many veterans of the wars in Iraq and Afghanistan have faced significant physical, emotional, and relational disruptions. In response, the United States Marine Corps has instituted programs to assist them in re-adjusting to civilian life, especially in their relationships with spouses and loved ones, to help them communicate better and understand what the other has gone through. Walter Reed Army Institute of Research (WRAIR) developed the Battlemind program to assist service members avoid or ameliorate PTSD and related problems. Wounded Warrior Project partnered with the US Department of Veterans Affairs to create Warrior Care Network, a national health system of PTSD treatment centers.^[65]

Notes

↑ ^1.00 ^1.01 ^1.02 ^1.03 ^1.04 ^1.05 ^1.06 ^1.07 ^1.08 ^1.09 ^1.10 ^1.11 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5 (American Psychiatric Publishing, 2013, ISBN 978-0890425558).
↑ ^2.0 ^2.1 ^2.2 ^2.3 ^2.4 ^2.5 Jonathan I. Bisson, Sarah Cosgrove, Catrin Lewis, and Neil P Roberts, Post-traumatic stress disorder BMJ 351 (November 2015): h6161. Retrieved October 9, 2023.
↑ ^3.0 ^3.1 ICD-10-CM Code for Post-traumatic stress disorder (PTSD) F43.1 Codify by AAPC. Retrieved October 10, 2023.
↑ Roland Carlstedt, Handbook of Integrative Clinical Psychology, Psychiatry, and Behavioral Medicine Perspectives, Practices, and Research (Springer Publishing Company, 2009, ISBN 0826110940).
↑ L. Stephen O'Brien, Traumatic Events and Mental Health (Cambridge University Press, 1998, ISBN 978-0521578868)
↑ Jonathan Shay, Achilles in Vietnam: Combat Trauma and the Undoing of Character (Simon & Schuster, 1995, ISBN 978-0684813219).
↑ American Psychiatric Association, DSM I: Diagnostic and Statistical Manual Mental Disorders (American Psychiatric Publishing, 1952, ISBN 978-0890420171).
↑ Arieh Y. Shalev, Rachel Yehuda, and Alexander C. McFarlane (eds.), International Handbook of Human Response to Trauma (Springer, 2012 (original 1999), ISBN 978-1461368731).
↑ Robert L. Spitzer (ed.), Diagnostic and Statistical Manual of Mental Disorders: DSM-III (American Psychiatric Association, 1980).
↑ William M. Klykylo, Jerald Kay, and David Rube, Clinical Child Psychiatry (Saunders, 1998, ISBN 978-0721638409).
↑ ^11.0 ^11.1 ^11.2 ^11.3 Judith Herman, Trauma and Recovery: The Aftermath of Violence—from Domestic Abuse to Political Terror (Basic Books, 1997, ISBN 978-0465087303).
↑ Nancy C. Andreasen, Brave New Brain: Conquering Mental Illness in the Era of the Genome (Oxford University Press, 2001, ISBN 978-0195145090).
↑ Stéphane Audoin-Rouzeau and Annette Becker, 1914-1918 Understanding the Great War (Profile Books, 2002, ISBN 978-1861973528).
↑ Sascha Möbius, Im Kugelhagel der Musketen (In the hail of musket bullets) Damals 47(12) (2015): 64–69. Retrieved October 10, 2023.
↑ Laura Clark, Ancient Assyrian Soldiers Were Haunted by War, Too Smithsonian Magazine (January 26, 2015). Retrieved October 10, 2023.
↑ Hans van Wees (ed.), War and Violence in Ancient Greece (Classical Press of Wales, 2009, ISBN 978-1905125340).
↑ Lynda Lytle Holmstrom and Ann Wolbert Burgess, The Victim of Rape: Institutional Reactions (Routledge, 1983, ISBN 978-0878559329).
↑ Alexandra Cook et al., Complex trauma in children and adolescents Psychiatric Annals 35(5) (2005): 390–398. Retrieved October 10, 2023.
↑ CPTSD (Complex PTSD) Cleveland Clinic. Retrieved October 10, 2023.
↑ ^20.0 ^20.1 World Health Organization, 6B41 Complex post traumatic stress disorder ICD-11 for Mortality and Morbidity Statistics (Version: 01/2023). Retrieved October 10, 2023.
↑ ^21.0 ^21.1 Julian D. Ford, Damion Grasso, Carolyn Greene, Joan Levine, Joseph Spinazzola, and Bessel van der Kolk, Clinical significance of a proposed developmental trauma disorder diagnosis: results of an international survey of clinicians The Journal of Clinical Psychiatry 74(8) (August 2013): 841–849. Retrieved October 10, 2023.
↑ ^22.0 ^22.1 ^22.2 L. Atwoli, et al., Posttraumatic stress disorder associated with unexpected death of a loved one: Cross-national findings from the world mental health surveys Depression and Anxiety 34(4) (April 2017): 315–326. Retrieved October 11, 2023.
↑ ^23.0 ^23.1 ^23.2 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders: DSM-IV (American Psychiatric Association, 1994, ISBN 0890420610).
↑ ^24.0 ^24.1 Chris R. Brewin et al., A review of current evidence regarding the ICD-11 proposals for diagnosing PTSD and complex PTSD Clinical Psychology Review 58 (2017): 1–15. Retrieved October 10, 2023.
↑ ^25.0 ^25.1 ^25.2 Ronald C. Kessler, Trauma and PTSD in the WHO World Mental Health Surveys European Journal of Psychotraumatology 8(sup5) (2017): 1353383. Retrieved October 10, 2023.
↑ ^26.0 ^26.1 Babette Rothschild, The Body Remembers: The Psychophysiology of Trauma and Trauma Treatment (W. W. Norton & Company, 2000, ISBN 978-0393703276).
↑ Fiona Mason and Zoe Lodrick, Psychological consequences of sexual assault Best Practice & Research. Clinical Obstetrics & Gynaecology 27(1) (2013): 27–37. Retrieved October 10, 2023.
↑ M. Porter and N. Haslam, Forced displacement in Yugoslavia: a meta-analysis of psychological consequences and their moderators Journal of Traumatic Stress 14(4) (October 2001): 817–834. Retrieved October 10, 2023.
↑ ^29.0 ^29.1 Cancer-Related Post-traumatic Stress National Cancer Institute. Retrieved October 11, 2023.
↑ D.S Davydow et al., Posttraumatic stress disorder in general intensive care unit survivors: a systematic review General Hospital Psychiatry 30(5) (September 2008): 421–434.
↑ M. Cabizuca, et al., Posttraumatic stress disorder in parents of children with chronic illnesses: A meta-analysis Health Psychology 28(3) (2009): 379–388. Retrieved October 11, 2023.
↑ D.M. Christiansen, Posttraumatic stress disorder in parents following infant death: A systematic review Clinical Psychology Review 51 (February 2017): 60–74.
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↑ David Forbes, Jonathan I. Bisson, Candice M. Monson, and Lucy Berliner (eds.), Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies (The Guilford Press, 2020, ISBN 978-1462543564).
↑ PTSD Checklist for DSM-5 (PCL-5) National Center for PTSD. Retrieved October 12, 2023.
↑ Michael B. First, DSM-5® Handbook of Differential Diagnosis (American Psychiatric Publishing, 2013, ISBN 978-1585624621).
↑ {J. Zohar, A. Juven-Wetzler, V. Myers, and L. Fostick, Post-traumatic stress disorder: facts and fiction Current Opinion in Psychiatry 21(1) (January 2008): 74–77
↑ J.W. Mason, E.L. Giller, T.R. Kosten, and L. Harkness, Elevation of urinary norepinephrine/cortisol ratio in posttraumatic stress disorder The Journal of Nervous and Mental Disease 176(8) (August 1988): 498–502.
↑ N. Bohnen, N. Nicolson, J. Sulon, and J. Jolles, Coping style, trait anxiety and cortisol reactivity during mental stress Journal of Psychosomatic Research 35(2–3) (1991): 141–147.
↑ ^40.0 ^40.1 E. Ronald de Kloet, Melly S. Oitzl, and Eric Vermetten (eds.), Stress Hormones and Post Traumatic Stress Disorder: Basic Studies and Clinical Perspectives (Elsevier Science, 2008, ISBN 978-0444531407).
↑ T.M. Olszewski, and J.F. Varrasse, The neurobiology of PTSD: implications for nurses Journal of Psychosocial Nursing and Mental Health Services 43(6) (June 2005): 40–47.
↑ A. Etkin A, and T.D. Wager, Functional neuroimaging of anxiety: a meta-analysis of emotional processing in PTSD, social anxiety disorder, and specific phobia The American Journal of Psychiatry 164(10) (October 2007): 1476–1488.
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↑ M.L. O'Donnell, et al., Posttraumatic disorders following injury: an empirical and methodological review Clinical Psychology Review 23(4) (July 2003): 587–603.
↑ Sidney H. Kennedy, Jerrold S. Maxmen, and Roger S. McIntyre, Psychotropic Drugs: Fast facts (W. W. Norton & Company, 2008, ISBN 978-0393705201).
↑ L. Villalta, P. Smith, N. Hickin, and A. Stringaris, Emotion regulation difficulties in traumatized youth: a meta-analysis and conceptual review European Child & Adolescent Psychiatry 27(4) (April 2018): 527–544.
↑ U.S. Department of Health and Human Services, Interventions for the Prevention of Posttraumatic Stress Disorder (PTSD) in Adults After Exposure to Psychological Trauma (Agency for Healthcare Research and Quality (US), 2013, ISBN 978-1490363608).
↑ Post-Traumatic Stress Disorder National Institute of Mental Health. Retrieved October 13, 2023.
↑ ^49.0 ^49.1 PTSD Treatments Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults (American Psychological Association, June 2020). Retrieved October 13, 2023.
↑ J.L. Hamblen, et al., A guide to guidelines for the treatment of posttraumatic stress disorder in adults: An update Psychotherapy 56(3) (September 2019): 359–373.
↑ C.L. Straud, J. Siev, S. Messer, and A.K. Zalta, Examining military population and trauma type as moderators of treatment outcome for first-line psychotherapies for PTSD: A meta-analysis Journal of Anxiety Disorders 67 (October 2019): 102133.
↑ Steven Taylor (ed.), Advances in the Treatment of Posttraumatic Stress Disorder: Cognitive-behavioral perspectives (Springer Publishing Company, 2004, ISBN 978-0826120472).
↑ Denise M. Sloan and Brian P. Marx, Written Exposure Therapy for PTSD: A Brief Treatment Approach for Mental Health Professionals (Washington DC: American Psychological Association, 2019, ISBN 978-1433830129).
↑ E.S. Rolfsnes and T. Idsoe, School-based intervention programs for PTSD symptoms: a review and meta-analysis Journal of Traumatic Stress 24(2) (April 2011): 155–165.
↑ ^55.0 ^55.1 V. Hoffman, et al., Psychological and Pharmacological Treatments for Adults With Posttraumatic Stress Disorder: A Systematic Review Update Rockville, MD: Agency for Healthcare Research and Quality (May 2018). Retrieved October 13, 2023.
↑ Cognitive Behavioral Therapy (CBT) Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults (American Psychological Association, June 2020). Retrieved October 13, 2023.
↑ Francine Shapiro, Efficacy of the eye movement desensitization procedure in the treatment of traumatic memories Journal of Traumatic Stress 2(2) (April 1989): 199–223.
↑ ^58.0 ^58.1 National Collaborating Centre for Mental Health, Post-Traumatic Stress Disorder: The Management of PTSD in Adults and Children in Primary and Secondary Care (British Psychological Society and RCPsych Publications, 2005, ISBN 978-1904671251).
↑ F.W. Jeffries and P. Davis, What is the role of eye movements in eye movement desensitization and reprocessing (EMDR) for post-traumatic stress disorder (PTSD)? a review Behavioural and Cognitive Psychotherapy 41(3) (May 2013): 290–300.
↑ M. Hoskins, et al., Pharmacotherapy for post-traumatic stress disorder: systematic review and meta-analysis The British Journal of Psychiatry 206(2) (February 2015): 93–100.
↑ J.H. Krystal and A. Neumeister, Noradrenergic and serotonergic mechanisms in the neurobiology of posttraumatic stress disorder and resilience Brain Research 1293 (October 2009): 13–23.
↑ B. Green, Prazosin in the treatment of PTSD Journal of Psychiatric Practice 20(4) (July 2014): 253–259.
↑ Lifestyle Changes Recommended for PTSD Patients National Center for PTSD. Retrieved October 12, 2023.
↑ Eric J. Mash and Russell A. Barkley (eds.), Child Psychopathology (The Guilford Press, 2002, ISBN 978-1572306097).
↑ Kevin Cullen, Covering all the bases for veterans The Boston Globe (May 2, 2016). Retrieved October 12, 2023.

References
ISBN links support NWE through referral fees

American Psychiatric Association. DSM I: Diagnostic and Statistical Manual Mental Disorders. American Psychiatric Publishing, 1952. ISBN 978-0890420171
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV. American Psychiatric Association, 1994. ISBN 0890420610
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5. American Psychiatric Publishing, 2013. ISBN 978-0890425558
Andreasen, Nancy C. Brave New Brain: Conquering Mental Illness in the Era of the Genome. Oxford University Press, 2001. ISBN 978-0195145090
Audoin-Rouzeau, Stéphane, and Annette Becker. 1914-1918 Understanding the Great War. Profile Books, 2002. ISBN 978-1861973528
Carlstedt, Roland. Handbook of Integrative Clinical Psychology, Psychiatry, and Behavioral Medicine Perspectives, Practices, and Research. Springer Publishing Company, 2009. ISBN 0826110940
First, Michael B. DSM-5® Handbook of Differential Diagnosis. American Psychiatric Publishing, 2013. ISBN 978-1585624621
Forbes, David, Jonathan I. Bisson, Candice M. Monson, and Lucy Berliner (eds.). Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies. The Guilford Press, 2020. ISBN 978-1462543564
Holmstrom, Lynda Lytle, and Ann Wolbert Burgess. The Victim of Rape: Institutional Reactions. Routledge, 1983. ISBN 978-0878559329
Kennedy, Sidney H., Jerrold S. Maxmen, and Roger S. McIntyre. Psychotropic Drugs: Fast facts. W. W. Norton & Company, 2008. ISBN 978-0393705201
de Kloet, E. Ronald, Melly S. Oitzl, and Eric Vermetten (eds.). Stress Hormones and Post Traumatic Stress Disorder: Basic Studies and Clinical Perspectives. Elsevier Science, 2008. ISBN 978-0444531407
Klykylo, William M., Jerald Kay, and David Rube. Clinical Child Psychiatry. Saunders, 1998. ISBN 978-0721638409
Mash, Eric J., and Russell A. Barkley (eds.). Child Psychopathology. The Guilford Press, 2002. ISBN 978-1572306097
National Collaborating Centre for Mental Health. Post-Traumatic Stress Disorder: The Management of PTSD in Adults and Children in Primary and Secondary Care. British Psychological Society and RCPsych Publications, 2005. ISBN 978-1904671251
O'Brien, L. Stephen. Traumatic Events and Mental Health. Cambridge University Press, 1998. ISBN 978-0521578868
Rothschild, Babette. The Body Remembers: The Psychophysiology of Trauma and Trauma Treatment. W. W. Norton & Company, 2000. ISBN 978-0393703276
Shalev, Arieh Y., Rachel Yehuda, and Alexander C. McFarlane (eds.). International Handbook of Human Response to Trauma. Springer, 2012 (original 1999). ISBN 978-1461368731
Shay, Jonathan. Achilles in Vietnam: Combat Trauma and the Undoing of Character. Simon & Schuster, 1995. ISBN 978-0684813219
Sloan, Denise M., and Brian P. Marx. Written Exposure Therapy for PTSD: A Brief Treatment Approach for Mental Health Professionals. Washington DC: American Psychological Association, 2019. ISBN 978-1433830129
Spitzer, Robert L. (ed.). Diagnostic and Statistical Manual of Mental Disorders: DSM-III. American Psychiatric Association, 1980. ASIN B000P1A7CK
Taylor,Steven (ed.). Advances in the Treatment of Posttraumatic Stress Disorder: Cognitive-behavioral perspectives. Springer Publishing Company, 2004. ISBN 978-0826120472
U.S. Department of Health and Human Services. Interventions for the Prevention of Posttraumatic Stress Disorder (PTSD) in Adults After Exposure to Psychological Trauma. Agency for Healthcare Research and Quality (US), 2013. ISBN 978-1490363608
van Wees, Hans (ed.). War and Violence in Ancient Greece. Classical Press of Wales, 2009., ISBN 978-1905125340

External links

All links retrieved

Post-Traumatic Stress Disorder (PTSD) SAMHSA
Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults (2017) APA
PTSD: National Center for PTSD U.S. Department of Veterans Affairs
Post-traumatic stress disorder (PTSD) Mayo Clinic
Understanding Complex PTSD New Method Wellness
What is Posttraumatic Stress Disorder (PTSD)? American Psychiatric Association
Post-Traumatic Stress Disorder National Institute of Mental Health

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The history of this article since it was imported to New World Encyclopedia:

History of "Post-traumatic stress disorder"

Note: Some restrictions may apply to use of individual images which are separately licensed.

[DSM5-1] 1.00 ^1.01 ^1.02 ^1.03 ^1.04 ^1.05 ^1.06 ^1.07 ^1.08 ^1.09 ^1.10 ^1.11 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5 (American Psychiatric Publishing, 2013, ISBN 978-0890425558).

[BMJ2015-2] 2.0 ^2.1 ^2.2 ^2.3 ^2.4 ^2.5 Jonathan I. Bisson, Sarah Cosgrove, Catrin Lewis, and Neil P Roberts, Post-traumatic stress disorder BMJ 351 (November 2015): h6161. Retrieved October 9, 2023.

[ICD10-3] 3.0 ^3.1 ICD-10-CM Code for Post-traumatic stress disorder (PTSD) F43.1 Codify by AAPC. Retrieved October 10, 2023.

[4] Roland Carlstedt, Handbook of Integrative Clinical Psychology, Psychiatry, and Behavioral Medicine Perspectives, Practices, and Research (Springer Publishing Company, 2009, ISBN 0826110940).

[5] L. Stephen O'Brien, Traumatic Events and Mental Health (Cambridge University Press, 1998, ISBN 978-0521578868)

[6] Jonathan Shay, Achilles in Vietnam: Combat Trauma and the Undoing of Character (Simon & Schuster, 1995, ISBN 978-0684813219).

[7] American Psychiatric Association, DSM I: Diagnostic and Statistical Manual Mental Disorders (American Psychiatric Publishing, 1952, ISBN 978-0890420171).

[8] Arieh Y. Shalev, Rachel Yehuda, and Alexander C. McFarlane (eds.), International Handbook of Human Response to Trauma (Springer, 2012 (original 1999), ISBN 978-1461368731).

[9] Robert L. Spitzer (ed.), Diagnostic and Statistical Manual of Mental Disorders: DSM-III (American Psychiatric Association, 1980).

[10] William M. Klykylo, Jerald Kay, and David Rube, Clinical Child Psychiatry (Saunders, 1998, ISBN 978-0721638409).

[Herman-11] 11.0 ^11.1 ^11.2 ^11.3 Judith Herman, Trauma and Recovery: The Aftermath of Violence—from Domestic Abuse to Political Terror (Basic Books, 1997, ISBN 978-0465087303).

[12] Nancy C. Andreasen, Brave New Brain: Conquering Mental Illness in the Era of the Genome (Oxford University Press, 2001, ISBN 978-0195145090).

[13] Stéphane Audoin-Rouzeau and Annette Becker, 1914-1918 Understanding the Great War (Profile Books, 2002, ISBN 978-1861973528).

[14] Sascha Möbius, Im Kugelhagel der Musketen (In the hail of musket bullets) Damals 47(12) (2015): 64–69. Retrieved October 10, 2023.

[15] Laura Clark, Ancient Assyrian Soldiers Were Haunted by War, Too Smithsonian Magazine (January 26, 2015). Retrieved October 10, 2023.

[16] Hans van Wees (ed.), War and Violence in Ancient Greece (Classical Press of Wales, 2009, ISBN 978-1905125340).

[17] Lynda Lytle Holmstrom and Ann Wolbert Burgess, The Victim of Rape: Institutional Reactions (Routledge, 1983, ISBN 978-0878559329).

[Cook2005-18] Alexandra Cook et al., Complex trauma in children and adolescents Psychiatric Annals 35(5) (2005): 390–398. Retrieved October 10, 2023.

[19] CPTSD (Complex PTSD) Cleveland Clinic. Retrieved October 10, 2023.

[ICD11-20] 20.0 ^20.1 World Health Organization, 6B41 Complex post traumatic stress disorder ICD-11 for Mortality and Morbidity Statistics (Version: 01/2023). Retrieved October 10, 2023.

[Ford-21] 21.0 ^21.1 Julian D. Ford, Damion Grasso, Carolyn Greene, Joan Levine, Joseph Spinazzola, and Bessel van der Kolk, Clinical significance of a proposed developmental trauma disorder diagnosis: results of an international survey of clinicians The Journal of Clinical Psychiatry 74(8) (August 2013): 841–849. Retrieved October 10, 2023.

[Atwoli-22] 22.0 ^22.1 ^22.2 L. Atwoli, et al., Posttraumatic stress disorder associated with unexpected death of a loved one: Cross-national findings from the world mental health surveys Depression and Anxiety 34(4) (April 2017): 315–326. Retrieved October 11, 2023.

[DSM4-23] 23.0 ^23.1 ^23.2 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders: DSM-IV (American Psychiatric Association, 1994, ISBN 0890420610).

[:7-24] 24.0 ^24.1 Chris R. Brewin et al., A review of current evidence regarding the ICD-11 proposals for diagnosing PTSD and complex PTSD Clinical Psychology Review 58 (2017): 1–15. Retrieved October 10, 2023.

[Kessler-25] 25.0 ^25.1 ^25.2 Ronald C. Kessler, Trauma and PTSD in the WHO World Mental Health Surveys European Journal of Psychotraumatology 8(sup5) (2017): 1353383. Retrieved October 10, 2023.

[Rothschild-26] 26.0 ^26.1 Babette Rothschild, The Body Remembers: The Psychophysiology of Trauma and Trauma Treatment (W. W. Norton & Company, 2000, ISBN 978-0393703276).

[27] Fiona Mason and Zoe Lodrick, Psychological consequences of sexual assault Best Practice & Research. Clinical Obstetrics & Gynaecology 27(1) (2013): 27–37. Retrieved October 10, 2023.

[28] M. Porter and N. Haslam, Forced displacement in Yugoslavia: a meta-analysis of psychological consequences and their moderators Journal of Traumatic Stress 14(4) (October 2001): 817–834. Retrieved October 10, 2023.

[cancer.gov-29] 29.0 ^29.1 Cancer-Related Post-traumatic Stress National Cancer Institute. Retrieved October 11, 2023.

[30] D.S Davydow et al., Posttraumatic stress disorder in general intensive care unit survivors: a systematic review General Hospital Psychiatry 30(5) (September 2008): 421–434.

[31] M. Cabizuca, et al., Posttraumatic stress disorder in parents of children with chronic illnesses: A meta-analysis Health Psychology 28(3) (2009): 379–388. Retrieved October 11, 2023.

[32] D.M. Christiansen, Posttraumatic stress disorder in parents following infant death: A systematic review Clinical Psychology Review 51 (February 2017): 60–74.

[Skelton_2012_628.E2.80.93637-33] 33.0 ^33.1 ^33.2 Kelly Skelton, Kerry J Ressler, Seth D Norrholm, Tanja Jovanovic, and Bekh Bradley-Davino, PTSD and gene variants: new pathways and new thinking Neuropharmacology 62(2) (February 2012): 628–637. Retrieved October 12, 2023.

[34] David Forbes, Jonathan I. Bisson, Candice M. Monson, and Lucy Berliner (eds.), Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies (The Guilford Press, 2020, ISBN 978-1462543564).

[35] PTSD Checklist for DSM-5 (PCL-5) National Center for PTSD. Retrieved October 12, 2023.

[36] Michael B. First, DSM-5® Handbook of Differential Diagnosis (American Psychiatric Publishing, 2013, ISBN 978-1585624621).

[37] {J. Zohar, A. Juven-Wetzler, V. Myers, and L. Fostick, Post-traumatic stress disorder: facts and fiction Current Opinion in Psychiatry 21(1) (January 2008): 74–77

[38] J.W. Mason, E.L. Giller, T.R. Kosten, and L. Harkness, Elevation of urinary norepinephrine/cortisol ratio in posttraumatic stress disorder The Journal of Nervous and Mental Disease 176(8) (August 1988): 498–502.

[39] N. Bohnen, N. Nicolson, J. Sulon, and J. Jolles, Coping style, trait anxiety and cortisol reactivity during mental stress Journal of Psychosomatic Research 35(2–3) (1991): 141–147.

[Kloet-40] 40.0 ^40.1 E. Ronald de Kloet, Melly S. Oitzl, and Eric Vermetten (eds.), Stress Hormones and Post Traumatic Stress Disorder: Basic Studies and Clinical Perspectives (Elsevier Science, 2008, ISBN 978-0444531407).

[41] T.M. Olszewski, and J.F. Varrasse, The neurobiology of PTSD: implications for nurses Journal of Psychosocial Nursing and Mental Health Services 43(6) (June 2005): 40–47.

[42] A. Etkin A, and T.D. Wager, Functional neuroimaging of anxiety: a meta-analysis of emotional processing in PTSD, social anxiety disorder, and specific phobia The American Journal of Psychiatry 164(10) (October 2007): 1476–1488.

[43] M.R. Milad, et al., Neurobiological basis of failure to recall extinction memory in posttraumatic stress disorder Biological Psychiatry 66(12) (December 2009): 1075–1082.

[44] M.L. O'Donnell, et al., Posttraumatic disorders following injury: an empirical and methodological review Clinical Psychology Review 23(4) (July 2003): 587–603.

[45] Sidney H. Kennedy, Jerrold S. Maxmen, and Roger S. McIntyre, Psychotropic Drugs: Fast facts (W. W. Norton & Company, 2008, ISBN 978-0393705201).

[46] L. Villalta, P. Smith, N. Hickin, and A. Stringaris, Emotion regulation difficulties in traumatized youth: a meta-analysis and conceptual review European Child & Adolescent Psychiatry 27(4) (April 2018): 527–544.

[47] U.S. Department of Health and Human Services, Interventions for the Prevention of Posttraumatic Stress Disorder (PTSD) in Adults After Exposure to Psychological Trauma (Agency for Healthcare Research and Quality (US), 2013, ISBN 978-1490363608).

[48] Post-Traumatic Stress Disorder National Institute of Mental Health. Retrieved October 13, 2023.

[PTSDTreatements-49] 49.0 ^49.1 PTSD Treatments Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults (American Psychological Association, June 2020). Retrieved October 13, 2023.

[50] J.L. Hamblen, et al., A guide to guidelines for the treatment of posttraumatic stress disorder in adults: An update Psychotherapy 56(3) (September 2019): 359–373.

[51] C.L. Straud, J. Siev, S. Messer, and A.K. Zalta, Examining military population and trauma type as moderators of treatment outcome for first-line psychotherapies for PTSD: A meta-analysis Journal of Anxiety Disorders 67 (October 2019): 102133.

[52] Steven Taylor (ed.), Advances in the Treatment of Posttraumatic Stress Disorder: Cognitive-behavioral perspectives (Springer Publishing Company, 2004, ISBN 978-0826120472).

[53] Denise M. Sloan and Brian P. Marx, Written Exposure Therapy for PTSD: A Brief Treatment Approach for Mental Health Professionals (Washington DC: American Psychological Association, 2019, ISBN 978-1433830129).

[54] E.S. Rolfsnes and T. Idsoe, School-based intervention programs for PTSD symptoms: a review and meta-analysis Journal of Traumatic Stress 24(2) (April 2011): 155–165.

[Hoffman-55] 55.0 ^55.1 V. Hoffman, et al., Psychological and Pharmacological Treatments for Adults With Posttraumatic Stress Disorder: A Systematic Review Update Rockville, MD: Agency for Healthcare Research and Quality (May 2018). Retrieved October 13, 2023.

[56] Cognitive Behavioral Therapy (CBT) Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults (American Psychological Association, June 2020). Retrieved October 13, 2023.

[57] Francine Shapiro, Efficacy of the eye movement desensitization procedure in the treatment of traumatic memories Journal of Traumatic Stress 2(2) (April 1989): 199–223.

[UK2005-58] 58.0 ^58.1 National Collaborating Centre for Mental Health, Post-Traumatic Stress Disorder: The Management of PTSD in Adults and Children in Primary and Secondary Care (British Psychological Society and RCPsych Publications, 2005, ISBN 978-1904671251).

[59] F.W. Jeffries and P. Davis, What is the role of eye movements in eye movement desensitization and reprocessing (EMDR) for post-traumatic stress disorder (PTSD)? a review Behavioural and Cognitive Psychotherapy 41(3) (May 2013): 290–300.

[60] M. Hoskins, et al., Pharmacotherapy for post-traumatic stress disorder: systematic review and meta-analysis The British Journal of Psychiatry 206(2) (February 2015): 93–100.

[61] J.H. Krystal and A. Neumeister, Noradrenergic and serotonergic mechanisms in the neurobiology of posttraumatic stress disorder and resilience Brain Research 1293 (October 2009): 13–23.

[62] B. Green, Prazosin in the treatment of PTSD Journal of Psychiatric Practice 20(4) (July 2014): 253–259.

[63] Lifestyle Changes Recommended for PTSD Patients National Center for PTSD. Retrieved October 12, 2023.

[64] Eric J. Mash and Russell A. Barkley (eds.), Child Psychopathology (The Guilford Press, 2002, ISBN 978-1572306097).

[65] Kevin Cullen, Covering all the bases for veterans The Boston Globe (May 2, 2016). Retrieved October 12, 2023.

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@@ Line 1: / Line 1: @@
+{{Images OK}}{{Submitted}}{{Approved}}{{Copyedited}}
 {{Infobox medical condition (new)
 | name          = Post-traumatic stress disorder
-| image        =
+| image        = File:PTSD.png
 | image_size    =
-| caption      = [[Art therapy]] project created by a [[U.S. Marine]] with post-traumatic stress disorder
+| caption      =
 | field        = [[Psychiatry]], [[clinical psychology]]
 | symptoms      = Disturbing thoughts, feelings, or [[dreams]] related to the event; mental or physical distress to trauma-related cues; efforts to avoid trauma-related situations; increased [[fight-or-flight response]]<ref name=DSM5/>
-| complications = [[Self-harm]], [[suicide]]<ref name=BMJ2015/>
+| complications = [[Self-harm]], [[suicide]]<ref name=BMJ2015>Jonathan I. Bisson, Sarah Cosgrove, Catrin Lewis, and Neil P Roberts, [https://www.bmj.com/content/351/bmj.h6161 Post-traumatic stress disorder] ''BMJ'' 351 (November 2015): h6161. Retrieved October 9, 2023.</ref>
 | onset        =
 | duration      = > 1 month<ref name=DSM5/>
@@ Line 15: / Line 15: @@
 | differential  =
 | prevention    =
-| treatment    = Counseling, medication<ref name=NIH2016/>
+| treatment    = Counseling, medication
-| medication    = [[Selective serotonin reuptake inhibitor]]<ref name="Berger-2009"/>
+| medication    = [[Selective serotonin reuptake inhibitor]]
 | prognosis    =
-| frequency    = 8.7% ([[Prevalence#Lifetime prevalence|lifetime risk]]); 3.5% ([[Prevalence#Period prevalence|12-month risk]]) (US)<ref>{{Cite book|title=Diagnostic and statistical manual of mental disorders: DSM-5|date=2013|publisher=American Psychiatric Association |isbn=9780890425558|edition=5th|location=Arlington, VA|oclc=830807378|page=[https://archive.org/details/diagnosticstatis0005unse/page/276 276]|url=https://archive.org/details/diagnosticstatis0005unse/page/276}}</ref>
+| frequency    = 8.7% ([[Prevalence#Lifetime prevalence|lifetime risk]]); 3.5% ([[Prevalence#Period prevalence|12-month risk]]) (US)<ref name=DSM5/>
 | deaths        =
 | alt          =
 }}
-<!-- Definition and symptoms —>
-'''Post-traumatic stress disorder''' ('''PTSD'''){{efn|Acceptable variants of this term exist; see the ''[[#Terminology|Terminology]]'' section in this article.}} is a [[mental disorder|mental]] and [[Abnormal behavior|behavioral]] [[Disorder (medicine)|disorder]]<ref>Drs; {{cite web |url=https://www.who.int/classifications/icd/en/bluebook.pdf |title= The ICD-10 Classification of Mental and Behavioural Disorders Clinical descriptions and diagnostic guidelines |first1=Norman|last1= Sartorius|author-link=Norman Sartorius|last2=  Henderson|first2=A.S.|last3= Strotzka|first3=H.|last4= Lipowski|first4=Z. |last5= Yu-cun|first5=Shen|last6=You-xin|first6=Xu |last7=Strömgren|first7=E. |last8= Glatzel|first8=J. |last9= Kühne|first9=G.-E.|last10= Misès|first10=R.|last11=Soldatos|first11=C.R. |last12= Pull|first12=C.B.|last13= Giel|first13=R.|last14= Jegede|first14=R.|last15=Malt|first15=U. |last16= Nadzharov|first16=R.A.|last17=  Smulevitch|first17=A.B.|last18= Hagberg|first18=B.|last19=  Perris|first19=C.|last20= Scharfetter|first20=C. |last21= Clare|first21=A. |last22= Cooper|first22=J.E. |last23= Corbett|first23=J.A. |last24=Griffith Edwards |first24=J. |last25= Gelder|first25=M.|last26= Goldberg|first26=D.|last27= Gossop|first27=M.|last28= Graham|first28=P.|last29=Kendell|first29=R.E. |last30= Marks|first30=I.|last31= Russell|first31=G.|last32= Rutter|first32=M.|last33=  Shepherd|first33=M.|last34=  West |first34=D.J.|last35= Wing |first35=J. |last36= Wing|first36=L.|last37= Neki|first37=J.S. |last38= Benson|first38=F.|last39= Cantwell|first39=D. |last40=Guze|first40=S. |last41= Helzer|first41=J.|last42=  Holzman|first42=P.|last43=  Kleinman|first43=A.|last44=Kupfer|first44=D.J.|last45= Mezzich|first45=J. |last46= Spitzer|first46=R. |last47=Lokar |first47=J. |website=www.who.int [[World Health Organization]] |publisher=[[Microsoft Word]]  |agency=bluebook.doc |pages=110|access-date=3 July 2021 |via=[[Microsoft Bing]]}}</ref> that can develop because of exposure to a [[Psychological trauma|traumatic]] event, such as [[sexual assault]], [[warfare]], [[traffic collision]]s, [[child abuse]], [[domestic violence]], or other threats on a person's life.<ref name=DSM5>{{cite book |author=American Psychiatric Association |year=2013 |title=Diagnostic and Statistical Manual of Mental Disorders |edition=5th |publisher=American Psychiatric Publishing |location=Arlington, VA |pages=[https://archive.org/details/diagnosticstatis0005unse/page/271 271–80] |isbn=978-0-89042-555-8 |url=https://archive.org/details/diagnosticstatis0005unse/page/271 }}</ref><ref>{{Cite web|url=https://www.mayoclinic.org/diseases-conditions/post-traumatic-stress-disorder/symptoms-causes/syc-20355967|title=Post-traumatic stress disorder (PTSD) - Symptoms and causes|website=Mayo Clinic|access-date=2019-10-08}}</ref> Symptoms may include disturbing [[thoughts]], [[emotions|feelings]], or [[dreams]] related to the events, mental or physical [[distress (medicine)|distress]] to [[Psychological trauma|trauma]]-related cues, attempts to avoid trauma-related cues, alterations in the way a person thinks and feels, and an increase in the [[fight-or-flight response]].<ref name=DSM5/><ref name=NIH2016/> These symptoms last for more than a month after the event.<ref name=DSM5/> Young children are less likely to show distress but instead may express their memories through [[play (activity)|play]].<ref name=DSM5/> A person with PTSD is at a higher risk of [[suicide]] and intentional [[self-harm]].<ref name=BMJ2015/><ref>{{cite journal | vauthors = Panagioti M, Gooding PA, Triantafyllou K, Tarrier N | s2cid = 23314414 | title = Suicidality and posttraumatic stress disorder (PTSD) in adolescents: a systematic review and meta-analysis | journal = Social Psychiatry and Psychiatric Epidemiology | volume = 50 | issue = 4 | pages = 525–37 | date = April 2015 | pmid = 25398198 | doi = 10.1007/s00127-014-0978-x }}</ref>
-<!-- Cause and diagnosis -->
+'''Post-traumatic stress disorder''' ('''PTSD''') is a [[mental disorder|mental]] and [[Abnormal behavior|behavioral]] [[Disorder (medicine)|disorder]] that can develop because of exposure to a [[Psychological trauma|traumatic]] event, such as [[sexual assault]], [[warfare]], [[traffic collision]]s, [[child abuse]], [[domestic violence]], or other threats on a person's life. Symptoms may include disturbing [[thoughts]], [[emotions|feelings]], or [[dreams]] related to the events, mental or physical [[distress (medicine)|distress]] to [[Psychological trauma|trauma]]-related cues, attempts to avoid trauma-related cues, alterations in the way a person thinks and feels, and an increase in the [[fight-or-flight response]]. These symptoms last for more than a month after the event.
-Most people who experience traumatic events do not develop PTSD.<ref name=BMJ2015/> People who experience interpersonal violence such as rape, other sexual assaults, being kidnapped, stalking, physical abuse by an intimate partner, and incest or other forms of childhood sexual abuse are more likely to develop PTSD than those who experience non-[[assault]] based trauma, such as accidents and [[natural disasters]].<ref name=Zoladz>{{cite journal | vauthors = Zoladz PR, Diamond DM | s2cid = 14440116 | title = Current status on behavioral and biological markers of PTSD: a search for clarity in a conflicting literature | journal = Neuroscience and Biobehavioral Reviews | volume = 37 | issue = 5 | pages = 860–95 | date = June 2013 | pmid = 23567521 | doi = 10.1016/j.neubiorev.2013.03.024 }}</ref><ref>{{Cite journal|last1=Kessler|first1=Ronald C.|last2=Aguilar-Gaxiola|first2=Sergio|last3=Alonso|first3=Jordi|last4=Benjet|first4=Corina|last5=Bromet|first5=Evelyn J.|last6=Cardoso|first6=Graça|last7=Degenhardt|first7=Louisa|last8=Girolamo|first8=Giovanni de|last9=Dinolova|first9=Rumyana V.|last10=Ferry|first10=Finola|last11=Florescu|first11=Silvia|date=2017-10-27|title=Trauma and PTSD in the WHO World Mental Health Surveys|url=https://doi.org/10.1080/20008198.2017.1353383|journal=European Journal of Psychotraumatology|volume=8|issue=sup5|pages=1353383|doi=10.1080/20008198.2017.1353383|issn=2000-8198|pmc=5632781|pmid=29075426|quote=As detailed in another recent WMH report, conditional risk of PTSD after trauma exposure is 4.0%, but varies significantly by trauma type. The highest conditional risk is associated with being raped (19.0%), physical abuse by a romantic partner (11.7%), being kidnapped (11.0%), and being sexually assaulted other than rape (10.5%). In terms of broader categories, the traumas associated with the highest PTSD risk are those involving ''intimate partner or sexual violence'' (11.4%), and ''other traumas'' (9.2%), with aggregate conditional risk much lower in the other broad trauma categories (2.0–5.4%) [citations omitted; emphasis added].}}</ref><ref>{{Cite journal|last1=Darves-Bornoz|first1=Jean-Michel|last2=Alonso|first2=Jordi|last3=Girolamo|first3=Giovanni de|last4=Graaf|first4=Ron de|last5=Haro|first5=Josep-Maria|last6=Kovess-Masfety|first6=Viviane|last7=Lepine|first7=Jean-Pierre|last8=Nachbaur|first8=Gaëlle|last9=Negre-Pages|first9=Laurence|last10=Vilagut|first10=Gemma|last11=Gasquet|first11=Isabelle|date=2008|title=Main traumatic events in Europe: PTSD in the European study of the epidemiology of mental disorders survey|url=https://onlinelibrary.wiley.com/doi/abs/10.1002/jts.20357|journal=Journal of Traumatic Stress|language=en|volume=21|issue=5|pages=455–462|doi=10.1002/jts.20357|pmid=18956444|issn=1573-6598|quote=In univariate analyses adjusted on gender, six events were found to be the most significantly associated with PTSD ( p < .001) among individuals exposed to at least one event. They were being raped (OR = 8.9), being beaten up by spouse or romantic partner (OR = 7.3), experiencing an undisclosed private event (OR = 5.5), having a child with serious illness (OR = 5.1), being beaten up by a caregiver (OR = 4.5), or being stalked (OR = 4.2)" [OR = odds ratio].}}</ref> Those who experience prolonged trauma, such as slavery, concentration camps, or chronic domestic abuse, may develop [[complex post-traumatic stress disorder]] (C-PTSD). C-PTSD is similar to PTSD but has a distinct effect on a person's [[Emotional self-regulation|emotional regulation]] and core identity.<ref>Brewin CR, Cloitre M, Hyland P, Shevlin M, Maercker A, Bryant RA, et al. (December 2017). "[http://mural.maynoothuniversity.ie/11577/1/Hyland_Review_2017.pdf A review of current evidence regarding the ICD-11 proposals for diagnosing PTSD and complex PTSD]" (PDF). Clinical Psychology Review. '''58''': 1–15. [[Doi (identifier)|doi]]:10.1016/j.cpr.2017.09.001. [[PMID (identifier)|PMID]] 29029837.</ref>
-<!-- Prevention and treatment —>
+A person with PTSD is at a higher risk of [[suicide]] and intentional [[self-harm]]. Their ability to function successfully in their work environment and to maintain [[family]] relationships may be severely impaired.
-Prevention may be possible when [[trauma focused cognitive behavioral therapy|counselling]] is targeted at those with early symptoms but is not effective when provided to all trauma-exposed individuals whether or not symptoms are present.<ref name=BMJ2015/> The main treatments for people with PTSD are [[counselling]] (psychotherapy) and medication.<ref name=NIH2016/><ref name=Haa2015>{{cite journal | vauthors = Haagen JF, Smid GE, Knipscheer JW, Kleber RJ | title = The efficacy of recommended treatments for veterans with PTSD: A metaregression analysis | journal = Clinical Psychology Review | volume = 40 | pages = 184–94 | date = August 2015 | pmid = 26164548 | doi = 10.1016/j.cpr.2015.06.008 }}</ref> [[Antidepressants]] of the [[selective serotonin reuptake inhibitor|SSRI]] or [[Serotonin–norepinephrine reuptake inhibitors|SNRI]] type are the first-line medications used for PTSD and are moderately beneficial for about half of people.<ref name="Berger-2009">{{cite journal | vauthors = Berger W, Mendlowicz MV, Marques-Portella C, Kinrys G, Fontenelle LF, Marmar CR, Figueira I | title = Pharmacologic alternatives to antidepressants in posttraumatic stress disorder: a systematic review | journal = Progress in Neuro-Psychopharmacology & Biological Psychiatry | volume = 33 | issue = 2 | pages = 169–80 | date = March 2009 | pmid = 19141307 | pmc = 2720612 | doi = 10.1016/j.pnpbp.2008.12.004 }}</ref> Benefits from medication are less than those seen with counselling.<ref name=BMJ2015/> It is not known whether using medications and counselling together has greater benefit than either method separately.<ref name=BMJ2015>{{cite journal | vauthors = Bisson JI, Cosgrove S, Lewis C, Robert NP | title = Post-traumatic stress disorder | journal = BMJ | volume = 351 | pages = h6161 | date = November 2015 | pmid = 26611143 | pmc = 4663500 | doi = 10.1136/bmj.h6161 }}</ref><ref name="pmid20614457">{{cite journal | vauthors = Hetrick SE, Purcell R, Garner B, Parslow R | title = Combined pharmacotherapy and psychological therapies for post traumatic stress disorder (PTSD) | journal = The Cochrane Database of Systematic Reviews | issue = 7 | pages = CD007316 | date = July 2010 | pmid = 20614457 | doi = 10.1002/14651858.CD007316.pub2 }}</ref> Medications, other than some SSRIs or SNRIs, do not have enough evidence to support their use and, in the case of [[benzodiazepine]]s, may worsen outcomes.<ref name=Gui2015>{{cite journal | vauthors = Guina J, Rossetter SR, DeRHODES BJ, Nahhas RW, Welton RS | title = Benzodiazepines for PTSD: A Systematic Review and Meta-Analysis | journal = Journal of Psychiatric Practice | volume = 21 | issue = 4 | pages = 281–303 | date = July 2015 | pmid = 26164054 | doi = 10.1097/pra.0000000000000091 | s2cid = 24968844 }}</ref><ref name=Hos2015>{{cite journal | vauthors = Hoskins M, Pearce J, Bethell A, Dankova L, Barbui C, Tol WA, van Ommeren M, de Jong J, Seedat S, Chen H, Bisson JI | title = Pharmacotherapy for post-traumatic stress disorder: systematic review and meta-analysis | journal = The British Journal of Psychiatry | volume = 206 | issue = 2 | pages = 93–100 | date = February 2015 | pmid = 25644881 | doi = 10.1192/bjp.bp.114.148551 | quote = Some drugs have a small positive impact on PTSD symptoms | doi-access = free }}</ref>
+{{toc}}
+Fortunately, most people who experience traumatic events do not develop PTSD. However, especially among military personnel who experienced combat during [[war]] time, the rate of PTSD occurrence is sufficiently high to be detrimental to society as a whole. If the occurrence of traumatic events is not reduced, then their effects need to be better understand and efforts to improve treatment options continue to be necessary.
-<!-- Epidemiology and history —>
+== Terminology ==
-In the United States, about 3.5% of adults have PTSD in a given year, and 9% of people develop it at some point in their life.<ref name=DSM5/> In much of the rest of the world, rates during a given year are between 0.5% and 1%.<ref name=DSM5/> Higher rates may occur in regions of [[armed conflict]].<ref name=BMJ2015/> It is more common in women than men.<ref name=NIH2016>{{cite web|title=Post-Traumatic Stress Disorder|url=http://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml|website=National Institute of Mental Health|access-date=10 March 2016|date=February 2016|url-status=live|archive-url=https://web.archive.org/web/20160309184015/http://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml|archive-date=9 March 2016}}</ref>
+'''Post-traumatic stress disorder''' ('''PTSD''') is a [[mental disorder|mental]] and [[Abnormal behavior|behavioral]] [[Disorder (medicine)|disorder]] that can develop because of exposure to a [[Psychological trauma|traumatic]] event, such as [[sexual assault]], [[warfare]], [[traffic collision]]s, [[child abuse]], [[domestic violence]], or other threats on a person's life.<ref name=DSM5>American Psychiatric Association, ''Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5'' (American Psychiatric Publishing, 2013, ISBN 978-0890425558). </ref>
-Symptoms of trauma-related mental disorders have been documented since at least the time of the [[ancient Greeks]].<ref>{{cite book|last1=Carlstedt|first1=Roland | name-list-style = vanc |title=Handbook of Integrative Clinical Psychology, Psychiatry, and Behavioral Medicine Perspectives, Practices, and Research.|date=2009|publisher=Springer Pub. Co.|location=New York|isbn=9780826110954|page=353|url=https://books.google.com/books?id=4Tkdm1vRFbUC&pg=PA353}}</ref> A few instances of evidence of post-traumatic illness have been argued to exist from the seventeenth and eighteenth centuries, such as the diary of [[Samuel Pepys]], who described intrusive and distressing symptoms following the 1666 [[Fire of London]].<ref>{{cite book|last=O'Brien |first=Samuel|title=Traumatic Events and Mental Health|date=1998|publisher=Cambridge University Press|page=7}}</ref> During the [[world war]]s, the condition was known under various terms, including '[[shell shock]]', 'war nerves', neurasthenia and '[[combat neurosis]]'.<ref>{{cite book|last1=Herman|first1=Judith| name-list-style = vanc |title=Trauma and Recovery: The Aftermath of Violence – From Domestic Abuse to Political Terror|date=2015|publisher=Basic Books|isbn=9780465098736|page=9|url=https://books.google.com/books?id=ABhpCQAAQBAJ}}</ref><ref>[https://www.realcleardefense.com/articles/2015/06/05/after_war_an_interview_with_author_nancy_sherman_108023.html After War: A Conversation with Author Nancy Sherman], by John Waters, Real Clear Defense, 4 June 2015</ref> The term "post-traumatic stress disorder" came into use in the 1970s in large part due to the diagnoses of U.S. [[military veterans]] of the [[Vietnam War]].<ref>{{cite book|last1=Klykylo|first1=William M.| name-list-style = vanc |title=Clinical child psychiatry|date=2012|publisher=John Wiley & Sons|location=Chichester, West Sussex, UK|isbn=9781119967705|page=Chapter 15|edition=3|url=https://books.google.com/books?id=EL8eMEkxzkYC&pg=PT411}}</ref> It was officially recognized by the [[American Psychiatric Association]] in 1980 in the third edition of the ''[[Diagnostic and Statistical Manual of Mental Disorders]]'' (DSM-III).<ref>{{cite journal | vauthors = Friedman MJ | title = Finalizing PTSD in DSM-5: getting here from there and where to go next | journal = Journal of Traumatic Stress | volume = 26 | issue = 5 | pages = 548–56 | date = October 2013 | pmid = 24151001 | doi = 10.1002/jts.21840 }}</ref>
+The ''[[Diagnostic and Statistical Manual of Mental Disorders]]'' (''DSM'') does not hyphenate "post" and "traumatic," thus, the ''[[DSM-5]]'' lists the disorder as ''posttraumatic stress disorder''. However, the ''[[ICD-10]]'' does hyphenate the name of the disorder, ''viz.'', "post-traumatic stress disorder,"<ref name=ICD10>[https://www.aapc.com/codes/icd-10-codes/F43.1 ICD-10-CM Code for Post-traumatic stress disorder (PTSD) F43.1] ''Codify by AAPC''. Retrieved October 10, 2023.</ref> as do many scientific journal articles and other scholarly publications.
-{{TOC limit}}
-== Symptoms ==
+=== Classification===
-[[Image:Art of War, Service members use art to relieve PTSD symptoms DVIDS579803.jpg|thumb|Service members use art to relieve PTSD symptoms.]]
+PTSD was classified as an [[anxiety disorder]] in the ''DSM-IV''. It has since been reclassified as a "trauma and stressor-related disorder" in the ''DSM-5''.<ref name="DSM5" />
-{{See also|Psychological stress and sleep}}
-Symptoms of PTSD generally begin within the first three months after the inciting traumatic event, but may not begin until years later.<ref name="DSM5" /><ref name="NIH2016" /> In the typical case, the individual with PTSD persistently avoids either trauma-related thoughts and emotions or discussion of the traumatic event and may even have amnesia of the event.<ref name="DSM5" /> However, the event is commonly relived by the individual through intrusive, recurrent recollections, dissociative episodes of reliving the trauma ("[[Flashback (psychology)|flashbacks]]"), and nightmares (50 to 70%<ref name="Waltman Shearer Moore p. "/>).<ref name=DSM4>{{cite book |author=American Psychiatric Association |title=Diagnostic and statistical manual of mental disorders: DSM-IV |publisher=American Psychiatric Association |location=Washington, DC |year=1994 |isbn=978-0-89042-061-4 |url=https://archive.org/details/diagnosticstati00amer }}{{page needed|date=January 2014}}; [http://web.archive.bibalex.org/web/19991104151446/http://behavenet.com/capsules/disorders/ptsd.htm on-line].</ref> While it is common to have symptoms after any traumatic event, these must persist to a sufficient degree (i.e., causing dysfunction in life or clinical levels of distress) for longer than one month after the trauma to be classified as PTSD (clinically significant dysfunction or distress for less than one month after the trauma may be [[acute stress disorder]]).<ref name=DSM5 /><ref name="Rothschild 2000">{{cite book |last=Rothschild |first=Babette | name-list-style = vanc |title=The Body Remembers: The Psychophysiology of Trauma and Trauma Treatment |year=2000 |publisher=W.W. Norton & Company |location=New York |isbn=978-0-393-70327-6}}{{page needed|date=January 2014}}</ref><ref>{{cite book | vauthors = Kaplan HI, Sadock BJ |title=Kaplan and Sadock's synopsis of psychiatry: Behavioral sciences, clinical psychiatry |edition=7th | veditors = Grebb JA |publisher=Williams & Williams |year=1994 |location=Baltimore |pages=606–609 }}{{page needed|date=January 2014}}</ref><ref name="surgeon4">{{cite book |year=1999 |chapter=Chapter 4 | vauthors = Satcher D |author-link=David Satcher |title=Mental Health: A Report of the Surgeon General |publisher=[[Surgeon General of the United States]] |chapter-url=http://www.surgeongeneral.gov/library/mentalhealth/toc.html#chapter4 |url-status=live |archive-url=https://web.archive.org/web/20100702092029/http://www.surgeongeneral.gov/library/mentalhealth/toc.html#chapter4 |archive-date=2010-07-02 }}</ref> Some following a traumatic event experience [[post-traumatic growth]].<ref>{{cite journal | vauthors = Bernstein M, Pfefferbaum B | s2cid = 21721645 | title = Posttraumatic Growth as a Response to Natural Disasters in Children and Adolescents | journal = Current Psychiatry Reports | volume = 20 | issue = 5 | pages = 37 | date = May 2018 | pmid = 29766312 | doi = 10.1007/s11920-018-0900-4 }}</ref>
-=== Associated medical conditions ===
+''ICD-10'' classifies PTSD under "Reaction to severe stress, and adjustment disorders (F43)."<ref name=ICD10/>
-Trauma survivors often develop depression, anxiety disorders, and mood disorders in addition to PTSD.<ref>{{cite journal | vauthors = O'Donnell ML, Creamer M, Bryant RA, Schnyder U, Shalev A | title = Posttraumatic disorders following injury: an empirical and methodological review | journal = Clinical Psychology Review | volume = 23 | issue = 4 | pages = 587–603 | date = July 2003 | pmid = 12788111 | doi = 10.1016/S0272-7358(03)00036-9 }}</ref>
+===History of the terminology===
+Symptoms of trauma-related mental disorders have been documented since at least the time of the [[ancient Greeks]].<ref>Roland Carlstedt, ''Handbook of Integrative Clinical Psychology, Psychiatry, and Behavioral Medicine Perspectives, Practices, and Research'' (Springer Publishing Company, 2009, ISBN 0826110940).</ref> Several instances of post-traumatic illness have been noted in the seventeenth and eighteenth centuries, such as [[Samuel Pepys]]'s description of intrusive and distressing symptoms following the 1666 [[Fire of London]].<ref> L. Stephen O'Brien, ''Traumatic Events and Mental Health'' (Cambridge University Press, 1998, ISBN 978-0521578868) </ref> In a similar vein, psychiatrist [[Jonathan Shay]] has proposed that [[Lady Percy]]'s [[soliloquy]] in [[William Shakespeare]]'s play ''[[Henry IV, Part 1]]'' (act 2, scene 3, lines 40–62), written around 1597, represents an unusually accurate description of the symptom constellation of PTSD.<ref>Jonathan Shay, ''Achilles in Vietnam: Combat Trauma and the Undoing of Character'' (Simon & Schuster, 1995, ISBN 978-0684813219).</ref>
-[[Substance use disorder]], such as [[alcohol use disorder]], commonly co-occur with PTSD.<ref name="Maxmen2002-348">{{cite book|title=Psychotropic drugs: fast facts| vauthors = Maxmen JS, Ward NG |publisher=W. W. Norton|year=2002|isbn=978-0-393-70301-6|edition=3rd|place=New York|page=348}}</ref> Recovery from post-traumatic stress disorder or other anxiety disorders may be hindered, or the condition worsened, when substance use disorders are [[comorbid]] with PTSD. Resolving these problems can bring about improvement in an individual's mental health status and anxiety levels.<ref name="Cohen-1995">{{cite journal | vauthors = Cohen SI | title = Alcohol and benzodiazepines generate anxiety, panic and phobias | journal = Journal of the Royal Society of Medicine | volume = 88 | issue = 2 | pages = 73–7 | date = February 1995 | pmid = 7769598 | pmc = 1295099 }}</ref><ref>{{cite journal| vauthors = Spates R, Souza T | year=2007 |title=Treatment of PTSD and Substance Abuse Comorbidity|url=http://www.baojournal.com/BAT%20Journal/VOL-9/BAT%209-1.pdf|url-status=dead|journal=The Behavior Analyst Today|volume=9|issue=1|pages=11–26|doi=10.1037/h0100643|archive-url=https://web.archive.org/web/20141106235005/http://www.baojournal.com/BAT%20Journal/VOL-9/BAT%209-1.pdf|archive-date=6 November 2014}}</ref>
+The 1952 edition of the ''DSM-I'' includes a diagnosis of "gross stress reaction," which has similarities to the modern definition and understanding of PTSD. Gross stress reaction is defined as a normal personality using established patterns of reaction to deal with overwhelming fear as a response to conditions of great stress. The diagnosis includes language which relates the condition to combat as well as to "civilian catastrophe."<ref>American Psychiatric Association, ''DSM I: Diagnostic and Statistical Manual Mental Disorders'' (American Psychiatric Publishing, 1952, ISBN 978-0890420171).</ref>
-In children and adolescents, there is a strong association between emotional regulation difficulties (e.g. mood swings, anger outbursts, [[Tantrum|temper tantrums]]) and post-traumatic stress symptoms, independent of age, gender, or type of trauma.<ref>{{cite journal | vauthors = Villalta L, Smith P, Hickin N, Stringaris A | s2cid = 4731753 | title = Emotion regulation difficulties in traumatized youth: a meta-analysis and conceptual review | journal = European Child & Adolescent Psychiatry | volume = 27 | issue = 4 | pages = 527–544 | date = April 2018 | pmid = 29380069 | doi = 10.1007/s00787-018-1105-4 | url = https://kclpure.kcl.ac.uk/portal/files/87273928/Emotion_regulation_difficulties_in_VILLALTA_Publishedonline27January2018_GREEN_AAM.pdf }}</ref>
+Early in 1978, the diagnosis term "post-traumatic stress disorder" was first recommended in a working group finding presented to the Committee of Reactive Disorders.<ref> Arieh Y. Shalev, Rachel Yehuda, and Alexander C. McFarlane (eds.), ''International Handbook of Human Response to Trauma'' (Springer, 2012 (original 1999), ISBN 978-1461368731).</ref> The condition was officially recognized by the [[American Psychiatric Association]] in 1980 in ''DSM-III'' as "posttraumatic stress disorder."<ref>Robert L. Spitzer (ed.), ''Diagnostic and Statistical Manual of Mental Disorders: DSM-III'' (American Psychiatric Association, 1980).</ref>
-[[Moral injury]] the feeling of moral distress such as a shame or guilt following a moral transgression is associated with PTSD but is distinguished from it. Moral injury is associated with shame and guilt while PTSD is associated with anxiety and fear.<ref>{{Cite journal |last1=Hall |first1=Nicole A. |last2=Everson |first2=Adam T. |last3=Billingsley |first3=Madison R. |last4=Miller |first4=Mary Beth |date=January 2022 |title=Moral injury, mental health and behavioural health outcomes: A systematic review of the literature |url=https://onlinelibrary.wiley.com/doi/10.1002/cpp.2607 |journal=Clinical Psychology & Psychotherapy |language=en |volume=29 |issue=1 |pages=92–110 |doi=10.1002/cpp.2607 |pmid=33931926 |s2cid=233471425 |issn=1063-3995}}</ref>{{Rp|page=2,8,11}}
+The term "post-traumatic stress disorder" came into use in the 1970s in large part due to the diagnoses of U.S. military [[veteran]]s of the [[Vietnam War]].<ref>William M. Klykylo, Jerald Kay, and David Rube, ''Clinical Child Psychiatry'' (Saunders, 1998, ISBN 978-0721638409).</ref> Owing to its association with the war in Vietnam, PTSD has become synonymous with many historical war-time diagnoses such as "[[railway spine]]," stress syndrome, [[homesickness|nostalgia]], "soldier's heart," [[shell shock]], [[battle fatigue]], [[combat stress reaction]], traumatic war neurosis, "war nerves," neurasthenia, and "[[combat neurosis]]."<ref name=Herman>Judith Herman, ''Trauma and Recovery: The Aftermath of Violence—from Domestic Abuse to Political Terror'' (Basic Books, 1997, ISBN 978-0465087303).</ref><ref>Nancy C. Andreasen, ''Brave New Brain: Conquering Mental Illness in the Era of the Genome'' (Oxford University Press, 2001, ISBN 978-0195145090).</ref>
-== Risk factors ==
+[[File:Statue Three Servicemen Vietnam Veterans Memorial-editA.png|thumb|400px|Statue, ''Three Servicemen'', Vietnam Veterans Memorial]]
-[[File:Goya-Guerra (09).jpg|thumb|''[[The Disasters of War|No quieren (They do not want to)]]'' by [[Francisco Goya]] (1746–1828) depicts an elderly woman wielding a knife in defense of a girl being assaulted by a soldier.<ref>{{cite news|last=Robinson |first=Maisah | name-list-style = vanc |title=Review of Francisco Goya's Disasters of War |url=http://voices.yahoo.com/review-francisco-goyas-disasters-war-40022.html |agency=Associated Press |date=May 27, 2006 |url-status=dead |archive-url=https://web.archive.org/web/20140728204606/http://voices.yahoo.com/review-francisco-goyas-disasters-war-40022.html |archive-date=2014-07-28 }}</ref>{{unreliable source?|date=January 2014}}]]
-Persons considered at risk include combat military personnel, victims of natural disasters, concentration camp survivors, and victims of violent crime. Persons employed in occupations that expose them to violence (such as soldiers) or disasters (such as [[emergency service]] workers) are also at risk.<ref name="ASD-PTSD">{{cite journal | vauthors = Fullerton CS, Ursano RJ, Wang L | title = Acute stress disorder, posttraumatic stress disorder, and depression in disaster or rescue workers | journal = The American Journal of Psychiatry | volume = 161 | issue = 8 | pages = 1370–6 | date = August 2004 | pmid = 15285961 | doi = 10.1176/appi.ajp.161.8.1370 | citeseerx = 10.1.1.600.4486 }}</ref> Other occupations that are at higher risk include police officers, firefighters, ambulance personnel, health care professionals, train drivers, divers, journalists, and sailors, in addition to people who work at banks, post offices or in stores.<ref>{{cite journal | vauthors = Skogstad M, Skorstad M, Lie A, Conradi HS, Heir T, Weisæth L | title = Work-related post-traumatic stress disorder | journal = Occupational Medicine | volume = 63 | issue = 3 | pages = 175–82 | date = April 2013 | pmid = 23564090 | doi = 10.1093/occmed/kqt003 | doi-access = free }}</ref>
-=== Trauma ===
+The correlations between combat and PTSD are undeniable:
-{{main|Psychological trauma}}
+<blockquote>It is now known that soldiers on a battlefield can hope to preserve their psychological equilibrium for only several months at best; the strict selection process notwithstanding, one-tenth of mobilized American men were hospitalized for mental disturbances between 1942 and 1945, and after thirty-five days of uninterrupted combat, 98 percent of them manifested psychiatric disturbances in varying degrees.<ref>Stéphane Audoin-Rouzeau and Annette Becker, ''1914-1918 Understanding the Great War'' (Profile Books, 2002, ISBN 978-1861973528).</ref></blockquote>
-{{See also|Psychological resilience}}
-PTSD has been associated with a wide range of traumatic events. The risk of developing PTSD after a traumatic event varies by trauma type<ref>{{cite journal | vauthors = Vieweg WV, Julius DA, Fernandez A, Beatty-Brooks M, Hettema JM, Pandurangi AK | title = Posttraumatic stress disorder: clinical features, pathophysiology, and treatment | journal = The American Journal of Medicine | volume = 119 | issue = 5 | pages = 383–90 | date = May 2006 | pmid = 16651048 | doi = 10.1016/j.amjmed.2005.09.027 }}</ref><ref>{{Cite book |vauthors=Dekel S, Gilbertson MW, Orr SP, Rauch SL, Wood NE, Pitman RK |veditors=Stern TA, Fava M, Wilens TE, Rosenbaum JF |title=Massachusetts General Hospital comprehensive clinical psychiatry|publisher=Elsevier |year=2016|isbn=9780323295079|edition=Second|location=London|pages=380–392|chapter=Trauma and Posttraumatic Stress Disorder|oclc=905232521}}</ref> and is highest following exposure to sexual violence (11.4%), particularly rape (19.0%).<ref name=":13">{{cite journal | vauthors = Kessler RC, Aguilar-Gaxiola S, Alonso J, Benjet C, Bromet EJ, Cardoso G, Degenhardt L, de Girolamo G, Dinolova RV, Ferry F, Florescu S, Gureje O, Haro JM, Huang Y, Karam EG, Kawakami N, Lee S, Lepine JP, Levinson D, Navarro-Mateu F, Pennell BE, Piazza M, Posada-Villa J, Scott KM, Stein DJ, Ten Have M, Torres Y, Viana MC, Petukhova MV, Sampson NA, Zaslavsky AM, Koenen KC | title = Trauma and PTSD in the WHO World Mental Health Surveys | journal = European Journal of Psychotraumatology | volume = 8 | issue = sup5 | pages = 1353383 | date = 2017-10-27 | pmid = 29075426 | pmc = 5632781 | doi = 10.1080/20008198.2017.1353383 }}</ref> Men are more likely to experience a traumatic event (of any type), but women are more likely to experience the kind of high-impact traumatic event that can lead to PTSD, such as interpersonal violence and sexual assault.<ref name="UK20052">{{Cite book|url=https://www.ncbi.nlm.nih.gov/books/NBK56494/|title=Post-Traumatic Stress Disorder: The Management of PTSD in Adults and Children in Primary and Secondary Care|last=National Collaborating Centre for Mental Health (UK)|year=2005|work=NICE Clinical Guidelines, No. 26|publisher=Gaskell (Royal College of Psychiatrists) |isbn=9781904671251|series=National Institute for Health and Clinical Excellence: Guidance}}</ref>
+A study based on personal letters from soldiers of the eighteenth-century [[Prussian Army]] concludes that combatants may have had PTSD.<ref>Sascha Möbius, [https://www.wissenschaft.de/magazin/weitere-themen/im-kugelhagel-der-musketen/ Im Kugelhagel der Musketen (In the hail of musket bullets)] ''Damals'' 47(12) (2015): 64–69. Retrieved October 10, 2023.</ref> Aspects of PTSD in soldiers of ancient [[Assyria]] have been identified using written sources from 1300 to 600 B.C.E. These Assyrian soldiers would undergo a three-year rotation of combat before being allowed to return home, and were reported to have faced immense challenges in reconciling their past actions in war with their civilian lives.<ref>Laura Clark, [https://www.smithsonianmag.com/smart-news/ancient-assyrian-soldiers-were-haunted-war-too-180954022/ Ancient Assyrian Soldiers Were Haunted by War, Too] ''Smithsonian Magazine'' (January 26, 2015). Retrieved October 10, 2023.</ref> Connections between the actions of Viking [[berserkers]] and the hyper-arousal of post-traumatic stress disorder have also been drawn.<ref>Hans van Wees (ed.), ''War and Violence in Ancient Greece'' (Classical Press of Wales, 2009, ISBN 978-1905125340).</ref>
-Motor vehicle collision survivors, both children and adults, are at an increased risk of PTSD.<ref name=":02">{{cite journal | vauthors = Lin W, Gong L, Xia M, Dai W | title = Prevalence of posttraumatic stress disorder among road traffic accident survivors: A PRISMA-compliant meta-analysis | journal = Medicine | volume = 97 | issue = 3 | pages = e9693 | date = January 2018 | pmid = 29505023 | pmc = 5779792 | doi = 10.1097/md.0000000000009693 }}</ref><ref name=":12">{{cite journal | vauthors = Dai W, Liu A, Kaminga AC, Deng J, Lai Z, Wen SW | title = Prevalence of Posttraumatic Stress Disorder among Children and Adolescents following Road Traffic Accidents: A Meta-Analysis | journal = Canadian Journal of Psychiatry | volume = 63 | issue = 12 | pages = 798–808 | date = August 2018 | pmid = 30081648 | pmc = 6309043 | doi = 10.1177/0706743718792194 }}</ref> Globally, about 2.6% of adults are diagnosed with PTSD following a non-life-threatening traffic accident, and a similar proportion of children develop PTSD.<ref name=":13" /> Risk of PTSD almost doubles to 4.6% for life-threatening auto accidents.<ref name=":13" /> Females were more likely to be diagnosed with PTSD following a road traffic accident, whether the accident occurred during childhood or adulthood.<ref name=":02" /><ref name=":12" />
+The initial overt focus on PTSD was as a combat related disorder when it was first fleshed out in the years following the war in Vietnam. However, other traumas may also result in similar psychological disturbance. For example, Ann Wolbert Burgess and Lynda Lytle Holmstrom defined Rape Trauma Syndrome (RTS) in order to draw attention to the striking similarities between the experiences of soldiers returning from war and of victims of [[rape]].<ref> Lynda Lytle Holmstrom and Ann Wolbert Burgess, ''The Victim of Rape: Institutional Reactions'' (Routledge, 1983, ISBN 978-0878559329). </ref>
-Post-traumatic stress reactions have been studied in children and adolescents.<ref>{{cite journal | vauthors = Bisson JI, Berliner L, Cloitre M, Forbes D, Jensen TK, Lewis C, Monson CM, Olff M, Pilling S, Riggs DS, Roberts NP, Shapiro F  | title = The International Society for Traumatic Stress Studies New Guidelines for the Prevention and Treatment of Posttraumatic Stress Disorder: Methodology and Development Process | journal = Journal of Traumatic Stress | volume = 32 | issue = 4 | pages = 475–483 | date = August 2019 | doi = 10.1002/jts.22421| pmid = 31283056 | url = http://orca.cf.ac.uk/120985/1/Binder3.pdf | hdl = 10852/77258 | s2cid = 195830995 | hdl-access = free }}</ref> The rate of PTSD might be lower in children than adults, but in the absence of therapy, symptoms may continue for decades.<ref name="UK2005">{{Cite book |last=National Collaborating Centre for Mental Health (UK) |title=Post-Traumatic Stress Disorder: The Management of PTSD in Adults and Children in Primary and Secondary Care |publisher=Gaskell (Royal College of Psychiatrists) |url=https://www.ncbi.nlm.nih.gov/books/NBK56494/ |year=2005 |url-status=live |archive-url=https://web.archive.org/web/20170908143630/https://www.ncbi.nlm.nih.gov/books/NBK56494/ |archive-date=2017-09-08 |isbn=9781904671251 |series=National Institute for Health and Clinical Excellence: Guidance No. 26}}</ref> One estimate suggests that the proportion of children and adolescents having PTSD in a non-wartorn population in a developed country may be 1% compared to 1.5% to 3% of adults.<ref name="UK2005" /> On average, 16% of children exposed to a traumatic event develop PTSD, varying according to type of exposure and gender.<ref name="AlisicZalta2014">{{cite journal | vauthors = Alisic E, Zalta AK, van Wesel F, Larsen SE, Hafstad GS, Hassanpour K, Smid GE | title = Rates of post-traumatic stress disorder in trauma-exposed children and adolescents: meta-analysis | journal = The British Journal of Psychiatry | volume = 204 | issue = 5 | pages = 335–40 | year = 2014 | pmid = 24785767 | doi = 10.1192/bjp.bp.113.131227 | url = https://www.zora.uzh.ch/id/eprint/101391/1/BJP-2014-Alisic-335-40.pdf | doi-access = free }}</ref> Similar to the adult population, risk factors for PTSD in children include: female gender, exposure to disasters (natural or manmade), negative coping behaviours, and/or lacking proper social support systems.<ref>{{cite journal | vauthors = Lai BS, Lewis R, Livings MS, La Greca AM, Esnard AM | title = Posttraumatic Stress Symptom Trajectories Among Children After Disaster Exposure: A Review | journal = Journal of Traumatic Stress | volume = 30 | issue = 6 | pages = 571–582 | date = December 2017 | pmid = 29193316 | pmc = 5953201 | doi = 10.1002/jts.22242  }}</ref>
+===Complex PTSD===
+'''[[Complex post-traumatic stress disorder]]''' ('''C-PTSD''' or '''CPTSD'''; also known as '''complex trauma disorder''')<ref name="Cook2005">Alexandra Cook et al., [https://psycnet.apa.org/record/2005-05449-004 Complex trauma in children and adolescents] ''Psychiatric Annals'' 35(5) (2005): 390–398. Retrieved October 10, 2023.</ref> is a psychological disorder that may develop in response to exposure to a series of [[Psychological trauma|traumatic]] events in a context in which the individual perceives little or no chance of escape, and particularly where the exposure is prolonged or repetitive. It is not yet recognized by the American Psychiatric Association or the ''DSM-5'' as a valid disorder. However, the ''DSM-5'' does list a sub-type of post-traumatic stress disorder (PTSD) called dissociative PTSD that seems to encompass C-PTSD symptoms.<ref>[https://my.clevelandclinic.org/health/diseases/24881-cptsd-complex-ptsd CPTSD (Complex PTSD)] ''Cleveland Clinic''. Retrieved October 10, 2023.</ref> C-PTSD was added to the eleventh revision of the International Classification of Diseases (''ICD-11'').<ref name="ICD11" /> Complex PTSD is also recognized by the [[United States Department of Veterans Affairs]] (VA), [[Healthdirect Australia]] (HDA), and the British [[National Health Service]] (NHS).
-Predictor models have consistently found that childhood trauma, chronic adversity, neurobiological differences, and familial stressors are associated with risk for PTSD after a traumatic event in adulthood.<ref>{{cite journal | vauthors = Koenen KC, Moffitt TE, Poulton R, Martin J, Caspi A | title = Early childhood factors associated with the development of post-traumatic stress disorder: results from a longitudinal birth cohort | journal = Psychological Medicine | volume = 37 | issue = 2 | pages = 181–92 | date = February 2007 | pmid = 17052377 | pmc = 2254221 | doi = 10.1017/S0033291706009019 }}</ref><ref>{{cite journal | vauthors = Lapp KG, Bosworth HB, Strauss JL, Stechuchak KM, Horner RD, Calhoun PS, Meador KG, Lipper S, Butterfield MI | title = Lifetime sexual and physical victimization among male veterans with combat-related post-traumatic stress disorder | journal = Military Medicine | volume = 170 | issue = 9 | pages = 787–90 | date = September 2005 | pmid = 16261985 | doi = 10.7205/MILMED.170.9.787 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Otte C, Neylan TC, Pole N, Metzler T, Best S, Henn-Haase C, Yehuda R, Marmar CR | s2cid = 35801179 | title = Association between childhood trauma and catecholamine response to psychological stress in police academy recruits | journal = Biological Psychiatry | volume = 57 | issue = 1 | pages = 27–32 | date = January 2005 | pmid = 15607297 | doi = 10.1016/j.biopsych.2004.10.009 }}</ref>  It has been difficult to find consistently aspects of the events that predict, but [[Dissociation (psychology)#Peritraumatic dissociation|peritraumatic dissociation]] has been a fairly consistent predictive indicator of the development of PTSD.<ref name="Skelton 2012 628–637" /> Proximity to, duration of, and severity of the trauma make an impact. It has been speculated that interpersonal traumas cause more problems than impersonal ones,<ref>{{cite book | vauthors = Janoff-Bulman R |title=Shattered Assumptions: Toward a New Psychology of Trauma |place=New York |publisher=Free Press |year=1992}}{{page needed|date=January 2014}}</ref>  but this is controversial.<ref>{{cite journal | vauthors = Scheeringa MS  | title = Untangling Psychiatric Comorbidity in Young Children Who Experienced Single, Repeated, or Hurricane Katrina Traumatic Events | journal = Child and Youth Care Forum | volume = 44 | issue = 4 | pages = 475–492 | date = 2015 | doi = 10.1007/s10566-014-9293-7| pmid = 26213455 | pmc = 4511493 }}</ref> The risk of developing PTSD is increased in individuals who are exposed to physical abuse, physical assault, or kidnapping.<ref name="Kessler95" /><ref>{{cite journal | vauthors = Liu H, Petukhova MV, Sampson NA, Aguilar-Gaxiola S, Alonso J, Andrade LH, Bromet EJ, de Girolamo G, Haro JM, Hinkov H, Kawakami N, Koenen KC, Kovess-Masfety V, Lee S, Medina-Mora ME, Navarro-Mateu F, O'Neill S, Piazza M, Posada-Villa J, Scott KM, Shahly V, Stein DJ, Ten Have M, Torres Y, Gureje O, Zaslavsky AM, Kessler RC | title = Association of DSM-IV Posttraumatic Stress Disorder With Traumatic Experience Type and History in the World Health Organization World Mental Health Surveys | journal = JAMA Psychiatry | volume = 74 | issue = 3 | pages = 270–281 | date = March 2017 | pmid = 28055082 | pmc = 5441566 | doi = 10.1001/jamapsychiatry.2016.3783 }}</ref> Women who experience physical violence are more likely to develop PTSD than men.<ref name="Kessler95" />
+C-PTSD was first described in 1992 by American psychiatrist and scholar [[Judith Lewis Herman]] in her book ''Trauma & Recovery'', in which she described C-PTSD as distinct from, but similar to, PTSD, [[somatization disorder]], [[dissociative identity disorder]], and [[borderline personality disorder]].<ref name=Herman/>
-==== Intimate partner violence ====
+Children can suffer chronic trauma such as maltreatment, family violence, dysfunction, or a disruption in attachment to their primary caregiver.<ref name = Ford/> The term '''Developmental Trauma Disorder''' ('''DTD''') has been proposed as the childhood equivalent of C-PTSD. This developmental form of trauma places children at risk for developing psychiatric and medical disorders.<ref name = Ford>Julian D. Ford, Damion Grasso, Carolyn Greene, Joan Levine, Joseph Spinazzola, and Bessel van der Kolk, [https://pubmed.ncbi.nlm.nih.gov/24021504/ Clinical significance of a proposed developmental trauma disorder diagnosis: results of an international survey of clinicians] ''The Journal of Clinical Psychiatry'' 74(8) (August 2013): 841–849. Retrieved October 10, 2023.</ref> [[Bessel van der Kolk]] explains DTD as numerous encounters with interpersonal trauma such as physical assault, sexual assault, violence or death. It can also be brought on by subjective events such as abandonment, betrayal, defeat or shame.<ref name=Atwoli/>
-{{see also|Rape trauma syndrome}}
-An individual that has been exposed to [[domestic violence]] is predisposed to the development of PTSD. However, being exposed to a traumatic experience does not automatically indicate that an individual will develop PTSD.<ref name="Rothschild 20002">{{cite book|title=The Body Remembers: The Psychophysiology of Trauma and Trauma Treatment|last=Rothschild|first=Babette | name-list-style = vanc |publisher=W.W. Norton & Company|year=2000|isbn=978-0-393-70327-6|location=New York}}{{page needed|date=January 2014}}</ref> There is a strong association between the development of PTSD in mothers that experienced domestic violence during the [[perinatal]] period of their pregnancy.<ref name=":42">{{cite journal | vauthors = Howard LM, Oram S, Galley H, Trevillion K, Feder G | title = Domestic violence and perinatal mental disorders: a systematic review and meta-analysis | journal = PLOS Medicine | volume = 10 | issue = 5 | pages = e1001452 | date = 2013 | pmid = 23723741 | pmc = 3665851 | doi = 10.1371/journal.pmed.1001452 }}</ref>
-Those who have experienced sexual assault or rape may develop symptoms of PTSD.<ref name="Hoffman20162">{{cite book|title=Williams Gynecology|editor1-last=Hoffman|editor1-first=Barbara L.|editor2-last=Schorge|editor2-first=John O.|editor3-last=Bradshaw|editor3-first=Karen D.|editor4-last=Halvorson|editor4-first=Lisa M.|editor5-last=Schaffer|editor5-first=Joseph I.|editor6-last=Corton|editor6-first=Marlene M. | name-list-style = vanc |date=2016|publisher=McGraw Hill Professional|isbn=9780071849098|edition=3rd}}</ref><ref name="Suris20042">{{cite journal | vauthors = Surís A, Lind L, Kashner TM, Borman PD, Petty F | s2cid = 14118203 | title = Sexual assault in women veterans: an examination of PTSD risk, health care utilization, and cost of care | journal = Psychosomatic Medicine | volume = 66 | issue = 5 | pages = 749–56 | date = 2004 | pmid = 15385701 | doi = 10.1097/01.psy.0000138117.58559.7b | citeseerx = 10.1.1.508.9827 }}</ref> PTSD symptoms include re-experiencing the assault, avoiding things associated with the assault, numbness, and increased anxiety and an increased [[startle response]]. The likelihood of sustained symptoms of PTSD is higher if the rapist confined or restrained the person, if the person being raped believed the rapist would kill them, the person who was raped was very young or very old, and if the rapist was someone they knew. The likelihood of sustained severe symptoms is also higher if people around the survivor ignore (or are ignorant of) the rape or blame the rape survivor.<ref>{{cite journal | vauthors = Mason F, Lodrick Z | title = Psychological consequences of sexual assault | journal = Best Practice & Research. Clinical Obstetrics & Gynaecology | volume = 27 | issue = 1 | pages = 27–37 | date = February 2013 | pmid = 23182852 | doi = 10.1016/j.bpobgyn.2012.08.015 }}</ref>
+== Symptoms ==
+Symptoms of PTSD generally begin within the first three months after the inciting traumatic event, but may not begin until years later.<ref name="DSM5" /> A person with PTSD is at a higher risk of [[suicide]] and intentional [[self-harm]].<ref name=BMJ2015/>
-====War-related trauma ====
+Symptoms may include disturbing [[thought]]s, [[emotion|feelings]], or [[dream]]s related to the events, mental or physical [[distress (medicine)|distress]] to trauma-related cues, attempts to avoid trauma-related cues, alterations in the way a person thinks and feels, and an increase in the [[fight-or-flight response]]. The ''DSM-5'' diagnostic criteria for PTSD include four symptom clusters: re-experiencing, avoidance, negative alterations in cognition/mood, and alterations in arousal and reactivity.<ref name="DSM5" /> Young children are less likely to show distress but instead may express their memories through [[play (activity)|play]].<ref name=DSM5/>
-{{See also|Veteran|Refugee health}}
+In the typical case, the individual with PTSD persistently avoids either trauma-related thoughts and emotions or discussion of the traumatic event and may even have amnesia of the event.<ref name="DSM5" /> However, the event is commonly relived by the individual through intrusive, recurrent recollections, dissociative episodes of reliving the trauma ("[[Flashback (psychology)|flashbacks]]"), and [[nightmare]]s.<ref name=DSM4>American Psychiatric Association, ''Diagnostic and Statistical Manual of Mental Disorders: DSM-IV'' (American Psychiatric Association, 1994, ISBN 0890420610).</ref> While it is common to have symptoms after any traumatic event, these must persist to a sufficient degree, causing dysfunction in life or clinical levels of distress, for longer than one month after the trauma to be classified as PTSD (clinically significant dysfunction or distress for less than one month after the trauma may be [[acute stress disorder]]).<ref name=DSM5 />
-Military service is a risk factor for developing PTSD.<ref name="NEJM20172">{{cite journal | vauthors = Shalev A, Liberzon I, Marmar C | title = Post-Traumatic Stress Disorder | journal = The New England Journal of Medicine | volume = 376 | issue = 25 | pages = 2459–2469 | date = June 2017 | pmid = 28636846 | doi = 10.1056/NEJMra1612499 }}</ref> Around 78% of people exposed to combat do not develop PTSD; in about 25% of military personnel who develop PTSD, its appearance is delayed.<ref name="NEJM20172" />
-Refugees are also at an increased risk for PTSD due to their exposure to war, hardships, and traumatic events. The rates for PTSD within refugee populations range from 4% to 86%.<ref>{{cite journal | vauthors = Hollifield M, Warner TD, Lian N, Krakow B, Jenkins JH, Kesler J, Stevenson J, Westermeyer J | title = Measuring trauma and health status in refugees: a critical review | journal = JAMA | volume = 288 | issue = 5 | pages = 611–21 | date = August 2002 | pmid = 12150673 | doi = 10.1001/jama.288.5.611 }}</ref> While the stresses of war affect everyone involved, displaced persons have been shown to be more so than others.<ref>{{cite journal | vauthors = Porter M, Haslam N | s2cid = 41804120 | title = Forced displacement in Yugoslavia: a meta-analysis of psychological consequences and their moderators | journal = Journal of Traumatic Stress | volume = 14 | issue = 4 | pages = 817–34 | date = October 2001 | pmid = 11776427 | doi = 10.1023/A:1013054524810 }}</ref>
+The ''ICD-10'' criteria for PTSD include re-experiencing, avoidance, and either increased reactivity or inability to recall certain details related to the event.
-Challenges related to the overall psychosocial well-being of refugees are complex and individually nuanced. Refugees have reduced levels of well-being and a high rates of mental distress due to past and ongoing trauma. Groups that are particularly affected and whose needs often remain unmet are women, older people and unaccompanied minors.<ref name=":8">{{Cite book|last=UNESCO|url=https://unesdoc.unesco.org/ark:/48223/pf0000261278|title=A Lifeline to learning: leveraging mobile technology to support education for refugees|publisher=UNESCO|year=2018|isbn=978-92-3-100262-5}}</ref> Post-traumatic stress and depression in refugee populations also tend to affect their educational success.<ref name=":8" />
+The ''ICD-11'' diagnostic description for PTSD contains three components or symptom groups (1) re-experiencing, (2) avoidance, and (3) heightened sense of threat; ''ICD-11'' no longer includes verbal thoughts about the traumatic event as a symptom.<ref name=":7">Chris R. Brewin et al., [http://mural.maynoothuniversity.ie/11577/1/Hyland_Review_2017.pdf A review of current evidence regarding the ICD-11 proposals for diagnosing PTSD and complex PTSD] ''Clinical Psychology Review'' 58 (2017): 1–15. Retrieved October 10, 2023. </ref>
-==== Unexpected death of a loved one ====
+''ICD-11'' also proposes identifying a distinct group with complex post-traumatic stress disorder (C-PTSD), who have more often experienced several or sustained traumas and have greater functional impairment than those with PTSD.<ref name=":7" />
-Sudden, unexpected death of a loved one is the most common traumatic event type reported in cross-national studies.<ref name=":13"/><ref name=":0">{{cite journal | vauthors = Atwoli L, Stein DJ, King A, Petukhova M, Aguilar-Gaxiola S, Alonso J, Bromet EJ, de Girolamo G, Demyttenaere K, Florescu S, Maria Haro J, Karam EG, Kawakami N, Lee S, Lepine JP, Navarro-Mateu F, O'Neill S, Pennell BE, Piazza M, Posada-Villa J, Sampson NA, Ten Have M, Zaslavsky AM, Kessler RC | title = Posttraumatic stress disorder associated with unexpected death of a loved one: Cross-national findings from the world mental health surveys | journal = Depression and Anxiety | volume = 34 | issue = 4 | pages = 315–326 | date = April 2017 | pmid = 27921352 | pmc = 5661943 | doi = 10.1002/da.22579 }}</ref> However, the majority of people who experience this type of event will not develop PTSD. An analysis from the WHO World Mental Health Surveys found a 5.2% risk of developing PTSD after learning of the unexpected death of a loved one.<ref name=":0" /> Because of the high prevalence of this type of traumatic event, unexpected death of a loved one accounts for approximately 20% of PTSD cases worldwide.<ref name=":13" />
-==== Life-threatening illness ====
+In addition to the symptoms of PTSD, an individual with C-PTSD experiences [[emotional dysregulation]], negative self-beliefs and feelings of shame, guilt, or failure regarding the trauma, and interpersonal difficulties.<ref name=ICD11>World Health Organization, [https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f585833559 6B41 Complex post traumatic stress disorder] ''ICD-11 for Mortality and Morbidity Statistics (Version: 01/2023)''. Retrieved October 10, 2023.</ref> C-PTSD relates to the [[trauma model of mental disorders]] and is associated with chronic [[Child sexual abuse|sexual]], [[Psychological abuse|psychological]], and [[physical abuse]] or [[Child neglect|neglect]], or chronic [[intimate partner violence]], [[bullying]], victims of [[kidnapping]] and [[hostage]] situations, [[indentured servitude|indentured servants]], victims of [[slavery]] and [[human trafficking]], [[sweatshop]] workers, [[prisoner of war|prisoners of war]], [[concentration camp]] survivors, and prisoners kept in [[solitary confinement]] for a long period of time, or defectors from authoritarian religions. Situations involving captivity/entrapment (a situation lacking a viable escape route for the victim or a perception of such) can lead to C-PTSD-like symptoms, which can include prolonged feelings of terror, worthlessness, helplessness, and deformation of one's identity and sense of self.<ref name=Herman/>
-Medical conditions associated with an increased risk of PTSD include cancer,<ref name="cancer.gov">{{Cite web|url=https://www.cancer.gov/about-cancer/coping/survivorship/new-normal/ptsd-hp-pdq|title=Cancer-Related Post-traumatic Stress|website=National Cancer Institute|access-date=2017-09-16|date=January 1980}}</ref><ref>{{cite journal | vauthors = Swartzman S, Booth JN, Munro A, Sani F | s2cid = 1828418 | title = Posttraumatic stress disorder after cancer diagnosis in adults: A meta-analysis | journal = Depression and Anxiety | volume = 34 | issue = 4 | pages = 327–339 | date = April 2017 | pmid = 27466972 | doi = 10.1002/da.22542 | url = https://discovery.dundee.ac.uk/en/publications/04e54111-8d61-418b-b36b-62fc4b496470 | type = Submitted manuscript }}</ref><ref>{{cite journal | vauthors = Cordova MJ, Riba MB, Spiegel D | title = Post-traumatic stress disorder and cancer | journal = The Lancet. Psychiatry | volume = 4 | issue = 4 | pages = 330–338 | date = April 2017 | pmid = 28109647 | pmc = 5676567 | doi = 10.1016/S2215-0366(17)30014-7 }}</ref> heart attack,<ref>{{cite journal | vauthors = Edmondson D, Richardson S, Falzon L, Davidson KW, Mills MA, Neria Y | title = Posttraumatic stress disorder prevalence and risk of recurrence in acute coronary syndrome patients: a meta-analytic review | journal = PLOS ONE | volume = 7 | issue = 6 | pages = e38915 | date = 2012 | pmid = 22745687 | pmc = 3380054 | doi = 10.1371/journal.pone.0038915 | bibcode = 2012PLoSO...738915E | doi-access = free }}</ref> and stroke.<ref>{{cite journal | vauthors = Edmondson D, Richardson S, Fausett JK, Falzon L, Howard VJ, Kronish IM | title = Prevalence of PTSD in Survivors of Stroke and Transient Ischemic Attack: A Meta-Analytic Review | journal = PLOS ONE | volume = 8 | issue = 6 | pages = e66435 | date = 2013-06-19 | pmid = 23840467 | pmc = 3686746 | doi = 10.1371/journal.pone.0066435 | bibcode = 2013PLoSO...866435E | doi-access = free }}</ref> 22% of cancer survivors present with lifelong PTSD like symptoms.<ref>{{cite journal | vauthors = Abbey G, Thompson SB, Hickish T, Heathcote D | title = A meta-analysis of prevalence rates and moderating factors for cancer-related post-traumatic stress disorder | journal = Psycho-Oncology | volume = 24 | issue = 4 | pages = 371–81 | date = April 2015 | pmid = 25146298 | pmc = 4409098 | doi = 10.1002/pon.3654 }}</ref> Intensive-care unit (ICU) hospitalization is also a risk factor for PTSD.<ref>{{cite journal | vauthors = Davydow DS, Gifford JM, Desai SV, Needham DM, Bienvenu OJ | title = Posttraumatic stress disorder in general intensive care unit survivors: a systematic review | journal = General Hospital Psychiatry | volume = 30 | issue = 5 | pages = 421–34 | date = September 2008 | pmid = 18774425 | pmc = 2572638 | doi = 10.1016/j.genhosppsych.2008.05.006 }}</ref> Some women experience PTSD from their experiences related to [[breast cancer]] and [[mastectomy]].<ref name="ArnaboldiRiva2017">{{cite journal | vauthors = Arnaboldi P, Riva S, Crico C, Pravettoni G | title = A systematic literature review exploring the prevalence of post-traumatic stress disorder and the role played by stress and traumatic stress in breast cancer diagnosis and trajectory | journal = Breast Cancer: Targets and Therapy| volume = 9 | pages = 473–485 | year = 2017 | pmid = 28740430 | pmc = 5505536 | doi = 10.2147/BCTT.S111101 }}</ref><ref name="Liu e0177055">{{cite journal | vauthors = Liu C, Zhang Y, Jiang H, Wu H | title = Association between social support and post-traumatic stress disorder symptoms among Chinese patients with ovarian cancer: A multiple mediation model | journal = PLOS ONE | volume = 12 | issue = 5 | pages = e0177055 | date = 2017-05-05 | pmid = 28475593 | pmc = 5419605 | doi = 10.1371/journal.pone.0177055 | bibcode = 2017PLoSO..1277055L | doi-access = free }}</ref><ref name="cancer.gov"/> Loved ones of those who experience life-threatening illnesses are also at risk for developing PTSD, such as parents of child with chronic illnesses.<ref>{{Cite web|url=http://psycnet.apa.org/record/2009-06704-015|title=PsycNET|website=psycnet.apa.org|access-date=2018-09-30}}</ref>
-==== Pregnancy-related trauma ====
+== Risk factors ==
-{{Main|Childbirth-related post-traumatic stress disorder}}
+Persons considered at risk include combat [[military]] personnel, victims of natural disasters, [[concentration camp]] survivors, and victims of violent crime. Persons employed in occupations that expose them to violence (such as soldiers) or disasters (such as [[emergency service]] workers) are also at risk.
-Women who experience [[miscarriage]] are at risk of PTSD.<ref name=Christiansen2017>{{cite journal | vauthors = Christiansen DM | title = Posttraumatic stress disorder in parents following infant death: A systematic review | journal = Clinical Psychology Review | volume = 51 | pages = 60–74 | date = February 2017 | pmid = 27838460 | doi = 10.1016/j.cpr.2016.10.007 }}</ref><ref name="kirs2">{{cite journal | vauthors = Kersting A, Wagner B | title = Complicated grief after perinatal loss | journal = Dialogues in Clinical Neuroscience | volume = 14 | issue = 2 | pages = 187–94 | date = June 2012 | doi = 10.31887/DCNS.2012.14.2/akersting | pmid = 22754291 | pmc = 3384447 }}</ref><ref>{{cite journal | vauthors = Daugirdaitė V, van den Akker O, Purewal S | title = Posttraumatic stress and posttraumatic stress disorder after termination of pregnancy and reproductive loss: a systematic review | journal = Journal of Pregnancy | volume = 2015 | pages = 646345 | date = 2015 | pmid = 25734016 | pmc = 4334933 | doi = 10.1155/2015/646345 | doi-access = free }}</ref> Those who experience subsequent miscarriages have an increased risk of PTSD compared to those experiencing only one.<ref name="Christiansen2017" /> PTSD can also occur after childbirth and the risk increases if a woman has experienced trauma prior to the pregnancy.<ref>{{cite journal | vauthors = Ayers S, Bond R, Bertullies S, Wijma K | title = The aetiology of post-traumatic stress following childbirth: a meta-analysis and theoretical framework | journal = Psychological Medicine | volume = 46 | issue = 6 | pages = 1121–34 | date = April 2016 | pmid = 26878223 | doi = 10.1017/s0033291715002706 | doi-access = free }}</ref><ref>{{cite journal | vauthors = James S | title = Women's experiences of symptoms of posttraumatic stress disorder (PTSD) after traumatic childbirth: a review and critical appraisal | journal = Archives of Women's Mental Health | volume = 18 | issue = 6 | pages = 761–71 | date = December 2015 | pmid = 26264506 | pmc = 4624822 | doi = 10.1007/s00737-015-0560-x }}</ref> Prevalence of PTSD following normal childbirth (that is, excluding stillbirth or major complications) is estimated to be between 2.8 and 5.6% at six weeks postpartum,<ref name="Olde20062">{{cite journal | vauthors = Olde E, van der Hart O, Kleber R, van Son M | title = Posttraumatic stress following childbirth: a review | journal = Clinical Psychology Review | volume = 26 | issue = 1 | pages = 1–16 | date = January 2006 | pmid = 16176853 | doi = 10.1016/j.cpr.2005.07.002 | hdl = 1874/16760 | s2cid = 22137961 | hdl-access = free }}</ref> with rates dropping to 1.5% at six months postpartum.<ref name="Olde20062" /><ref name="Alder20062">{{cite journal | vauthors = Alder J, Stadlmayr W, Tschudin S, Bitzer J | s2cid = 21859634 | title = Post-traumatic symptoms after childbirth: what should we offer? | journal = Journal of Psychosomatic Obstetrics and Gynaecology | volume = 27 | issue = 2 | pages = 107–12 | date = June 2006 | pmid = 16808085 | doi = 10.1080/01674820600714632 }}</ref> Symptoms of PTSD are common following childbirth, with prevalence of 24–30.1%<ref name="Olde20062"/> at six weeks, dropping to 13.6% at six months.<ref>{{cite journal | vauthors = Montmasson H, Bertrand P, Perrotin F, El-Hage W | title = [Predictors of postpartum post-traumatic stress disorder in primiparous mothers] | journal = Journal de Gynécologie, Obstétrique et Biologie de la Reproduction | volume = 41 | issue = 6 | pages = 553–60 | date = October 2012 | pmid = 22622194 | doi = 10.1016/j.jgyn.2012.04.010 }}</ref> Emergency childbirth is also associated with PTSD.<ref>{{cite book|title=Perinatal Mental Health : a Clinical Guide|last=Martin|first=Colin | name-list-style = vanc |publisher=M & K Pub|year=2012|isbn=9781907830495|location=Cumbria England|page=26}}</ref>
-=== Genetics ===
+=== Trauma ===
-{{Main|Genetics of post-traumatic stress disorder}}
+PTSD has been associated with a wide range of traumatic events. The risk of developing PTSD after a traumatic event varies by trauma type, and most people who experience traumatic events do not develop PTSD.<ref name=BMJ2015/>
-There is evidence that susceptibility to PTSD is [[hereditary]]. Approximately 30% of the variance in PTSD is caused from genetics alone.<ref name="Skelton 2012 628–637" /> For twin pairs exposed to combat in Vietnam, having a monozygotic (identical) twin with PTSD was associated with an increased risk of the co-twin's having PTSD compared to twins that were dizygotic (non-identical twins).<ref>{{cite journal | vauthors = True WR, Rice J, Eisen SA, Heath AC, Goldberg J, Lyons MJ, Nowak J | title = A twin study of genetic and environmental contributions to liability for posttraumatic stress symptoms | journal = Archives of General Psychiatry | volume = 50 | issue = 4 | pages = 257–64 | date = April 1993 | pmid = 8466386 | doi = 10.1001/archpsyc.1993.01820160019002 }}</ref> Women with a smaller hippocampus might be more likely to develop PTSD following a traumatic event based on preliminary findings.<ref>{{Cite journal|last1=Quidé|first1=Y.|last2=Andersson|first2=F.|last3=Dufour-Rainfray|first3=D.|last4=Descriaud|first4=C.|last5=Brizard|first5=B.|last6=Gissot|first6=V.|last7=Cléry|first7=H.|last8=Carrey Le Bas|first8=M-P.|last9=Osterreicher|first9=S.|last10=Ogielska|first10=M.|last11=Saint-Martin|first11=P.|date=October 2018|title=Smaller hippocampal volume following sexual assault in women is associated with post-traumatic stress disorder|url=http://doi.wiley.com/10.1111/acps.12920|journal=Acta Psychiatrica Scandinavica|language=en|volume=138|issue=4|pages=312–324|doi=10.1111/acps.12920|pmid=29952088|s2cid=49484570}}</ref> Research has also found that PTSD shares many genetic influences common to other psychiatric disorders. Panic and generalized anxiety disorders and PTSD share 60% of the same genetic variance. Alcohol, nicotine, and [[drug dependence]] share greater than 40% genetic similarities.<ref name="Skelton 2012 628–637" />
-Several biological indicators have been identified that are related to later PTSD development. Heightened [[startle responses]] and, with only preliminary results, a smaller [[hippocampus|hippocampal]] volume have been identified as possible biomarkers for heightened [[Risk factors|risk]] of developing PTSD.<ref name="Marcus ME 2003">{{cite journal | vauthors = Yamasue H, Kasai K, Iwanami A, Ohtani T, Yamada H, Abe O, Kuroki N, Fukuda R, Tochigi M, Furukawa S, Sadamatsu M, Sasaki T, Aoki S, Ohtomo K, Asukai N, Kato N | title = Voxel-based analysis of MRI reveals anterior cingulate gray-matter volume reduction in posttraumatic stress disorder due to terrorism | journal = Proceedings of the National Academy of Sciences of the United States of America | volume = 100 | issue = 15 | pages = 9039–43 | date = July 2003 | pmid = 12853571 | pmc = 166434 | doi = 10.1073/pnas.1530467100 | bibcode = 2003PNAS..100.9039Y | doi-access = free }}</ref> Additionally, one study found that soldiers whose [[leukocytes]] had greater numbers of [[glucocorticoid receptors]] were more prone to developing PTSD after experiencing trauma.<ref name="Delahanty DL 2011">{{cite journal | vauthors = Delahanty DL | title = Toward the predeployment detection of risk for PTSD | journal = The American Journal of Psychiatry | volume = 168 | issue = 1 | pages = 9–11 | date = January 2011 | pmid = 21205813 | doi = 10.1176/appi.ajp.2010.10101519 }}</ref>
+People who experience interpersonal violence such as [[rape]], other [[sexual assault]]s, being [[Kidnapping|kidnapped]], stalking, physical abuse by an intimate partner, and [[incest]] or other forms of childhood [[sexual abuse]] are more likely to develop PTSD than those who experience non-[[assault]] based trauma, such as accidents and [[natural disasters]].<ref name=Kessler>Ronald C. Kessler, [https://www.tandfonline.com/doi/full/10.1080/20008198.2017.1353383 Trauma and PTSD in the WHO World Mental Health Surveys] ''European Journal of Psychotraumatology'' 8(sup5) (2017): 1353383. Retrieved October 10, 2023.</ref> Those who experience prolonged trauma, such as slavery, concentration camps, or chronic domestic abuse, may develop [[complex post-traumatic stress disorder]] (C-PTSD).
-== Pathophysiology ==
+==== Intimate partner violence ====
+{{see also|Rape trauma syndrome}}
+An individual that has been exposed to [[domestic violence]] is predisposed to the development of PTSD. However, being exposed to a traumatic experience does not automatically indicate that an individual will develop PTSD.<ref name=Rothschild/>
-=== Neuroendocrinology ===
+PTSD symptoms include re-experiencing the assault, avoiding things associated with the assault, numbness, and increased anxiety and an increased [[startle response]]. The likelihood of sustained symptoms of PTSD is higher if the rapist confined or restrained the person, if the person being raped believed the rapist would kill them, the person who was raped was very young or very old, and if the rapist was someone they knew. The likelihood of sustained severe symptoms is also higher if people around the survivor ignore (or are ignorant of) the rape or blame the rape survivor.<ref>Fiona Mason and Zoe Lodrick, [https://pubmed.ncbi.nlm.nih.gov/23182852/ Psychological consequences of sexual assault] ''Best Practice & Research. Clinical Obstetrics & Gynaecology'' 27(1) (2013): 27–37. Retrieved October 10, 2023.</ref>
-PTSD symptoms may result when a traumatic event causes an over-reactive adrenaline response, which creates deep neurological patterns in the brain. These patterns can persist long after the event that triggered the fear, making an individual hyper-responsive to future fearful situations.<ref name="Rothschild 2000" /><ref name="secret">{{cite AV media |url=https://www.pbs.org/wnet/brain/outreach/episode4.html |publisher=PBS |title=The Secret Life of the Brain (Series), episode 4 |year=2001 |access-date=2014-01-29 |url-status=live |archive-url=https://web.archive.org/web/20140202181815/http://www.pbs.org/wnet/brain/outreach/episode4.html |archive-date=2014-02-02 }}</ref>  During traumatic experiences, the high levels of stress hormones secreted suppress [[hypothalamus|hypothalamic]] activity that may be a major factor toward the development of PTSD.<ref name="PTSD fact and fiction">{{cite journal | vauthors = Zohar J, Juven-Wetzler A, Myers V, Fostick L | s2cid = 206142172 | title = Post-traumatic stress disorder: facts and fiction | journal = Current Opinion in Psychiatry | volume = 21 | issue = 1 | pages = 74–7 | date = January 2008 | pmid = 18281844 | doi = 10.1097/YCO.0b013e3282f269ee }}</ref>
-PTSD causes [[biochemistry|biochemical]] changes in the brain and body, that differ from other psychiatric disorders such as [[major depression]]. Individuals diagnosed with PTSD respond more strongly to a [[dexamethasone suppression test]] than individuals diagnosed with [[clinical depression]].<ref>{{cite journal | vauthors = Yehuda R, Halligan SL, Golier JA, Grossman R, Bierer LM | s2cid = 21615196 | title = Effects of trauma exposure on the cortisol response to dexamethasone administration in PTSD and major depressive disorder | journal = Psychoneuroendocrinology | volume = 29 | issue = 3 | pages = 389–404 | date = April 2004 | pmid = 14644068 | doi = 10.1016/S0306-4530(03)00052-0 }}</ref><ref>{{cite journal | vauthors = Yehuda R, Halligan SL, Grossman R, Golier JA, Wong C | s2cid = 21403230 | title = The cortisol and glucocorticoid receptor response to low dose dexamethasone administration in aging combat veterans and holocaust survivors with and without posttraumatic stress disorder | journal = Biological Psychiatry | volume = 52 | issue = 5 | pages = 393–403 | date = September 2002 | pmid = 12242055 | doi = 10.1016/S0006-3223(02)01357-4 }}</ref>
+====War-related trauma ====
+While active [[military]] service is a serious risk factor for developing PTSD, [[refugee]]s are also at an increased risk for PTSD due to their exposure to [[war]], hardships, and traumatic events. While the stresses of war affect everyone involved, displaced persons have been shown to be more so than others.<ref>M. Porter and N. Haslam, [https://pubmed.ncbi.nlm.nih.gov/11776427/ Forced displacement in Yugoslavia: a meta-analysis of psychological consequences and their moderators] ''Journal of Traumatic Stress'' 14(4) (October 2001): 817–834. Retrieved October 10, 2023.</ref>
-Most people with PTSD show a low secretion of [[cortisol]] and high secretion of [[catecholamine]]s in [[urine]],<ref>{{cite journal | vauthors = Heim C, Ehlert U, Hellhammer DH | s2cid = 25151441 | title = The potential role of hypocortisolism in the pathophysiology of stress-related bodily disorders | journal = Psychoneuroendocrinology | volume = 25 | issue = 1 | pages = 1–35 | date = January 2000 | pmid = 10633533 | doi = 10.1016/S0306-4530(99)00035-9 }}</ref> with a [[norepinephrine]]/cortisol ratio consequently higher than comparable non-diagnosed individuals.<ref>{{cite journal | vauthors = Mason JW, Giller EL, Kosten TR, Harkness L | s2cid = 24585702 | title = Elevation of urinary norepinephrine/cortisol ratio in posttraumatic stress disorder | journal = The Journal of Nervous and Mental Disease | volume = 176 | issue = 8 | pages = 498–502 | date = August 1988 | pmid = 3404142 | doi = 10.1097/00005053-198808000-00008 }}</ref> This is in contrast to the normative [[fight-or-flight response]], in which both catecholamine and cortisol levels are elevated after exposure to a stressor.<ref>{{cite journal | vauthors = Bohnen N, Nicolson N, Sulon J, Jolles J | title = Coping style, trait anxiety and cortisol reactivity during mental stress | journal = Journal of Psychosomatic Research | volume = 35 | issue = 2–3 | pages = 141–7 | year = 1991 | pmid = 2046048 | doi = 10.1016/0022-3999(91)90068-Y | citeseerx = 10.1.1.467.4323 }}</ref>
+==== Unexpected death of a loved one ====
+Sudden, unexpected death of a loved one is the most common traumatic event type reported in cross-national studies.<ref name=Kessler/><ref name=Atwoli>L. Atwoli, et al., [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5661943/ Posttraumatic stress disorder associated with unexpected death of a loved one: Cross-national findings from the world mental health surveys] ''Depression and Anxiety'' 34(4) (April 2017): 315–326. Retrieved October 11, 2023.</ref> However, the majority of people who experience this type of event will not develop PTSD. An analysis from the WHO World Mental Health Surveys found a 5.2 percent risk of developing PTSD after learning of the unexpected death of a loved one.<ref name=Atwoli/> Because of the high prevalence of this type of traumatic event, unexpected death of a loved one accounts for approximately 20 percent of PTSD cases worldwide.<ref name="Kessler />
-Brain catecholamine levels are high,<ref>{{cite journal | vauthors = Geracioti TD, Baker DG, Ekhator NN, West SA, Hill KK, Bruce AB, Schmidt D, Rounds-Kugler B, Yehuda R, Keck PE, Kasckow JW | title = CSF norepinephrine concentrations in posttraumatic stress disorder | journal = The American Journal of Psychiatry | volume = 158 | issue = 8 | pages = 1227–30 | date = August 2001 | pmid = 11481155 | doi = 10.1176/appi.ajp.158.8.1227 }}</ref> and [[corticotropin-releasing factor]] (CRF) concentrations are high.<ref>{{cite journal | vauthors = Sautter FJ, Bissette G, Wiley J, Manguno-Mire G, Schoenbachler B, Myers L, Johnson JE, Cerbone A, Malaspina D | s2cid = 35766262 | title = Corticotropin-releasing factor in posttraumatic stress disorder (PTSD) with secondary psychotic symptoms, nonpsychotic PTSD, and healthy control subjects | journal = Biological Psychiatry | volume = 54 | issue = 12 | pages = 1382–8 | date = December 2003 | pmid = 14675802 | doi = 10.1016/S0006-3223(03)00571-7 }}</ref><ref>{{Cite book | vauthors = de Kloet CS, Vermetten E, Geuze E, Lentjes EG, Heijnen CJ, Stalla GK, Westenberg HG | volume = 167 | pages = 287–91 | year = 2008 | pmid = 18037027 | doi = 10.1016/S0079-6123(07)67025-3 | isbn = 978-0-444-53140-7 | series = Progress in Brain Research | title = Stress Hormones and Post Traumatic Stress Disorder Basic Studies and Clinical Perspectives | chapter = Elevated plasma corticotrophin-releasing hormone levels in veterans with posttraumatic stress disorder }}</ref> Together, these findings suggest abnormality in the [[hypothalamic-pituitary-adrenal axis|hypothalamic-pituitary-adrenal (HPA) axis]].
+==== Medical trauma ====
+Medical conditions associated with an increased risk of PTSD include [[cancer]],<ref name="cancer.gov">[https://www.cancer.gov/about-cancer/coping/survivorship/new-normal/ptsd-hp-pdq Cancer-Related Post-traumatic Stress] ''National Cancer Institute''. Retrieved October 11, 2023.</ref> heart attack, and stroke. Intensive-care unit (ICU) hospitalization is also a risk factor for PTSD.<ref>D.S Davydow et al., Posttraumatic stress disorder in general intensive care unit survivors: a systematic review ''General Hospital Psychiatry'' 30(5) (September 2008): 421–434. </ref> Some women experience PTSD from their experiences related to [[breast cancer]] and [[mastectomy]].<ref name="cancer.gov"/> Loved ones of those who experience life-threatening illnesses are also at risk for developing PTSD, such as parents of child with chronic illnesses.<ref> M. Cabizuca, et al., [https://psycnet.apa.org/record/2009-06704-015 Posttraumatic stress disorder in parents of children with chronic illnesses: A meta-analysis] ''Health Psychology'' 28(3)  (2009): 379–388. Retrieved October 11, 2023.</ref>
-The maintenance of fear has been shown to include the HPA axis, the [[locus coeruleus]]-[[noradrenergic]] systems, and the connections between the [[limbic system]] and [[frontal cortex]]. The HPA axis that coordinates the hormonal response to stress,<ref name="Radley 2011 481–497">{{cite journal | vauthors = Radley JJ, Kabbaj M, Jacobson L, Heydendael W, Yehuda R, Herman JP|author-link6=James P. Herman | title = Stress risk factors and stress-related pathology: neuroplasticity, epigenetics and endophenotypes | journal = Stress | volume = 14 | issue = 5 | pages = 481–97 | date = September 2011 | pmid = 21848436 | pmc = 3641164 | doi = 10.3109/10253890.2011.604751 }}</ref> which activates the LC-noradrenergic system, is implicated in the over-consolidation of memories that occurs in the aftermath of trauma.<ref name="Pitman 1989">{{cite journal | vauthors = Pitman RK | s2cid = 39057765 | title = Post-traumatic stress disorder, hormones, and memory | journal = Biological Psychiatry | volume = 26 | issue = 3 | pages = 221–3 | date = July 1989 | pmid = 2545287 | doi = 10.1016/0006-3223(89)90033-4 }}</ref> This over-consolidation increases the likelihood of one's developing PTSD. The [[amygdala]] is responsible for threat detection and the conditioned and unconditioned fear responses that are carried out as a response to a threat.<ref name="Skelton 2012 628–637" />
+Women who experience [[miscarriage]] are at risk of PTSD, and those who experience subsequent miscarriages have an increased risk of PTSD compared to those experiencing only one.<ref>D.M. Christiansen, Posttraumatic stress disorder in parents following infant death: A systematic review ''Clinical Psychology Review'' 51 (February 2017): 60–74.</ref>
-The HPA axis is responsible for coordinating the hormonal response to stress.<ref name="Skelton 2012 628–637">{{cite journal | vauthors = Skelton K, Ressler KJ, Norrholm SD, Jovanovic T, Bradley-Davino B | title = PTSD and gene variants: new pathways and new thinking | journal = Neuropharmacology | volume = 62 | issue = 2 | pages = 628–37 | date = February 2012 | pmid = 21356219 | pmc = 3136568 | doi = 10.1016/j.neuropharm.2011.02.013 }}</ref> Given the strong cortisol suppression to [[dexamethasone]] in PTSD, HPA axis abnormalities are likely predicated on strong negative feedback inhibition of cortisol, itself likely due to an increased sensitivity of [[glucocorticoid receptor]]s.<ref>{{cite journal | vauthors = Yehuda R | title = Biology of posttraumatic stress disorder | journal = The Journal of Clinical Psychiatry | volume = 62 Suppl 17 | pages = 41–6 | year = 2001 | pmid = 11495096 | series = 62 }}</ref>
+=== Genetics ===
-PTSD has been hypothesized to be a maladaptive learning pathway to fear response through a hypersensitive, hyperreactive, and hyperresponsive HPA axis.<ref>{{cite journal | vauthors = Yehuda R | s2cid = 19767960 | title = Clinical relevance of biologic findings in PTSD | journal = The Psychiatric Quarterly | volume = 73 | issue = 2 | pages = 123–33 | year = 2002 | pmid = 12025720 | doi = 10.1023/A:1015055711424 }}</ref>
+There is evidence that susceptibility to PTSD is [[hereditary]]. Approximately 30 percent of the variance in PTSD is caused from genetics alone.<ref name="Skelton 2012 628–637" /> Research has also found that PTSD shares many genetic influences common to other psychiatric disorders. Panic and generalized anxiety disorders and PTSD share 60 percent of the same genetic variance. Alcohol, nicotine, and [[drug dependence]] share greater than 40 percent genetic similarities.<ref name="Skelton 2012 628–637">Kelly Skelton, Kerry J Ressler, Seth D Norrholm, Tanja Jovanovic, and Bekh Bradley-Davino, [https://pubmed.ncbi.nlm.nih.gov/21356219/ PTSD and gene variants: new pathways and new thinking] ''Neuropharmacology'' 62(2) (February 2012): 628–637. Retrieved October 12, 2023.</ref>
-Low [[cortisol]] levels may predispose individuals to PTSD: Following war trauma, [[Sweden|Swedish]] soldiers serving in [[Bosnia and Herzegovina]] with low pre-service salivary cortisol levels had a higher risk of reacting with PTSD symptoms, following war trauma, than soldiers with normal pre-service levels.<ref>{{cite journal | vauthors = Aardal-Eriksson E, Eriksson TE, Thorell LH | s2cid = 9149956 | title = Salivary cortisol, posttraumatic stress symptoms, and general health in the acute phase and during 9-month follow-up | journal = Biological Psychiatry | volume = 50 | issue = 12 | pages = 986–93 | date = December 2001 | pmid = 11750895 | doi = 10.1016/S0006-3223(01)01253-7 }}</ref> Because cortisol is normally important in restoring [[homeostasis]] after the stress response, it is thought that trauma survivors with low cortisol experience a poorly contained—that is, longer and more distressing—response, setting the stage for PTSD.
+== Diagnosis ==
+[[Evidence-based assessment]] principles, including a multimethod assessment approach, form the foundation of PTSD assessment.<ref> David Forbes, Jonathan I. Bisson, Candice M. Monson, and Lucy Berliner (eds.), ''Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies'' (The Guilford Press, 2020, ISBN 978-1462543564).</ref> There are a number of PTSD screening instruments for adults, such as the PTSD Checklist for ''DSM-5'' (PCL-5).<ref>[https://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp PTSD Checklist for DSM-5 (PCL-5)] ''National Center for PTSD''. Retrieved October 12, 2023. </ref>
-It is thought that the locus coeruleus-noradrenergic system mediates the over-consolidation of fear memory. High levels of cortisol reduce noradrenergic activity, and because people with PTSD tend to have reduced levels of cortisol, it has been proposed that individuals with PTSD cannot regulate the increased noradrenergic response to traumatic stress.<ref name="PTSD fact and fiction"/> Intrusive memories and conditioned fear responses are thought to be a result of the response to associated triggers. [[Neuropeptide Y]] (NPY) has been reported to reduce the release of norepinephrine and has been demonstrated to have [[anxiolytic]] properties in animal models. Studies have shown people with PTSD demonstrate reduced levels of NPY, possibly indicating their increased anxiety levels.<ref name="Skelton 2012 628–637" />
+There are also several screening and assessment instruments for use with children and adolescents, such as the Child PTSD Symptom Scale (CPSS) and the Child Trauma Screening Questionnaire. In addition, there are also screening and assessment instruments for caregivers of very young children (six years of age and younger), including the Young Child PTSD Screen, the Young Child PTSD Checklist, and the Diagnostic Infant and Preschool Assessment.
-Other studies indicate that people with PTSD have chronically low levels of [[serotonin]], which contributes to the commonly associated behavioral symptoms such as anxiety, ruminations, irritability, aggression, suicidality, and impulsivity.<ref name="Olszewski 2005 40">{{cite journal | vauthors = Olszewski TM, Varrasse JF | title = The neurobiology of PTSD: implications for nurses | journal = Journal of Psychosocial Nursing and Mental Health Services | volume = 43 | issue = 6 | pages = 40–7 | date = June 2005 | pmid = 16018133 | doi =  10.3928/02793695-20050601-09}}</ref> Serotonin also contributes to the stabilization of glucocorticoid production.
+PTSD can be difficult to diagnose, for several reasons:
+* the subjective nature of most of the diagnostic criteria (although this is true for many mental disorders);
+* the potential for over-reporting, such as while seeking disability benefits, or when PTSD could be a [[mitigating factor]] at criminal sentencing
+* the potential for under-reporting, due to stigma, pride, or fear that a PTSD diagnosis might preclude certain employment opportunities;
+* symptom overlap with other mental disorders such as [[obsessive compulsive disorder]] and [[anxiety disorder|generalized anxiety disorder]];<ref> Michael B. First, ''DSM-5® Handbook of Differential Diagnosis'' (American Psychiatric Publishing, 2013, ISBN 978-1585624621). </ref>
+* association with other mental disorders such as [[major depressive disorder]] and generalized anxiety disorder;
+* [[substance use disorder]]s, which often produce some of the same signs and symptoms as PTSD; and
+* substance use disorders can increase vulnerability to PTSD or exacerbate PTSD symptoms or both; and
+* PTSD increases the risk for developing substance use disorders.
+* the differential expression of symptoms culturally (specifically with respect to avoidance and numbing symptoms, distressing [[dream]]s, and somatic symptoms)<ref name=DSM5/>
-[[Dopamine]] levels in a person with PTSD can contribute to symptoms: low levels can contribute to [[anhedonia]], [[apathy]], [[Attentional control|impaired attention]], and motor deficits; high levels can contribute to [[psychosis]], [[Psychomotor agitation|agitation]], and restlessness.<ref name="Olszewski 2005 40" />
+=== Differential diagnosis ===
+A diagnosis of PTSD requires that the person has been exposed to an extreme stressor. Any stressor can result in a diagnosis of [[adjustment disorder]] and it is an appropriate diagnosis for a stressor and a symptom pattern that does not meet the criteria for PTSD.
-Several studies described elevated concentrations of the [[thyroid hormone]] [[triiodothyronine]] in PTSD.<ref name = "Chatzitomaris_2017">{{cite journal | vauthors = Chatzitomaris A, Hoermann R, Midgley JE, Hering S, Urban A, Dietrich B, Abood A, Klein HH, Dietrich JW | title = Thyroid Allostasis-Adaptive Responses of Thyrotropic Feedback Control to Conditions of Strain, Stress, and Developmental Programming | journal = Frontiers in Endocrinology | volume = 8 | pages = 163 | date = 20 July 2017 | pmid = 28775711 | pmc = 5517413 | doi = 10.3389/fendo.2017.00163 | doi-access = free }}</ref> This kind of type 2 [[Allostatic load|allostatic]] adaptation may contribute to increased sensitivity to catecholamines and other stress mediators.
+The symptom pattern for [[acute stress disorder]] must occur and be resolved within four weeks of the trauma. If it lasts longer, and the symptom pattern fits that characteristic of PTSD, the diagnosis may be changed.<ref name=DSM4 />
-Hyperresponsiveness in the norepinephrine system can also be caused by continued exposure to high stress. Overactivation of norepinephrine receptors in the prefrontal cortex can be connected to the flashbacks and nightmares frequently experienced by those with PTSD. A decrease in other norepinephrine functions (awareness of the current environment) prevents the memory mechanisms in the brain from processing the experience, and emotions the person is experiencing during a flashback are not associated with the current environment.<ref name="Olszewski 2005 40" />
+[[Obsessive compulsive disorder]] may be diagnosed for [[intrusive thought]]s that are recurring but not related to a specific traumatic event.<ref name=DSM4 />
-There is considerable controversy within the medical community regarding the neurobiology of PTSD. A 2012 review showed no clear relationship between cortisol levels and PTSD.  The majority of reports indicate people with PTSD have elevated levels of [[corticotropin-releasing hormone]], lower basal [[cortisol]] levels, and enhanced negative feedback suppression of the HPA axis by [[dexamethasone]].<ref name="Skelton 2012 628–637" /><ref>{{cite journal | vauthors = Lindley SE, Carlson EB, Benoit M | s2cid = 31580825 | title = Basal and dexamethasone suppressed salivary cortisol concentrations in a community sample of patients with posttraumatic stress disorder | journal = Biological Psychiatry | volume = 55 | issue = 9 | pages = 940–5 | date = May 2004 | pmid = 15110738 | doi = 10.1016/j.biopsych.2003.12.021 }}</ref>
+In extreme cases of prolonged, repeated traumatization where there is no viable chance of escape, survivors may develop [[complex post-traumatic stress disorder]]. This occurs as a result of layers of trauma rather than a single traumatic event, and includes additional symptomatology, such as the loss of a coherent sense of self.<ref name=Herman/>
-=== Neuroanatomy ===
+== Pathophysiology ==
-[[File:PTSD stress brain.gif|thumb|220px|Regions of the brain associated with stress and post-traumatic stress disorder<ref>{{cite web |url=http://www.nimh.nih.gov/health/publications/post-traumatic-stress-disorder-research-fact-sheet/index.shtml |title=NIMH · Post Traumatic Stress Disorder Research Fact Sheet |work=National Institutes of Health |access-date=2014-01-29 |url-status=live |archive-url=https://web.archive.org/web/20140123205303/http://www.nimh.nih.gov/health/publications/post-traumatic-stress-disorder-research-fact-sheet/index.shtml |archive-date=2014-01-23 }}</ref>]]
-A [[meta-analysis]] of structural MRI studies found an association with reduced total brain volume, intracranial volume, and volumes of the [[hippocampus]], [[insula cortex]], and [[anterior cingulate]].<ref>{{cite journal | vauthors = Bromis K, Calem M, Reinders AA, Williams SC, Kempton MJ | title = Meta-Analysis of 89 Structural MRI Studies in Posttraumatic Stress Disorder and Comparison With Major Depressive Disorder | journal = The American Journal of Psychiatry | volume = 175 | issue = 10 | pages = 989–998 | date = July 2018 | pmid = 30021460 | pmc = 6169727 | doi = 10.1176/appi.ajp.2018.17111199 }}</ref> Much of this research stems from PTSD in those exposed to the Vietnam War.<ref>{{Cite book | vauthors = Liberzon I, Sripada CS | volume = 167 | pages = 151–69 | date = 2008 | pmid = 18037013 | doi = 10.1016/S0079-6123(07)67011-3 | isbn = 9780444531407 | series = Progress in Brain Research | title = Stress Hormones and Post Traumatic Stress Disorder Basic Studies and Clinical Perspectives | chapter = The functional neuroanatomy of PTSD: A critical review }}</ref><ref>{{cite journal | vauthors = Hughes KC, Shin LM | title = Functional neuroimaging studies of post-traumatic stress disorder | journal = Expert Review of Neurotherapeutics | volume = 11 | issue = 2 | pages = 275–85 | date = February 2011 | pmid = 21306214 | pmc = 3142267 | doi = 10.1586/ern.10.198 }}</ref>
+=== Neuroendocrinology ===
+PTSD symptoms may result when a traumatic event causes an over-reactive adrenaline response, which creates deep neurological patterns in the brain. These patterns can persist long after the event that triggered the fear, making an individual hyper-responsive to future fearful situations.<ref name=Rothschild> Babette Rothschild, ''The Body Remembers: The Psychophysiology of Trauma and Trauma Treatment'' (W. W. Norton & Company, 2000, ISBN 978-0393703276). </ref>  During traumatic experiences, the high levels of stress hormones secreted suppress [[hypothalamus|hypothalamic]] activity that may be a major factor toward the development of PTSD.<ref>{J. Zohar, A. Juven-Wetzler, V. Myers, and L. Fostick, Post-traumatic stress disorder: facts and fiction ''Current Opinion in Psychiatry'' 21(1) (January 2008): 74–77</ref>
-People with PTSD have decreased brain activity in the dorsal and rostral [[Anterior cingulate cortex|anterior cingulate]] cortices and the [[ventromedial prefrontal cortex]], areas linked to the experience and regulation of emotion.<ref>{{cite journal | vauthors = Etkin A, Wager TD | title = Functional neuroimaging of anxiety: a meta-analysis of emotional processing in PTSD, social anxiety disorder, and specific phobia | journal = The American Journal of Psychiatry | volume = 164 | issue = 10 | pages = 1476–88 | date = October 2007 | pmid = 17898336 | pmc = 3318959 | doi = 10.1176/appi.ajp.2007.07030504 }}</ref>
+PTSD causes [[biochemistry|biochemical]] changes in the brain and body, that differ from other psychiatric disorders such as [[major depression]]. Most people with PTSD show a low secretion of [[cortisol]] and high secretion of [[catecholamine]]s in [[urine]], with a [[norepinephrine]]/cortisol ratio consequently higher than comparable non-diagnosed individuals.<ref>J.W. Mason, E.L. Giller, T.R. Kosten, and L. Harkness, Elevation of urinary norepinephrine/cortisol ratio in posttraumatic stress disorder ''The Journal of Nervous and Mental Disease'' 176(8) (August 1988): 498–502. </ref> This is in contrast to the normative [[fight-or-flight response]], in which both catecholamine and cortisol levels are elevated after exposure to a stressor.<ref>N. Bohnen, N. Nicolson, J. Sulon, and J. Jolles, Coping style, trait anxiety and cortisol reactivity during mental stress ''Journal of Psychosomatic Research'' 35(2–3) (1991): 141–147.</ref>
-The amygdala is strongly involved in forming emotional memories, especially fear-related memories.  During high stress, the [[hippocampus]], which is associated with placing memories in the correct context of space and time and memory recall, is suppressed. According to one theory this suppression may be the cause of the [[flashbacks (psychology)|flashbacks]] that can affect people with PTSD. When someone with PTSD undergoes [[stimulus (physiology)|stimuli]] similar to the traumatic event, the body perceives the event as occurring again because the memory was never properly recorded in the person's memory.<ref name="Skelton 2012 628–637" /><ref>{{cite journal | vauthors = van der Kolk B | title = Posttraumatic stress disorder and the nature of trauma | journal = Dialogues in Clinical Neuroscience | volume = 2 | issue = 1 | pages = 7–22 | date = March 2000 | doi = 10.31887/DCNS.2000.2.1/bvdkolk | pmid = 22034447 | pmc = 3181584 }}</ref>
+Brain catecholamine levels are high, and [[corticotropin-releasing factor]] (CRF) concentrations are high.<ref name=Kloet> E. Ronald de Kloet, Melly S. Oitzl, and Eric Vermetten (eds.), ''Stress Hormones and Post Traumatic Stress Disorder: Basic Studies and Clinical Perspectives'' (Elsevier Science, 2008, ISBN 978-0444531407).</ref> Together, these findings suggest abnormality in the [[hypothalamic-pituitary-adrenal axis|hypothalamic-pituitary-adrenal (HPA) axis]].
-The amygdalocentric model of PTSD proposes that the amygdala is very much aroused and insufficiently controlled by the medial [[prefrontal cortex]] and the hippocampus, in particular during [[Extinction (psychology)|extinction]].<ref name="Milad">{{cite journal | vauthors = Milad MR, Pitman RK, Ellis CB, Gold AL, Shin LM, Lasko NB, Zeidan MA, Handwerger K, Orr SP, Rauch SL | title = Neurobiological basis of failure to recall extinction memory in posttraumatic stress disorder | journal = Biological Psychiatry | volume = 66 | issue = 12 | pages = 1075–82 | date = December 2009 | pmid = 19748076 | pmc = 2787650 | doi = 10.1016/j.biopsych.2009.06.026 }}</ref> This is consistent with an interpretation of PTSD as a syndrome of deficient extinction ability.<ref name="Milad" /><ref name="Stein">{{cite journal | vauthors = Stein MB, Paulus MP | title = Imbalance of approach and avoidance: the yin and yang of anxiety disorders | journal = Biological Psychiatry | volume = 66 | issue = 12 | pages = 1072–4 | date = December 2009 | pmid = 19944792 | pmc = 2825567 | doi = 10.1016/j.biopsych.2009.09.023 }}</ref>
+Hyperresponsiveness in the norepinephrine system can also be caused by continued exposure to high stress. Overactivation of norepinephrine receptors in the prefrontal cortex can be connected to the flashbacks and nightmares frequently experienced by those with PTSD. A decrease in other norepinephrine functions (awareness of the current environment) prevents the memory mechanisms in the brain from processing the experience, and emotions the person is experiencing during a flashback are not associated with the current environment.<ref>T.M. Olszewski, and J.F. Varrasse, The neurobiology of PTSD: implications for nurses ''Journal of Psychosocial Nursing and Mental Health Services'' 43(6) (June 2005): 40–47.</ref>
-The [[basolateral amygdala|basolateral]] nucleus (BLA) of the amygdala is responsible for the comparison and development of associations between unconditioned and conditioned responses to stimuli, which results in the fear conditioning present in PTSD. The BLA activates the [[central nucleus]] (CeA) of the amygdala, which elaborates the fear response, (including behavioral response to threat and elevated startle response). Descending inhibitory inputs from the [[medial prefrontal cortex]] (mPFC) regulate the transmission from the BLA to the CeA, which is hypothesized to play a role in the extinction of conditioned fear responses.<ref name="Skelton 2012 628–637" />  While as a whole, amygdala hyperactivity is reported by meta analysis of functional neuroimaging in PTSD, there is a large degree of heterogeniety, more so than in social anxiety disorder or phobic disorder.  Comparing dorsal (roughly the CeA) and ventral(roughly the BLA) clusters, hyperactivity is more robust in the ventral cluster, while hypoactivity is evident in the dorsal cluster.  The distinction may explain the blunted emotions in PTSD (via desensitization in the CeA) as well as the fear related component.<ref>{{cite book | vauthors = Goodkind M, Etkin A | veditors = Sklar P, Buxbaum J, Nestler E, Charney D | title=Neurobiology of Mental Illness|publisher=Oxford University Press|edition=5th|chapter=Functional Neurocircuitry and Neuroimaging Studies of Anxiety Disorders}}</ref>
+=== Neuroanatomy ===
+[[File:PTSD stress brain.gif|thumb|350px|Regions of the brain associated with stress and post-traumatic stress disorder]]
-In a 2007 study [[Vietnam War]] combat veterans with PTSD showed a 20% reduction in the volume of their hippocampus compared with veterans who did not have such symptoms.<ref>Carlson, Neil R. (2007). Physiology of Behavior  (9 ed.). Pearson Education, Inc.{{full citation needed|date=January 2014}}</ref> This finding was not replicated in chronic PTSD patients traumatized at an [[Ramstein air show disaster|air show plane crash in 1988]] (Ramstein, Germany).<ref name="Jatzko">{{cite journal | vauthors = Jatzko A, Rothenhöfer S, Schmitt A, Gaser C, Demirakca T, Weber-Fahr W, Wessa M, Magnotta V, Braus DF | title = Hippocampal volume in chronic posttraumatic stress disorder (PTSD): MRI study using two different evaluation methods | journal = Journal of Affective Disorders | volume = 94 | issue = 1–3 | pages = 121–6 | date = August 2006 | pmid = 16701903 | doi = 10.1016/j.jad.2006.03.010 | url = http://dbm.neuro.uni-jena.de/pdf-files/Jatzko-JAD06.pdf | archive-url = https://web.archive.org/web/20131019153804/http://dbm.neuro.uni-jena.de/pdf-files/Jatzko-JAD06.pdf | url-status = live | archive-date = 2013-10-19 }}</ref>
-Evidence suggests that endogenous cannabinoid levels are reduced in PTSD, particularly [[anandamide]], and that cannabinoid receptors (CB1) are increased in order to compensate.<ref name="ECS_PTSD">{{cite journal | vauthors = Neumeister A, Seidel J, Ragen BJ, Pietrzak RH | title = Translational evidence for a role of endocannabinoids in the etiology and treatment of posttraumatic stress disorder | journal = Psychoneuroendocrinology | volume = 51 | pages = 577–84 | date = January 2015 | pmid = 25456347 | pmc = 4268027 | doi = 10.1016/j.psyneuen.2014.10.012 }}</ref> There appears to be a link between increased CB1 receptor availability in the amygdala and abnormal threat processing and hyperarousal, but not dysphoria, in trauma survivors.
-A 2020 study found no evidence for conclusions from prior research that suggested low IQ is a risk factor for developing PTSD.<ref>{{Cite journal|last1=Shura|first1=Robert D.|last2=Epstein|first2=Erica L.|last3=Ord|first3=Anna S.|last4=Martindale|first4=Sarah L.|last5=Rowland|first5=Jared A.|last6=Brearly|first6=Timothy W.|last7=Taber|first7=Katherine H.|date=2020-09-01|title=Relationship between intelligence and posttraumatic stress disorder in veterans|journal=Intelligence|language=en|volume=82|pages=101472|doi=10.1016/j.intell.2020.101472|issn=0160-2896|doi-access=free}}</ref>
-== Diagnosis ==
-PTSD can be difficult to diagnose, because of:
-* the subjective nature of most of the diagnostic criteria (although this is true for many mental disorders);
-* the potential for over-reporting, e.g., while seeking disability benefits, or when PTSD could be a [[mitigating factor]] at criminal sentencing<ref>{{cite journal |title=Fake Posttraumatic Stress Disorder (PTSD) Costs Real Money |journal=The Inquisitive Mind |year=2018 |last1=Boskovic |first1=Irena |last2=Merckelbach |first2=Harald |volume=4 |issue=36 |url=https://www.in-mind.org/article/fake-posttraumatic-stress-disorder-ptsd-costs-real-money |accessdate=2021-09-30 }}</ref>
-* the potential for under-reporting, e.g., stigma, pride, fear that a PTSD diagnosis might preclude certain employment opportunities;
-* symptom overlap with other mental disorders such as obsessive compulsive disorder and generalized anxiety disorder;<ref>{{cite book |last1=First |first1=Michael B. | name-list-style = vanc |title=DSM-5® Handbook of Differential Diagnosis |date=2013 |publisher=American Psychiatric Pub |isbn=9781585629985 |page=225 |url=https://books.google.com/books?id=haOvBAAAQBAJ&pg=PA225 }}</ref>
-* association with other mental disorders such as major depressive disorder and generalized anxiety disorder;
-* substance use disorders, which often produce some of the same signs and symptoms as PTSD; and
-* substance use disorders can increase vulnerability to PTSD or exacerbate PTSD symptoms or both; and
-* PTSD increases the risk for developing substance use disorders.
-*the differential expression of symptoms culturally (specifically with respect to avoidance and numbing symptoms, distressing dreams, and somatic symptoms)<ref>{{Citation|title=Trauma- and Stressor-Related Disorders|date=2013-05-22|work=Diagnostic and Statistical Manual of Mental Disorders|publisher=American Psychiatric Association|doi=10.1176/appi.books.9780890425596.dsm07|isbn=978-0890425558|url-access=registration|url=https://archive.org/details/diagnosticstatis0005unse}}</ref>
-=== Screening ===
-There are a number of PTSD screening instruments for adults, such as the PTSD Checklist for ''DSM-5'' (PCL-5)<ref>{{Cite web|url=https://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp|title=PTSD Checklist for DSM-5 (PCL-5) | date=11 May 2017|website=National Center for PTSD}}</ref><ref name="PCL-5">{{cite journal | vauthors = Blevins CA, Weathers FW, Davis MT, Witte TK, Domino JL | title = The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): Development and Initial Psychometric Evaluation | journal = Journal of Traumatic Stress | volume = 28 | issue = 6 | pages = 489–98 | date = December 2015 | pmid = 26606250 | doi = 10.1002/jts.22059 }}</ref> and the Primary Care PTSD Screen for ''DSM-5'' (PC-PTSD-5).<ref>{{Cite web|url=https://www.ptsd.va.gov/professional/assessment/DSM_5_Validated_Measures.asp|title=Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) | date=7 Apr 2017|website=National Center for PTSD}}</ref>
-There are also several screening and assessment instruments for use with children and adolescents. These include the Child PTSD Symptom Scale (CPSS),<ref>{{Cite web|url=http://www.istss.org/assessing-trauma/child-ptsd-symptom-scale.aspx|title=Child PTSD Symptom Scale|website=International Society for Traumatic Stress Studies|access-date=14 December 2017|archive-date=6 October 2019|archive-url=https://web.archive.org/web/20191006052232/http://www.istss.org/assessing-trauma/child-ptsd-symptom-scale.aspx|url-status=dead}}</ref><ref>{{cite journal | vauthors = Foa EB, Johnson KM, Feeny NC, Treadwell KR | s2cid = 9334984 | title = The child PTSD Symptom Scale: a preliminary examination of its psychometric properties | journal = Journal of Clinical Child Psychology | volume = 30 | issue = 3 | pages = 376–84 | date = September 2001 | pmid = 11501254 | doi = 10.1207/S15374424JCCP3003_9 }}</ref> Child Trauma Screening Questionnaire,<ref>{{Cite web|url=http://www.nctsnet.org/content/child-trauma-screening-questionnaire|title=Child Trauma Screening Questionnaire|date=5 Sep 2013|website=The National Child Traumatic Stress Network|access-date=14 December 2017|archive-date=25 December 2017|archive-url=https://web.archive.org/web/20171225114555/http://www.nctsnet.org/content/child-trauma-screening-questionnaire|url-status=dead}}</ref><ref>{{cite journal | vauthors = Kenardy JA, Spence SH, Macleod AC | s2cid = 1320859 | title = Screening for posttraumatic stress disorder in children after accidental injury | journal = Pediatrics | volume = 118 | issue = 3 | pages = 1002–9 | date = September 2006 | pmid = 16950991 | doi = 10.1542/peds.2006-0406 }}</ref> and UCLA Post-traumatic Stress Disorder Reaction Index for ''DSM-IV''.<ref>{{Cite web|url=http://www.istss.org/assessing-trauma/ucla-posttraumatic-stress-disorder-reaction-index.aspx|title=UCLA Posttraumatic Stress Disorder Reaction Index|website=International Society for Traumatic Stress Studies|access-date=14 December 2017|archive-date=6 October 2019|archive-url=https://web.archive.org/web/20191006052306/http://www.istss.org/assessing-trauma/ucla-posttraumatic-stress-disorder-reaction-index.aspx|url-status=dead}}</ref><ref>{{cite journal | vauthors = Elhai JD, Layne CM, Steinberg AM, Brymer MJ, Briggs EC, Ostrowski SA, Pynoos RS | title = Psychometric properties of the UCLA PTSD reaction index. part II: investigating factor structure findings in a national clinic-referred youth sample | journal = Journal of Traumatic Stress | volume = 26 | issue = 1 | pages = 10–8 | date = February 2013 | pmid = 23417874 | doi = 10.1002/jts.21755 }}</ref>
-In addition, there are also screening and assessment instruments for caregivers of very young children (six years of age and younger). These include the Young Child PTSD Screen,<ref name="Scheeringa Tulane">{{cite web|url=https://medicine.tulane.edu/departments/psychiatry/research/dr-scheeringas-lab/manuals-measures-trainings|title=Young Child PTSD Screen|last1=Scheeringa|first1=Michael| name-list-style = vanc |publisher=Tulane University|access-date=8 April 2018}}</ref> the Young Child PTSD Checklist,<ref name="Scheeringa Tulane" /> and the Diagnostic Infant and Preschool Assessment.<ref>{{cite journal | vauthors = Scheeringa MS, Haslett N | title = The reliability and criterion validity of the Diagnostic Infant and Preschool Assessment: a new diagnostic instrument for young children | journal = Child Psychiatry and Human Development | volume = 41 | issue = 3 | pages = 299–312 | date = June 2010 | pmid = 20052532 | pmc = 2862973 | doi = 10.1007/s10578-009-0169-2 }}</ref>
-=== Assessment ===
-[[Evidence-based assessment]] principles, including a multimethod assessment approach, form the foundation of PTSD assessment.<ref>{{Cite journal| vauthors = Bovin MJ, Marx BP, Schnurr PP |date=2015|title=Evolving DSM Diagnostic Criteria for PTSD: Relevance for Assessment and Treatment|journal=Current Treatment Options in Psychiatry|volume=2|issue=1|pages=86–98|doi=10.1007/s40501-015-0032-y|quote=[... the use of a multi-measure approach eliminates the bias associated with any given instrument ...."|doi-access=free}}</ref><ref>{{cite journal | vauthors = Ben Barnes J, Presseau C, Jordan AH, Kline NK, Young-McCaughan S, Keane TM, Peterson AL, Litz BT | display-authors = 6 | title = Common Data Elements in the Assessment of Military-Related PTSD Research Applied in the Consortium to Alleviate PTSD | journal = Military Medicine | volume = 184 | issue = 5–6 | pages = e218–e226 | date = May 2019 | pmid = 30252077 | doi = 10.1093/milmed/usy226 | doi-access = free }}</ref><ref>Weathers, Frank W., Terence M. Keane, and Edna B. Foa, "Assessment and Diagnosis of Adults", in ''Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies'', 2nd ed., edited by Edna B. Foa, Terence M. Keane, and Matthew J. Friedman (New York: Guilford, 2009), 23–61. ("Thus, ample resources are now available to conduct psychometrically sound assessments of trauma survivors in any context, and it is no longer defensible for clinicians to do otherwise." (p. 25)).</ref>
-=== Diagnostic and statistical manual ===
-PTSD was classified as an [[anxiety disorder]] in the ''DSM-IV'', but has since been reclassified as a "trauma- and stressor-related disorder" in the ''DSM-5''.<ref name="DSM5" /> The ''DSM-5'' diagnostic criteria for PTSD include four symptom clusters: re-experiencing, avoidance, negative alterations in cognition/mood, and alterations in arousal and reactivity.<ref name="DSM5" /><ref name="NIH2016" />
-=== International classification of diseases ===
-The International Classification of Diseases and Related Health Problems 10 (ICD-10) classifies PTSD under "Reaction to severe stress, and adjustment disorders."<ref name="World Health Organization">{{cite web|url=https://www.who.int/classifications/icd/en/bluebook.pdf|title=The ICD-10 Classification of Mental and Behavioural Disorders|publisher=World Health Organization|pages=120–121|archive-url=https://web.archive.org/web/20140323025330/http://www.who.int/classifications/icd/en/bluebook.pdf|archive-date=2014-03-23|url-status=live|access-date=2014-01-29}}</ref> The ICD-10 criteria for PTSD include re-experiencing, avoidance, and either increased reactivity or inability to recall certain details related to the event.<ref name="World Health Organization" />
-The [[ICD-11]] diagnostic description for PTSD contains three components or symptom groups (1) re-experiencing, (2) avoidance, and (3) heightened sense of threat.<ref>{{Cite news|url=https://www.who.int/news-room/detail/18-06-2018-who-releases-new-international-classification-of-diseases-(icd-11)|title=WHO releases new International Classification of Diseases (ICD 11)|work=World Health Organization|access-date=2018-11-15}}</ref><ref name=":7">{{cite journal | vauthors = Brewin CR, Cloitre M, Hyland P, Shevlin M, Maercker A, Bryant RA, Humayun A, Jones LM, Kagee A, Rousseau C, Somasundaram D, Suzuki Y, Wessely S, van Ommeren M, Reed GM | display-authors = 6 | title = A review of current evidence regarding the ICD-11 proposals for diagnosing PTSD and complex PTSD | journal = Clinical Psychology Review | volume = 58 | pages = 1–15 | date = December 2017 | pmid = 29029837 | doi = 10.1016/j.cpr.2017.09.001 | url = http://mural.maynoothuniversity.ie/11577/1/Hyland_Review_2017.pdf }}</ref> ICD-11 no longer includes verbal thoughts about the traumatic event as a symptom.<ref name=":7" /> There is a predicted lower rate of diagnosed PTSD using ICD-11 compared to ICD10 or DSM-5.<ref name=":7" /> ICD-11 also proposes identifying a distinct group with complex post-traumatic stress disorder (CPTSD), who have more often experienced several or sustained traumas and have greater functional impairment than those with PTSD.<ref name=":7" />
+Structural MRI studies have found an association with reduced total brain volume, intracranial volume, and volumes of the [[hippocampus]], [[insula cortex]], and [[anterior cingulate]] in PTSD in those exposed to the Vietnam War.<ref name=Kloet/> People with PTSD have decreased brain activity in the dorsal and rostral [[Anterior cingulate cortex|anterior cingulate]] cortices and the [[ventromedial prefrontal cortex]], areas linked to the experience and regulation of emotion.<ref>A. Etkin A, and T.D. Wager, Functional neuroimaging of anxiety: a meta-analysis of emotional processing in PTSD, social anxiety disorder, and specific phobia ''The American Journal of Psychiatry'' 164(10) (October 2007): 1476–1488.</ref>
-=== Differential diagnosis ===
+The amygdala is strongly involved in forming emotional memories, especially fear-related memories. During high stress, the [[hippocampus]], which is associated with placing memories in the correct context of space and time and memory recall, is suppressed. According to one theory this suppression may be the cause of the [[flashbacks (psychology)|flashbacks]] that can affect people with PTSD. When someone with PTSD undergoes [[stimulus (physiology)|stimuli]] similar to the traumatic event, the body perceives the event as occurring again because the memory was never properly recorded in the person's memory.<ref name="Skelton 2012 628–637" />
-A diagnosis of PTSD requires that the person has been exposed to an extreme stressor. Any stressor can result in a diagnosis of [[adjustment disorder]] and it is an appropriate diagnosis for a stressor and a symptom pattern that does not meet the criteria for PTSD.
+The amygdalocentric model of PTSD proposes that the amygdala is very much aroused and insufficiently controlled by the medial [[prefrontal cortex]] and the hippocampus, in particular during [[Extinction (psychology)|extinction]]. This is consistent with an interpretation of PTSD as a syndrome of deficient extinction ability.<ref>M.R. Milad, et al.,  Neurobiological basis of failure to recall extinction memory in posttraumatic stress disorder ''Biological Psychiatry'' 66(12) (December 2009): 1075–1082.</ref>
-The symptom pattern for [[acute stress disorder]] must occur and be resolved within four weeks of the trauma. If it lasts longer, and the symptom pattern fits that characteristic of PTSD, the diagnosis may be changed.<ref name=DSM4 />
+== Associated medical conditions ==
+Trauma survivors often develop [[Clinical depression|depression]], [[anxiety disorder]]s, and [[mood disorder]]s in addition to PTSD.<ref>M.L. O'Donnell, et al., Posttraumatic disorders following injury: an empirical and methodological review ''Clinical Psychology Review'' 23(4) (July 2003): 587–603. </ref>
-[[Obsessive compulsive disorder]] may be diagnosed for [[intrusive thought]]s that are recurring but not related to a specific traumatic event.<ref name=DSM4 />
+[[Substance use disorder]], such as [[alcohol use disorder]], commonly co-occur with PTSD.<ref> Sidney H. Kennedy, Jerrold S. Maxmen, and Roger S. McIntyre, ''Psychotropic Drugs: Fast facts'' (W. W. Norton & Company, 2008, ISBN 978-0393705201).</ref> Recovery from post-traumatic stress disorder or other anxiety disorders may be hindered, or the condition worsened, when substance use disorders are [[comorbid]] with PTSD.
-In extreme cases of prolonged, repeated traumatization where there is no viable chance of escape, survivors may develop [[complex post-traumatic stress disorder]].<ref name="Herman1992">{{cite journal |last1=Herman |first1=Judith Lewis |s2cid=189943097 | name-list-style = vanc |title=Complex PTSD: A syndrome in survivors of prolonged and repeated trauma |journal=Journal of Traumatic Stress |date=July 1992 |volume=5 |issue=3 |pages=377–391 |doi=10.1007/BF00977235}}</ref> This occurs as a result of layers of trauma rather than a single traumatic event, and includes additional symptomatology, such as the loss of a coherent sense of self.<ref name="Herman1997">{{cite book |last1=Herman |first1=Judith Lewis |name-list-style=vanc |title=Trauma and Recovery |date=1997 |publisher=Basic Books |location=New York |isbn=978-0-465-08730-3 |pages=[https://archive.org/details/traumarecovery00herm_0/page/119 119–122] |edition=2nd |url=https://archive.org/details/traumarecovery00herm_0/page/119 }}</ref>
+In children and adolescents, there is a strong association between emotional regulation difficulties (such as mood swings, anger outbursts, [[Tantrum|temper tantrums]]) and post-traumatic stress symptoms, independent of age, gender, or type of trauma.<ref>L. Villalta, P. Smith, N. Hickin, and A. Stringaris, Emotion regulation difficulties in traumatized youth: a meta-analysis and conceptual review ''European Child & Adolescent Psychiatry'' 27(4) (April 2018): 527–544.</ref>
 == Prevention ==
-{{See also|Traumatic memories}}
+Prevention may be possible when [[counseling]] ([[psychotherapy]]) is targeted at those with early symptoms but has not been shown to be effective when provided to all trauma-exposed individuals whether or not symptoms are present.<ref name=BMJ2015/> Modest benefits have been seen from early access to [[cognitive behavioral therapy]].
-Modest benefits have been seen from early access to [[cognitive behavioral therapy]]. [[Critical incident stress management]] has been suggested as a means of preventing PTSD, but subsequent studies suggest the likelihood of its producing negative outcomes.<ref>{{cite journal |title=Disaster-related post-traumatic stress in police officers: A field study of the impact of debriefing |journal=Stress Medicine |volume=14 |issue=3 |pages=143–8 | vauthors = Carlier IV, Lamberts RD, van Uchelen AJ, Gersons BP |year=1998 |doi=10.1002/(SICI)1099-1700(199807)14:3<143::AID-SMI770>3.0.CO;2-S}}</ref><ref>{{cite journal | vauthors = Mayou RA, Ehlers A, Hobbs M | title = Psychological debriefing for road traffic accident victims. Three-year follow-up of a randomised controlled trial | journal = The British Journal of Psychiatry | volume = 176 | issue = 6 | pages = 589–93 | date = June 2000 | pmid = 10974967 | doi = 10.1192/bjp.176.6.589 | doi-access = free }}</ref> A 2019 Cochrane review did not find any evidence to support the use of an intervention offered to everyone", and that "multiple session interventions may result in worse outcome than no intervention for some individuals."<ref name=":9">{{cite journal | vauthors = Roberts NP, Kitchiner NJ, Kenardy J, Robertson L, Lewis C, Bisson JI | title = Multiple session early psychological interventions for the prevention of post-traumatic stress disorder | journal = The Cochrane Database of Systematic Reviews | volume = 8 | pages = CD006869 | date = August 2019 | pmid = 31425615 | pmc = 6699654 | doi = 10.1002/14651858.CD006869.pub3 }}</ref> The [[World Health Organization]] recommends against the use of [[benzodiazepines]] and [[antidepressants]] in for acute stress (symptoms lasting less than one month).<ref name=WHO2013>{{cite book |title=Assessment and Management of Conditions Specifically Related to Stress |year=2013 |publisher=World Health Organization |location=Geneva |isbn=978-92-4-150593-2 |url=http://apps.who.int/iris/bitstream/10665/85623/1/9789241505932_eng.pdf |access-date=2014-01-29 |url-status=live |archive-url=https://web.archive.org/web/20140201192439/http://apps.who.int/iris/bitstream/10665/85623/1/9789241505932_eng.pdf |archive-date=2014-02-01 }}</ref> Some evidence supports the use of [[hydrocortisone]] for prevention in adults, although there is limited or no evidence supporting [[propranolol]], [[escitalopram]], [[temazepam]], or [[gabapentin]].<ref>{{cite journal | vauthors = Amos T, Stein DJ, Ipser JC | title = Pharmacological interventions for preventing post-traumatic stress disorder (PTSD) | journal = The Cochrane Database of Systematic Reviews | volume = 7 | issue = 7 | pages = CD006239 | date = July 2014 | pmid = 25001071 | doi = 10.1002/14651858.CD006239.pub2 }}</ref>
-=== Psychological debriefing ===
-{{see also|Debriefing#Crisis intervention}}
-Trauma-exposed individuals often receive treatment called ''psychological debriefing'' in an effort to prevent PTSD, which consists of interviews that are meant to allow individuals to directly confront the event and share their feelings with the counselor and to help structure their memories of the event.<ref name=AHRQ2013/>  However, several [[Meta-analysis|meta-analyses]] find that psychological debriefing is unhelpful and is potentially harmful.<ref name=AHRQ2013>{{cite book|last1=Gartlehner|first1=Gerald|last2=Forneris|first2=Catherine A.|last3=Brownley|first3=Kimberly A.|last4=Gaynes|first4=Bradley N.|last5=Sonis|first5=Jeffrey|last6=Coker-Schwimmer|first6=Emmanuel|last7=Jonas|first7=Daniel E.|last8=Greenblatt|first8=Amy|last9=Wilkins|first9=Tania M.|last10=Woodell|first10=Carol L.|last11=Lohr|first11=Kathleen N. | name-list-style = vanc |title=Interventions for the Prevention of Posttraumatic Stress Disorder (PTSD) in Adults After Exposure to Psychological Trauma|date=2013|publisher=Agency for Healthcare Research and Quality (US)|url=https://www.ncbi.nlm.nih.gov/books/NBK133347|pmid=23658936}}</ref><ref name=Feldner2007>{{cite journal | vauthors = Feldner MT, Monson CM, Friedman MJ | title = A critical analysis of approaches to targeted PTSD prevention: current status and theoretically derived future directions | journal = Behavior Modification | volume = 31 | issue = 1 | pages = 80–116 | date = January 2007 | pmid = 17179532 | doi = 10.1177/0145445506295057 | citeseerx = 10.1.1.595.9186 | s2cid = 44619491 }}</ref><ref>{{cite journal | vauthors = Rose S, Bisson J, Churchill R, Wessely S | title = Psychological debriefing for preventing post traumatic stress disorder (PTSD) | journal = The Cochrane Database of Systematic Reviews | issue = 2 | pages = CD000560 | date = 2002 | pmid = 12076399 | doi = 10.1002/14651858.CD000560 | pmc = 7032695 }}</ref> This is true for both single-session debriefing and multiple session interventions.<ref name=":9" /> As of 2017 the [[American Psychological Association]] assessed psychological debriefing as ''No Research Support/Treatment is Potentially Harmful''.<ref>{{cite web|title=Psychological Debriefing for Post-Traumatic Stress Disorder|url=https://www.div12.org/psychological-treatments/treatments/psychological-debriefing-for-post-traumatic-stress-disorder/|website=www.div12.org|date=19 August 2014|publisher=Society of Clinical Psychology: Division 12 of The American Psychological Association|access-date=9 September 2017}}</ref>
-=== Risk-targeted interventions ===
+Trauma-exposed individuals often receive treatment called ''psychological debriefing'' in an effort to prevent PTSD, which consists of interviews that are meant to allow individuals to directly confront the event and share their feelings with the counselor and to help structure their memories of the event. However, several [[Meta-analysis|meta-analyses]] find that psychological debriefing is unhelpful and is potentially harmful.<ref> U.S. Department of Health and Human Services, ''Interventions for the Prevention of Posttraumatic Stress Disorder (PTSD) in Adults After Exposure to Psychological Trauma'' (Agency for Healthcare Research and Quality (US), 2013, ISBN 978-1490363608).</ref>
-{{For|one such method|trauma risk management}}
-Risk-targeted interventions are those that attempt to mitigate specific formative information or events. It can target modeling normal behaviors, instruction on a task, or giving information on the event.<ref name=Wiseman2013Rev>{{cite journal | vauthors = Wiseman T, Foster K, Curtis K | title = Mental health following traumatic physical injury: an integrative literature review | journal = Injury | volume = 44 | issue = 11 | pages = 1383–90 | date = November 2013 | pmid = 22409991 | doi = 10.1016/j.injury.2012.02.015 }}</ref><ref name=Kassam-Adams2013Rev>{{cite journal | vauthors = Kassam-Adams N, Marsac ML, Hildenbrand A, Winston F | title = Posttraumatic stress following pediatric injury: update on diagnosis, risk factors, and intervention | journal = JAMA Pediatrics | volume = 167 | issue = 12 | pages = 1158–65 | date = December 2013 | pmid = 24100470 | doi = 10.1001/jamapediatrics.2013.2741 }}</ref>
 == Management ==
-{{further|Treatments for PTSD}}
+The main treatments for people with PTSD are [[counseling]] (psychotherapy) and medication.<ref>[https://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd Post-Traumatic Stress Disorder] ''National Institute of Mental Health''. Retrieved October 13, 2023.</ref> Four interventions are strongly recommended, all of which are variations of cognitive behavioral therapy (CBT): Cognitive Behavioral Therapy (CBT), Cognitive Processing Therapy (CPT), Cognitive Therapy, and Prolonged Exposure. Additionally, three psychotherapies and four medications are conditionally recommended: Brief Eclectic Psychotherapy, Eye Movement Desensitization and Reprocessing (EMDR) Therapy, Narrative Exposure Therapy (NET), and the four medications sertraline, paroxetine, fluoxetine, and venlafaxine.<ref name=PTSDTreatements>[https://www.apa.org/ptsd-guideline/treatments PTSD Treatments] ''Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults'' (American Psychological Association, June 2020). Retrieved October 13, 2023.</ref>
-Reviews of studies have found that combination therapy (psychological and pharmacotherapy) is no more effective than psychological therapy alone.<ref name="pmid20614457" />
+Benefits from medication are less than those seen with counseling; it is not known whether using medications and counseling together has greater benefit than either method separately.<ref name=BMJ2015/>
-=== Counselling ===
+=== Psychotherapy ===
-The approaches with the strongest evidence include behavioral and cognitive-behavioral therapies such as [[exposure therapy|prolonged exposure therapy]],<ref>{{cite journal | vauthors = Powers MB, Halpern JM, Ferenschak MP, Gillihan SJ, Foa EB | title = A meta-analytic review of prolonged exposure for posttraumatic stress disorder | journal = Clinical Psychology Review | volume = 30 | issue = 6 | pages = 635–41 | date = August 2010 | pmid = 20546985 | doi = 10.1016/j.cpr.2010.04.007 }}</ref> [[cognitive processing therapy]], and [[eye movement desensitization and reprocessing]] (EMDR).<ref>{{Cite book|url=http://www.apa.org/ptsd-guideline/|title=Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults|last=Guideline Development Panel for the Treatment of PTSD in Adults|publisher=American Psychological Association|year=2017|location=Washington, D.C.|pages=ES–2|format=PDF}}</ref><ref name="pmid23266601">{{cite journal | vauthors = Lee CW, Cuijpers P | title = A meta-analysis of the contribution of eye movements in processing emotional memories | journal = Journal of Behavior Therapy and Experimental Psychiatry | volume = 44 | issue = 2 | pages = 231–9 | date = June 2013 | pmid = 23266601 | doi = 10.1016/j.jbtep.2012.11.001 | url = http://researchrepository.murdoch.edu.au/id/eprint/13100/ | type = Submitted manuscript }}</ref><ref>{{cite book | vauthors = Cahill SP, Foa EB |year=2004 |title=Advances in the Treatment of Posttraumatic Stress Disorder: Cognitive-behavioral perspectives | veditors = Taylor S |pages=267–313 |place=New York |publisher=Springer}}</ref> There is some evidence for brief eclectic psychotherapy (BEP), [[narrative exposure therapy]] (NET), and written exposure therapy.<ref>{{Citation|last1=Sloan|first1=Denise M.|date=2019|url=http://content.apa.org/books/16117-007|title=Written exposure therapy for PTSD: A brief treatment approach for mental health professionals.|place=Washington|publisher=American Psychological Association|language=en|doi=10.1037/0000139-001|isbn=978-1-4338-3013-6|access-date=2022-02-13|last2=Marx|first2=Brian P.|s2cid=239337813}}</ref><ref>{{cite book |title=VA/DOD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder |date=2017 |publisher=United States Department of Veterans Affairs |pages=46–47 |url=https://www.healthquality.va.gov/guidelines/MH/ptsd/VADoDPTSDCPGFinal012418.pdf}}</ref>
+Trauma-focused psychotherapies for PTSD (also known as "exposure-based" or "exposure" psychotherapies), such as prolonged exposure therapy (PE), eye movement desensitization and reprocessing (EMDR), and cognitive-reprocessing therapy (CPT) have the most evidence for efficacy and are recommended as first-line treatment for PTSD by almost all clinical practice guidelines.<ref>J.L. Hamblen, et al., A guide to guidelines for the treatment of posttraumatic stress disorder in adults: An update ''Psychotherapy'' 56(3) (September 2019): 359–373.</ref> Exposure-based psychotherapies demonstrate efficacy for PTSD caused by different trauma "types," such as combat, sexual-assault, or natural disasters.<ref>C.L. Straud, J. Siev, S. Messer, and A.K. Zalta, Examining military population and trauma type as moderators of treatment outcome for first-line psychotherapies for PTSD: A meta-analysis ''Journal of Anxiety Disorders'' 67 (October 2019): 102133. </ref>
-A 2019 Cochrane review evaluated couples and family therapies compared to no care and individual and group therapies for the treatment of PTSD.<ref name=":10">{{cite journal | vauthors = Suomi A, Evans L, Rodgers B, Taplin S, Cowlishaw S | title = Couple and family therapies for post-traumatic stress disorder (PTSD) | journal = The Cochrane Database of Systematic Reviews | volume = 2019 | pages = CD011257 | date = December 2019 | issue = 12 | pmid = 31797352 | pmc = 6890534 | doi = 10.1002/14651858.CD011257.pub2 }}</ref> There were too few studies on couples therapies to determine if substantive benefits were derived but preliminary [[Randomized controlled trial|RCTs]] suggested that couples therapies may be beneficial for reducing PTSD symptoms.<ref name=":10" />
+=== Counseling ===
+The approaches with the strongest evidence include behavioral and cognitive-behavioral therapies such as [[exposure therapy|prolonged exposure therapy]], [[cognitive processing therapy]], and [[eye movement desensitization and reprocessing]] (EMDR).<ref name=PTSDTreatements/><ref> Steven Taylor (ed.), ''Advances in the Treatment of Posttraumatic Stress Disorder: Cognitive-behavioral perspectives'' (Springer Publishing Company, 2004, ISBN 978-0826120472). </ref> There is some evidence for brief eclectic psychotherapy (BEP), [[narrative exposure therapy]] (NET), and written exposure therapy.<ref>Denise M. Sloan and Brian P. Marx, ''Written Exposure Therapy for PTSD: A Brief Treatment Approach for Mental Health Professionals'' (Washington DC: American Psychological Association, 2019, ISBN 978-1433830129).</ref>
-A [[meta-analysis|meta-analytic]] comparison of EMDR and [[cognitive behavioral therapy]] (CBT) found both protocols indistinguishable in terms of effectiveness in treating PTSD; however, "the contribution of the eye movement component in EMDR to treatment outcome" is unclear.<ref>{{cite journal | vauthors = Seidler GH, Wagner FE | title = Comparing the efficacy of EMDR and trauma-focused cognitive-behavioral therapy in the treatment of PTSD: a meta-analytic study | journal = Psychological Medicine | volume = 36 | issue = 11 | pages = 1515–22 | date = November 2006 | pmid = 16740177 | doi = 10.1017/S0033291706007963 | s2cid = 39751799 }}</ref> A meta-analysis in children and adolescents also found that EMDR was as efficacious as CBT.<ref name=MetaNSUE>{{cite journal | vauthors = Moreno-Alcázar A, Treen D, Valiente-Gómez A, Sio-Eroles A, Pérez V, Amann BL, Radua J | title = Efficacy of Eye Movement Desensitization and Reprocessing in Children and Adolescent with Post-traumatic Stress Disorder: A Meta-Analysis of Randomized Controlled Trials | journal = Frontiers in Psychology | volume = 8 | pages = 1750 | year = 2017 | pmid = 29066991 | pmc = 5641384 | doi = 10.3389/fpsyg.2017.01750 | doi-access = free }}</ref>
+Children with PTSD are far more likely to pursue treatment at school (because of its proximity and ease) than at a free clinic.<ref>E.S. Rolfsnes and T. Idsoe, School-based intervention programs for PTSD symptoms: a review and meta-analysis ''Journal of Traumatic Stress'' 24(2) (April 2011): 155–165.</ref>
-Children with PTSD are far more likely to pursue treatment at school (because of its proximity and ease) than at a free clinic.<ref>{{cite journal | vauthors = Rolfsnes ES, Idsoe T | title = School-based intervention programs for PTSD symptoms: a review and meta-analysis | journal = Journal of Traumatic Stress | volume = 24 | issue = 2 | pages = 155–65 | date = April 2011 | pmid = 21425191 | doi = 10.1002/jts.20622 }}</ref>
 ==== Cognitive behavioral therapy ====
-[[File:Depicting basic tenets of CBT.jpg|thumb|The diagram depicts how emotions, thoughts, and behaviors all influence each other. The triangle in the middle represents CBT's tenet that all humans' core beliefs can be summed up in three categories: self, others, future.]]
+[[File:Depicting basic tenets of CBT.jpg|thumb|350px|The diagram depicts how emotions, thoughts, and behaviors all influence each other. The triangle in the middle represents CBT's tenet that all humans' core beliefs can be summed up in three categories: self, others, future.]]
-CBT seeks to change the way a person feels and acts by changing the patterns of thinking or behavior, or both, responsible for negative emotions. Results from a 2018 systematic review found high strength of evidence that supports CBT-exposure therapy efficacious for a reduction in PTSD and depression symptoms, as well as the loss of PTSD diagnosis.<ref name=":11">{{Cite journal |last1=Forman-Hoffman|first1=Valerie|last2=Cook Middleton|first2=Jennifer|last3=Feltner|first3=Cynthia|last4=Gaynes|first4=Bradley N.|last5=Palmieri Weber|first5=Rachel|last6=Bann|first6=Carla|last7=Viswanathan|first7=Meera|last8=Lohr|first8=Kathleen N.|last9=Baker|first9=Claire|last10=Green|first10=Joshua|date=2018-05-17|title=Psychological and Pharmacological Treatments for Adults With Posttraumatic Stress Disorder: A Systematic Review Update |website=Agency for Healthcare Research and Quality |url=https://effectivehealthcare.ahrq.gov/topics/ptsd-adult-treatment-update/research-2018|doi=10.23970/ahrqepccer207|doi-access=free}}</ref> CBT has been proven to be an effective treatment for PTSD and is currently considered the standard of care for PTSD by the [[United States Department of Defense]].<ref>{{cite web |title=Treatment of PTSD – PTSD: National Center for PTSD |url=http://www.ptsd.va.gov/public/treatment/therapy-med/treatment-ptsd.asp |publisher=U.S. Department of Veterans Affairs |date=May 26, 2016 |url-status=live |archive-url=https://web.archive.org/web/20161201110743/http://www.ptsd.va.gov/public/treatment/therapy-med/treatment-ptsd.asp |archive-date=December 1, 2016}}</ref><ref>{{cite web |title=PTSD Treatment Options |url=http://dcoe.mil/PsychologicalHealth/About_PTSD/Treatment_Options.aspx |publisher=Defense Centers of Excellence |date=November 23, 2016 |url-status=live |archive-url=https://web.archive.org/web/20161130035254/http://dcoe.mil/PsychologicalHealth/About_PTSD/Treatment_Options.aspx |archive-date=November 30, 2016}}</ref> In CBT, individuals learn to identify thoughts that make them feel afraid or upset and replace them with less distressing thoughts. The goal is to understand how certain thoughts about events cause PTSD-related stress.<ref>{{Cite web |url=http://www.apa.org/ptsd-guideline/treatments/cognitive-behavioral-therapy.aspx |title=Cognitive Behavioral Therapy (CBT) for Treatment of PTSD |publisher=www.apa.org |archive-url=https://web.archive.org/web/20180109063624/http://www.apa.org/ptsd-guideline/treatments/cognitive-behavioral-therapy.aspx |archive-date=2018-01-09|url-status=dead |access-date=2018-01-08}}</ref><ref>{{Cite web |url=https://www.ptsd.va.gov/public/treatment/therapy-med/treatment-ptsd.asp |title=Treatment of PTSD - PTSD |publisher= National Center for PTSD |access-date=2018-01-08}}</ref>  The provision of CBT in an Internet-based format has also been studied in a 2018 Cochrane review.  This review did find similar beneficial effects for [[Internet-based treatments for trauma survivors|Internet-based settings]] as in face-to-face but the quality of the evidence was low due to the small number of trials reviewed.<ref>{{Cite journal |last1=Lewis |first1=Catrin |last2=Roberts |first2=Neil P. |last3=Bethell |first3=Andrew |last4=Robertson |first4=Lindsay |last5=Bisson |first5=Jonathan I. |date=2018-12-14 |title=Internet-based cognitive and behavioural therapies for post-traumatic stress disorder (PTSD) in adults |journal=The Cochrane Database of Systematic Reviews |volume=12 |pages=CD011710 |doi=10.1002/14651858.CD011710.pub2|issn=1469-493X |pmc=6516951 |pmid=30550643}}</ref>
-Exposure therapy is a type of cognitive behavioral therapy<ref>{{cite web | vauthors = Grohol JM |title=What Is Exposure Therapy? |url=http://psychcentral.com/lib/2009/what-is-exposure-therapy/ |access-date=2010-07-14 |publisher=Psychcentral.com |url-status=live |archive-url=https://web.archive.org/web/20100811161615/http://psychcentral.com/lib/2009/what-is-exposure-therapy/ |archive-date=2010-08-11 |date=2016-05-17 }}</ref> that involves assisting trauma survivors to re-experience distressing trauma-related memories and reminders in order to facilitate habituation and successful emotional processing of the trauma memory. Most exposure therapy programs include both imaginal confrontation with the traumatic memories and real-life exposure to trauma reminders; this therapy modality is well supported by clinical evidence.{{Citation needed|date=October 2015}} The success of exposure-based therapies has raised the question of whether exposure is a necessary ingredient in the treatment of PTSD.<ref name="JosephGray2008">{{cite journal| vauthors = Joseph JS, Gray MJ |title=Exposure Therapy for Posttraumatic Stress Disorder |journal=Journal of Behavior Analysis of Offender and Victim: Treatment and Prevention |volume=1 |issue=4 |pages=69–80 |year=2008 |url=http://www.baojournal.com/JOBA-OVTP/JOBA-OVTP-VOL-1/JOBA-OVTP-1-4.pdf |access-date=2010-05-10 |doi=10.1037/h0100457 |url-status=dead |archive-url=https://web.archive.org/web/20101229151823/http://www.baojournal.com/JOBA-OVTP/JOBA-OVTP-VOL-1/JOBA-OVTP-1-4.pdf |archive-date=2010-12-29 }}</ref> Some organizations{{which|date=December 2011}} have endorsed the need for exposure.<ref name="pmid15617511">{{cite journal | vauthors = Ursano RJ, Bell C, Eth S, Friedman M, Norwood A, Pfefferbaum B, Pynoos JD, Zatzick DF, Benedek DM, McIntyre JS, Charles SC, Altshuler K, Cook I, Cross CD, Mellman L, Moench LA, Norquist G, Twemlow SW, Woods S, Yager J | title = Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder | journal = The American Journal of Psychiatry | volume = 161 | issue = 11 Suppl | pages = 3–31 | date = November 2004 | pmid = 15617511 }}</ref><ref>{{cite book |title=Committee on Treatment of Posttraumatic Stress Disorder, Institute of Medicine: Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence |place=Washington, D.C. |publisher=National Academies Press |year=2008 |isbn=978-0-309-10926-0}}{{page needed|date=January 2014}}</ref> The U.S. Department of Veterans Affairs has been actively training mental health treatment staff in [[prolonged exposure therapy]]<ref>{{cite web |title=Prolonged Exposure Therapy |date=2009-09-29 |url=http://www.ptsd.va.gov/public/pages/prolonged-exposure-therapy.asp |archive-url=https://web.archive.org/web/20091114064548/http://www.ptsd.va.gov/public/pages/prolonged-exposure-therapy.asp |url-status=dead |archive-date=2009-11-14 |publisher=U.S. Department of Veteran Affairs |department=PTSD: National Center for PTSD |access-date=2010-07-14 }}</ref> and [[Cognitive Processing Therapy]]<ref>{{cite journal | vauthors = Karlin BE, Ruzek JI, Chard KM, Eftekhari A, Monson CM, Hembree EA, Resick PA, Foa EB | title = Dissemination of evidence-based psychological treatments for posttraumatic stress disorder in the Veterans Health Administration | journal = Journal of Traumatic Stress | volume = 23 | issue = 6 | pages = 663–73 | date = December 2010 | pmid = 21171126 | doi = 10.1002/jts.20588 }}</ref> in an effort to better treat U.S. veterans with PTSD.
+[[Cognitive behavioral therapy]] (CBT) seeks to change the way a person feels and acts by changing the patterns of thinking or behavior, or both, responsible for negative emotions. Results from a 2018 systematic review found high strength of evidence that supports CBT-exposure therapy efficacious for a reduction in PTSD and depression symptoms, as well as the loss of PTSD diagnosis.<ref name=Hoffman>V. Hoffman, et al., [https://effectivehealthcare.ahrq.gov/products/ptsd-adult-treatment-update/research-2018#toc-3 Psychological and Pharmacological Treatments for Adults With Posttraumatic Stress Disorder: A Systematic Review Update] Rockville, MD: Agency for Healthcare Research and Quality (May 2018). Retrieved October 13, 2023. </ref>
-Recent research on contextually based [[behavior therapy#Third generation|third-generation behavior therapies]] suggests that they may produce results comparable to some of the better validated therapies.<ref>{{cite journal |vauthors=Mulick PS, Landes S, Kanter JW |year=2005 |title=Contextual Behavior Therapies in the Treatment of PTSD: A Review |journal=International Journal of Behavioral Consultation and Therapy |volume=1 |issue=3 |pages=223–228 |url=http://www.uwm.edu/~jkanter/pdf/publication/IJBCT-1-3.pdf |archive-url=https://wayback.archive-it.org/all/20120916131249/http://www.uwm.edu/~jkanter/pdf/publication/IJBCT-1-3.pdf |url-status=dead |archive-date=16 September 2012 |doi=10.1037/h0100747 |citeseerx=10.1.1.625.4407 }}</ref> Many of these therapy methods have a significant element of exposure<ref name="Hassija 2007">{{cite journal | vauthors = Hassija CM, Gray MJ |year=2007 |title=Behavioral Interventions for Trauma and Posttraumatic Stress Disorder |journal=International Journal of Behavioral Consultation and Therapy |volume=3 |issue=2 |pages=166–175 |url=http://eric.ed.gov/ERICWebPortal/contentdelivery/servlet/ERICServlet?accno=EJ801196 |doi=10.1037/h0100797}}</ref> and have demonstrated success in treating the primary problems of PTSD and co-occurring depressive symptoms.<ref>{{cite journal | vauthors = Mulick PS, Naugle AE |year=2009 |title=Behavioral Activation in the Treatment of Comorbid Posttraumatic Stress Disorder and Major Depressive Disorder |journal=International Journal of Behavioral Consultation and Therapy |volume=5 |issue=2 |pages=330–339 |url=http://www.thefreelibrary.com/Behavioral+activation+in+the+treatment+of+comorbid+posttraumatic...-a0221920130 |doi=10.1037/h0100892}}</ref>
+In CBT, individuals learn to identify thoughts that make them feel afraid or upset and replace them with less distressing thoughts. The goal is to understand how certain thoughts about events cause PTSD-related stress.<ref>[https://www.apa.org/ptsd-guideline/treatments/cognitive-behavioral-therapy Cognitive Behavioral Therapy (CBT)] ''Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults'' (American Psychological Association, June 2020). Retrieved October 13, 2023.</ref>
-==== Eye movement desensitization and reprocessing ====
+==== EMDR ====
 {{Main|Eye movement desensitization and reprocessing}}
-Eye movement desensitization and reprocessing (EMDR) is a form of psychotherapy developed and studied by [[Francine Shapiro]].<ref name="Shapiro F 1989 199–223">{{cite journal |last1=Shapiro |first1=Francine | name-list-style = vanc |title=Efficacy of the eye movement desensitization procedure in the treatment of traumatic memories |journal=Journal of Traumatic Stress |date=April 1989 |volume=2 |issue=2 |pages=199–223 |doi=10.1002/jts.2490020207}}</ref> She had noticed that, when she was thinking about disturbing memories herself, her eyes were moving rapidly. When she brought her eye movements under control while thinking, the thoughts were less distressing.<ref name="Shapiro F 1989 199–223" />
+[[Eye movement desensitization and reprocessing]] (EMDR) is a form of psychotherapy which controls eye movements while thinking about disturbing memories.<ref>Francine Shapiro, Efficacy of the eye movement desensitization procedure in the treatment of traumatic memories ''Journal of Traumatic Stress'' 2(2) (April 1989): 199–223. </ref> This theory proposes that eye movement can be used to facilitate emotional processing of memories, changing the person's memory to attend to more adaptive information. The therapist initiates voluntary rapid eye movements while the person focuses on memories, feelings or thoughts about a particular trauma.<ref name=UK2005> National Collaborating Centre for Mental Health, ''Post-Traumatic Stress Disorder: The Management of PTSD in Adults and Children in Primary and Secondary Care'' (British Psychological Society and RCPsych Publications, 2005, ISBN 978-1904671251).</ref>
-In 2002, Shapiro and Maxfield published a theory of why this might work, called adaptive information processing.<ref>{{cite journal | vauthors = Shapiro F, Maxfield L | title = Eye Movement Desensitization and Reprocessing (EMDR): information processing in the treatment of trauma | journal = Journal of Clinical Psychology | volume = 58 | issue = 8 | pages = 933–46 | date = August 2002 | pmid = 12115716 | doi = 10.1002/jclp.10068 }}</ref> This theory proposes that eye movement can be used to facilitate emotional processing of memories, changing the person's memory to attend to more adaptive information.<ref name=VAguideline>{{cite web |last=The Management of Post-Traumatic Stress Working Group |title=VA/DoD clinical practice guideline for management of post-traumatic stress |url=http://www.healthquality.va.gov/Post_Traumatic_Stress_Disorder_PTSD.asp |access-date=2 June 2013 |publisher=Department of Veterans Affairs, Department of Defense |page=Version 2.0 |year=2010 |url-status=live |archive-url=https://web.archive.org/web/20130530234757/http://www.healthquality.va.gov/Post_Traumatic_Stress_Disorder_PTSD.asp |archive-date=30 May 2013 }}</ref> The therapist initiates voluntary rapid eye movements while the person focuses on memories, feelings or thoughts about a particular trauma.<ref name=UK2005/><ref name=CochraneGilliesKids>{{cite journal | vauthors = Gillies D, Taylor F, Gray C, O'Brien L, D'Abrew N | title = Psychological therapies for the treatment of post-traumatic stress disorder in children and adolescents | journal = The Cochrane Database of Systematic Reviews | volume = 12 | pages = CD006726 | date = December 2012 | pmid = 23235632 | doi = 10.1002/14651858.CD006726.pub2 | hdl = 1959.13/1311467 | hdl-access = free }}</ref> The therapists uses hand movements to get the person to move their eyes backward and forward, but hand-tapping or tones can also be used.<ref name=UK2005/>  EMDR closely resembles [[cognitive behavior therapy]] as it combines exposure (re-visiting the traumatic event), working on cognitive processes and relaxation/self-monitoring.<ref name=UK2005/> However, exposure by way of being asked to think about the experience rather than talk about it has been highlighted as one of the more important distinguishing elements of EMDR.<ref name="Jeffries/Davis">{{cite journal | vauthors = Jeffries FW, Davis P | title = What is the role of eye movements in eye movement desensitization and reprocessing (EMDR) for post-traumatic stress disorder (PTSD)? a review | journal = Behavioural and Cognitive Psychotherapy | volume = 41 | issue = 3 | pages = 290–300 | date = May 2013 | pmid = 23102050 | doi = 10.1017/S1352465812000793 | s2cid = 33309479 }}</ref>
-There have been several small controlled trials of four to eight weeks of EMDR in adults<ref name="AHRQtreat92">{{Cite book | vauthors = Jonas DE, Cusack K, Forneris CA |title=Psychological and pharmacological treatments for adults with posttraumatic stress disorder (PTSD) |publisher=Agency for Healthcare Research and Quality |url=https://www.ncbi.nlm.nih.gov/books/NBK137702/ |series=Comparative Effectiveness Reviews No. 92 |date=April 2013 |location=Rockville, MD |pmid=23658937 |url-status=live |archive-url=https://web.archive.org/web/20170118124526/https://www.ncbi.nlm.nih.gov/books/NBK137702/ |archive-date=2017-01-18 }}</ref> as well as children and adolescents.<ref name="CochraneGilliesKids" /> There is moderate strength of evidence to support the efficacy of EMDR "for reduction in PTSD symptoms, loss of diagnosis, and reduction in depressive symptoms" according to a 2018 systematic review update.<ref name=":11" /> EMDR reduced PTSD symptoms enough in the short term that one in two adults no longer met the criteria for PTSD, but the number of people involved in these trials was small and thus results should be interpreted with caution pending further research.<ref name="AHRQtreat92" /> There was not enough evidence to know whether or not EMDR could eliminate PTSD in adults.<ref name="AHRQtreat92" /> In children and adolescents, a recent meta-analysis of [[randomized controlled trials]] using [[MetaNSUE]] to avoid biases related to missing information found that EMDR was at least as efficacious as CBT, and superior to waitlist or placebo.<ref name=MetaNSUE/> There was some evidence that EMDR might prevent depression.<ref name="AHRQtreat92" /> There were no studies comparing EMDR to other psychological treatments or to medication.<ref name="AHRQtreat92" /> Adverse effects were largely unstudied.<ref name="AHRQtreat92" /> The benefits were greater for women with a history of sexual assault compared with people who had experienced other types of traumatizing events (such as accidents, physical assaults and war). There is a small amount of evidence that EMDR may improve re-experiencing symptoms in children and adolescents, but EMDR has not been shown to improve other PTSD symptoms, anxiety, or depression.<ref name="CochraneGilliesKids" />
+EMDR closely resembles [[cognitive behavior therapy]] as it combines exposure (re-visiting the traumatic event), working on cognitive processes and relaxation/self-monitoring.<ref name=UK2005/> However, exposure by way of being asked to think about the experience rather than talk about it has been highlighted as one of the more important distinguishing elements of EMDR.<ref>F.W. Jeffries and P. Davis, What is the role of eye movements in eye movement desensitization and reprocessing (EMDR) for post-traumatic stress disorder (PTSD)? a review ''Behavioural and Cognitive Psychotherapy'' 41(3) (May 2013): 290–300.</ref>
-The eye movement component of the therapy may not be critical for benefit.<ref name="UK2005" /><ref name="VAguideline" /> As there has been no major, high quality randomized trial of EMDR with eye movements versus EMDR without eye movements, the controversy over effectiveness is likely to continue.<ref name="Jeffries/Davis" /> Authors of a meta-analysis published in 2013 stated, "We found that people treated with eye movement therapy had greater improvement in their symptoms of post-traumatic stress disorder than people given therapy without eye movements.... Secondly we found that that in laboratory studies the evidence concludes that thinking of upsetting memories and simultaneously doing a task that facilitates eye movements reduces the vividness and distress associated with the upsetting memories."<ref name="pmid23266601"/>
+There is moderate strength of evidence to support the efficacy of EMDR "for reduction in PTSD symptoms, loss of diagnosis, and reduction in depressive symptoms" according to a 2018 systematic review update.<ref name=Hoffman/>
-==== Interpersonal psychotherapy ====
-Other approaches, in particular involving social supports,<ref name="Brewin">{{cite journal | vauthors = Brewin CR, Andrews B, Valentine JD | title = Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults | journal = Journal of Consulting and Clinical Psychology | volume = 68 | issue = 5 | pages = 748–66 | date = October 2000 | pmid = 11068961 | doi = 10.1037/0022-006X.68.5.748 | url = http://content.apa.org/journals/ccp/68/5/748 }}</ref><ref name=Ozer>{{cite journal | vauthors = Ozer EJ, Best SR, Lipsey TL, Weiss DS | title = Predictors of posttraumatic stress disorder and symptoms in adults: a meta-analysis | journal = Psychological Bulletin | volume = 129 | issue = 1 | pages = 52–73 | date = January 2003 | pmid = 12555794 | doi = 10.1037/0033-2909.129.1.52 | url = http://content.apa.org/journals/bul/129/1/52 }}</ref> may also be important. An open trial of interpersonal psychotherapy<ref>{{cite book | vauthors = Weissman MM, Markowitz JC, Klerman GL | title=Clinician's Quick Guide to Interpersonal Psychotherapy |place=New York |publisher=Oxford University Press |year=2007}}{{page needed|date=January 2014}}</ref> reported high rates of remission from PTSD symptoms without using exposure.<ref>{{cite journal | vauthors = Bleiberg KL, Markowitz JC | title = A pilot study of interpersonal psychotherapy for posttraumatic stress disorder | journal = The American Journal of Psychiatry | volume = 162 | issue = 1 | pages = 181–3 | date = January 2005 | pmid = 15625219 | doi = 10.1176/appi.ajp.162.1.181 }}</ref> A current, NIMH-funded trial in New York City is now (and into 2013) comparing interpersonal psychotherapy, [[prolonged exposure therapy]], and relaxation therapy.<ref>{{cite web |url=http://www.columbiatrauma.org/ |title=Trauma and PTSD Program – Columbia University Department of Psychiatry |publisher=Columbiatrauma.org |access-date=2014-01-29 |url-status=live |archive-url=https://web.archive.org/web/20140201232152/http://www.columbiatrauma.org/ |archive-date=2014-02-01 }}{{full citation needed|date=January 2014}}</ref>{{full citation needed|date=January 2014}}<ref>{{cite journal | vauthors = Markowitz JC, Milrod B, Bleiberg K, Marshall RD | title = Interpersonal factors in understanding and treating posttraumatic stress disorder | journal = Journal of Psychiatric Practice | volume = 15 | issue = 2 | pages = 133–40 | date = March 2009 | pmid = 19339847 | pmc = 2852131 | doi = 10.1097/01.pra.0000348366.34419.28 }}</ref><ref>{{cite journal | vauthors = Markowitz JC | title = IPT and PTSD | journal = Depression and Anxiety | volume = 27 | issue = 10 | pages = 879–81 | date = October 2010 | pmid = 20886608 | pmc = 3683871 | doi = 10.1002/da.20752 }}</ref>
 === Medication ===
-While many medications do not have enough evidence to support their use, four (sertraline, fluoxetine, paroxetine, and venlafaxine) have been shown to have a small to modest benefit over placebo.<ref name="Hos2015"/> With many medications, residual PTSD symptoms following treatment is the rule rather than the exception.<ref>{{cite journal | vauthors = Krystal JH, Neumeister A | title = Noradrenergic and serotonergic mechanisms in the neurobiology of posttraumatic stress disorder and resilience | journal = Brain Research | volume = 1293 | pages = 13–23 | date = October 2009 | pmid = 19332037 | pmc = 2761677 | doi = 10.1016/j.brainres.2009.03.044 }}</ref>
+While many medications do not have enough evidence to support their use, four [[antidepressant]]s of the [[selective serotonin reuptake inhibitor|SSRI]] or [[Serotonin–norepinephrine reuptake inhibitors|SNRI]] type (sertraline, fluoxetine, paroxetine, and venlafaxine) have been shown to have a small to modest benefit over placebo.<ref>M. Hoskins, et al., Pharmacotherapy for post-traumatic stress disorder: systematic review and meta-analysis ''The British Journal of Psychiatry'' 206(2) (February 2015): 93–100. </ref>
-==== Antidepressants ====
-[[Selective serotonin reuptake inhibitors]] (SSRIs) and [[serotonin-norepinephrine reuptake inhibitors]] (SNRIs) may have some benefit for PTSD symptoms.<ref name=Hos2015/><ref name=Jeffreys-2012>{{cite journal | vauthors = Jeffreys M, Capehart B, Friedman MJ | title = Pharmacotherapy for posttraumatic stress disorder: review with clinical applications | journal = Journal of Rehabilitation Research and Development | volume = 49 | issue = 5 | pages = 703–15 | date = 2012 | pmid = 23015581 | doi = 10.1682/JRRD.2011.09.0183 | quote = While evidence-based, trauma-focused psychotherapy is the preferred treatment for PTSD, pharmacotherapy is also an important treatment option. First-line pharmacotherapy agents include selective serotonin reuptake inhibitors and the selective serotonin-norepinephrine reuptake inhibitor venlafaxine. | doi-access = free }}</ref><ref>{{Cite journal |last1=Williams |first1=Taryn |last2=Phillips |first2=Nicole J. |last3=Stein |first3=Dan J. |last4=Ipser |first4=Jonathan C. |date=2022-03-02 |title=Pharmacotherapy for post traumatic stress disorder (PTSD) |journal=The Cochrane Database of Systematic Reviews |volume=2022 |issue=3 |pages=CD002795 |doi=10.1002/14651858.CD002795.pub3 |issn=1469-493X |pmc=8889888 |pmid=35234292|pmc-embargo-date=March 2, 2023 }}</ref> [[Tricyclic antidepressants]] are equally effective but are less well tolerated.<ref>{{cite journal | vauthors = Puetz TW, Youngstedt SD, Herring MP | title = Effects of Pharmacotherapy on Combat-Related PTSD, Anxiety, and Depression: A Systematic Review and Meta-Regression Analysis | journal = PLOS ONE | volume = 10 | issue = 5 | pages = e0126529 | date = 28 May 2015 | pmid = 26020791 | pmc = 4447407 | doi = 10.1371/journal.pone.0126529 | veditors = Hashimoto K | quote = The cumulative evidence summarized in this review indicates that pharmacotherapy significantly reduces PTSD, anxiety, and depressive symptom severity among combat veterans with PTSD. The magnitude of the overall effects of pharmacotherapy on PTSD (Δ = 0.38), anxiety (Δ = 0.42), and depressive symptoms (Δ = 0.52) were moderate... | bibcode = 2015PLoSO..1026529P | doi-access = free }}</ref> Evidence provides support for a small or modest improvement with [[sertraline]], [[fluoxetine]], [[paroxetine]], and [[venlafaxine]].<ref name=Hos2015/><ref>{{cite journal | vauthors = Kapfhammer HP | title = Patient-reported outcomes in post-traumatic stress disorder. Part II: focus on pharmacological treatment | language = en, es, fr | journal = Dialogues in Clinical Neuroscience | volume = 16 | issue = 2 | pages = 227–37 | date = June 2014 | doi = 10.31887/DCNS.2014.16.2/hkapfhammer | pmid = 25152660 | pmc = 4140515 }}</ref> Thus, these four medications are considered to be [[First-line treatment|first-line]] medications for PTSD.<ref name=Jeffreys-2012/><ref name="Berger-2009"/>
-==== Benzodiazepines ====
-[[Benzodiazepine]]s are not recommended for the treatment of PTSD due to a lack of evidence of benefit and risk of worsening PTSD symptoms.<ref name="pmid22302333">{{cite journal | vauthors = Jain S, Greenbaum MA, Rosen C | title = Concordance between psychotropic prescribing for veterans with PTSD and clinical practice guidelines | journal = Psychiatric Services | volume = 63 | issue = 2 | pages = 154–60 | date = February 2012 | pmid = 22302333 | doi = 10.1176/appi.ps.201100199 }}</ref> Some authors believe that the use of benzodiazepines is contraindicated for acute stress, as this group of drugs can cause [[Dissociation (psychology)|dissociation]].<ref name="pmid23062450">{{cite journal | vauthors = Auxéméry Y | title = [Posttraumatic stress disorder (PTSD) as a consequence of the interaction between an individual genetic susceptibility, a traumatogenic event and a social context] | language = fr | journal = L'Encephale | volume = 38 | issue = 5 | pages = 373–80 | date = October 2012 | pmid = 23062450 | doi = 10.1016/j.encep.2011.12.003 }}</ref> Nevertheless, some use benzodiazepines with caution for short-term anxiety and insomnia.<ref name="Kapfhammer-2008">{{cite journal | vauthors = Kapfhammer HP | title = [Therapeutic possibilities after traumatic experiences] | journal = Psychiatria Danubina | volume = 20 | issue = 4 | pages = 532–45 | date = December 2008 | pmid = 19011595 }}</ref><ref name="autogenerated1">Reist, C (2005). Post-traumatic Stress Disorder. Compendia, Build ID: F000005, published by Epocrates.com</ref><ref name="Maxmen2002-349">{{cite book | vauthors = Maxmen JS, Ward NG |title=Psychotropic drugs: fast facts |place=New York |publisher=W. W. Norton |year=2002 |edition=3rd |isbn=978-0-393-70301-6 |page=349}}</ref> While benzodiazepines can alleviate acute anxiety, there is no consistent evidence that they can stop the development of PTSD and may actually increase the risk of developing PTSD 2–5 times.<ref name=Gui2015/> Additionally, benzodiazepines may reduce the effectiveness of psychotherapeutic interventions, and there is some evidence that benzodiazepines may actually contribute to the development and chronification of PTSD. For those who already have PTSD, benzodiazepines may worsen and prolong the course of illness, by worsening psychotherapy outcomes, and causing or exacerbating aggression, depression (including suicidality), and substance use.<ref name=Gui2015/> Drawbacks include the risk of developing a [[benzodiazepine dependence]], [[Drug tolerance|tolerance]] (i.e., short-term benefits wearing off with time), and [[benzodiazepine withdrawal syndrome|withdrawal syndrome]]; additionally, individuals with PTSD (even those without a history of alcohol or drug misuse) are at an increased risk of [[benzodiazepine misuse|abusing benzodiazepines]].<ref name="Berger-2009" /><ref name="Martényi-2005">{{cite journal | vauthors = Martényi F | title = [Three paradigms in the treatment of posttraumatic stress disorder] | journal = Neuropsychopharmacologia Hungarica | volume = 7 | issue = 1 | pages = 11–21 | date = March 2005 | pmid = 16167463 }}</ref> Due to a number of other treatments with greater efficacy for PTSD and less risks (e.g., [[Prolonged exposure therapy|prolonged exposure]], [[cognitive processing therapy]], [[eye movement desensitization and reprocessing]], cognitive restructuring therapy, [[Trauma Focused Cognitive Behavioral Therapy|trauma-focused cognitive behavioral therapy]], brief eclectic psychotherapy, [[narrative therapy]], stress inoculation training, [[Antidepressants|serotonergic antidepressants]], [[Prazosin|adrenergic inhibitors]], [[antipsychotic]]s, and even [[anticonvulsant]]s), benzodiazepines should be considered [[Contraindicated|relatively contraindicated]] until all other treatment options are exhausted.<ref name=Haa2015/><ref name=":1"/> For those who argue that benzodiazepines should be used sooner in the most severe cases, the adverse risk of disinhibition (associated with suicidality, aggression and crimes) and clinical risks of delaying or inhibiting definitive efficacious treatments, make other alternative treatments preferable (e.g., inpatient, residential, partial hospitalization, intensive outpatient, dialectic behavior therapy; and other fast-acting sedating medications such as trazodone, mirtazapine, amitripytline, doxepin, prazosin, propranolol, guanfacine, clonidine, quetiapine, olanzapine, valproate, gabapentin).<ref name="Berger-2009"/><ref name=":1">{{Cite book|title = Veterans Affairs and Department of Defense clinical practice guideline for management of post-traumatic stress.|publisher = VA/DoD|year = 2010}}</ref><ref name=":4">{{cite journal | vauthors = Bandelow B, Zohar J, Hollander E, Kasper S, Möller HJ, Zohar J, Hollander E, Kasper S, Möller HJ, Bandelow B, Allgulander C, Ayuso-Gutierrez J, Baldwin DS, Buenvicius R, Cassano G, Fineberg N, Gabriels L, Hindmarch I, Kaiya H, Klein DF, Lader M, Lecrubier Y, Lépine JP, Liebowitz MR, Lopez-Ibor JJ, Marazziti D, Miguel EC, Oh KS, Preter M, Rupprecht R, Sato M, Starcevic V, Stein DJ, van Ameringen M, Vega J | title = World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of anxiety, obsessive-compulsive and post-traumatic stress disorders - first revision | journal = The World Journal of Biological Psychiatry | volume = 9 | issue = 4 | pages = 248–312 | year = 2008 | pmid = 18949648 | doi = 10.1080/15622970802465807 | doi-access = free }}</ref>
-==== Prazosin ====
-[[Prazosin]], an alpha-1 adrenergic antagonist, has been used in veterans with PTSD to reduce nightmares. Studies show variability in the symptom improvement, appropriate dosages, and efficacy in this population.<ref>{{cite journal | vauthors = Green B | s2cid = 40069887 | title = Prazosin in the treatment of PTSD | journal = Journal of Psychiatric Practice | volume = 20 | issue = 4 | pages = 253–9 | date = July 2014 | pmid = 25036580 | doi = 10.1097/01.pra.0000452561.98286.1e }}</ref><ref>{{cite journal | vauthors = Singh B, Hughes AJ, Mehta G, Erwin PJ, Parsaik AK | title = Efficacy of Prazosin in Posttraumatic Stress Disorder: A Systematic Review and Meta-Analysis | journal = The Primary Care Companion for CNS Disorders | volume = 18 | issue = 4 | date = July 2016 | pmid = 27828694 | doi = 10.4088/PCC.16r01943 }}</ref><ref name="Waltman Shearer Moore p. ">{{cite journal | last1=Waltman | first1=Scott H. | last2=Shearer | first2=David | last3=Moore | first3=Bret A. | title=Management of Post-Traumatic Nightmares: a Review of Pharmacologic and Nonpharmacologic Treatments Since 2013 | journal=Current Psychiatry Reports | publisher=Springer Science and Business Media LLC | volume=20 | issue=12 | date=2018-10-11 | issn=1523-3812 | pmid=30306339 | doi=10.1007/s11920-018-0971-2 | page=108| s2cid=52958432 }}</ref>
-==== Glucocorticoids ====
-[[Glucocorticoids]] may be useful for short-term therapy to protect against neurodegeneration caused by the extended stress response that characterizes PTSD, but long-term use may actually promote neurodegeneration.<ref>{{cite journal | vauthors = Griffin GD, Charron D, Al-Daccak R | title = Post-traumatic stress disorder: revisiting adrenergics, glucocorticoids, immune system effects and homeostasis | journal = Clinical & Translational Immunology | volume = 3 | issue = 11 | pages = e27 | date = November 2014 | pmid = 25505957 | pmc = 4255796 | doi = 10.1038/cti.2014.26 }}</ref>
-==== Cannabinoids ====
+With many medications, residual PTSD symptoms following treatment is the rule rather than the exception.<ref>J.H. Krystal and A. Neumeister, Noradrenergic and serotonergic mechanisms in the neurobiology of posttraumatic stress disorder and resilience ''Brain Research'' 1293 (October 2009): 13–23.</ref>
-[[Cannabis]] is not recommended as a treatment for PTSD because scientific evidence does not currently exist demonstrating treatment efficacy for cannabinoids.<ref>{{cite journal | vauthors = Black N, Stockings E, Campbell G, Tran LT, Zagic D, Hall WD, Farrell M, Degenhardt L | display-authors = 6 | title = Cannabinoids for the treatment of mental disorders and symptoms of mental disorders: a systematic review and meta-analysis | journal = The Lancet. Psychiatry | volume = 6 | issue = 12 | pages = 995–1010 | date = December 2019 | pmid = 31672337 | pmc = 6949116 | doi = 10.1016/S2215-0366(19)30401-8 }}</ref><ref>{{cite journal | vauthors = O'Neil ME, Nugent SM, Morasco BJ, Freeman M, Low A, Kondo K, Zakher B, Elven C, Motu'apuaka M, Paynter R, Kansagara D | display-authors = 6 | title = Benefits and Harms of Plant-Based Cannabis for Posttraumatic Stress Disorder: A Systematic Review | journal = Annals of Internal Medicine | volume = 167 | issue = 5 | pages = 332–340 | date = September 2017 | pmid = 28806794 | doi = 10.7326/M17-0477 | doi-access = free }}</ref>{{efn|As an ''example ''of such research, see: Bonn-Miller MO, Sisley S, Riggs P, Yazar-Klosinski B, Wang JB, Loflin MJE, et al. (2021) The short-term impact of 3 smoked cannabis preparations versus placebo on PTSD symptoms: A randomized cross-over clinical trial. ''PLoS ONE'' 16(3): e0246990.}} However, use of cannabis or derived products is widespread among U.S. veterans with PTSD.<ref>{{cite journal | vauthors = Betthauser K, Pilz J, Vollmer LE | title = Use and effects of cannabinoids in military veterans with posttraumatic stress disorder | journal = American Journal of Health-System Pharmacy | volume = 72 | issue = 15 | pages = 1279–84 | date = August 2015 | pmid = 26195653 | doi = 10.2146/ajhp140523 | type = Review }}</ref>
-The [[Cannabinoids|cannabinoid]] [[nabilone]] is sometimes used for nightmares in PTSD. Although some short-term benefit was shown, adverse effects are common and it has not been adequately studied to determine efficacy.<ref name=CADTH-Nabilone-2015>{{cite journal | title = Long-term Nabilone Use: A Review of the Clinical Effectiveness and Safety | journal = CADTH Rapid Response Reports | date = Oct 2015 | pmid = 26561692 | url = https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0079568/ }}</ref> An increasing number of states permit and have legalized the use of [[medical cannabis]] for the treatment of PTSD.<ref>{{cite news | vauthors = Gregg K |url= http://www.providencejournal.com/news/20160713/raimondo-signs-law-allowing-marijuana-for-treatment-of-ptsd |title=Raimondo signs law allowing marijuana for treatment of PTSD|access-date=18 August 2016|newspaper=Providence Journal|date=2016-07-13|url-status=live|archive-url= https://web.archive.org/web/20160816061718/http://www.providencejournal.com/news/20160713/raimondo-signs-law-allowing-marijuana-for-treatment-of-ptsd|archive-date=16 August 2016 }}</ref>
+[[Prazosin]], an alpha-1 adrenergic antagonist, has been used in veterans with PTSD to reduce [[nightmare]]s. Studies show variability in the symptom improvement, appropriate dosages, and efficacy in this population.<ref>B. Green, Prazosin in the treatment of PTSD ''Journal of Psychiatric Practice'' 20(4) (July 2014): 253–259.</ref>
 === Other ===
-====Exercise, sport and physical activity====
+====Exercise, sport, and physical activity====
-Physical activity can influence people's psychological<ref name=CR-Lawrence>{{cite journal | vauthors = Lawrence S, De Silva M, Henley R | title = Sports and games for post-traumatic stress disorder (PTSD) | journal = The Cochrane Database of Systematic Reviews | issue = 1 | pages = CD007171 | date = January 2010 | pmid = 20091620 | doi = 10.1002/14651858.CD007171.pub2 | pmc = 7390394 | url = https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0014346/ | editor1-last = Lawrence | editor1-first = Sue | archive-url = https://web.archive.org/web/20140201185206/http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0014346/ | url-status = live  | archive-date = 2014-02-01 }}</ref> and physical health.<ref name=VA-Jankowski>{{cite web | vauthors = Jankowski K |title=PTSD and physical health |url=http://www.ptsd.va.gov/professional/pages/ptsd-physical-health.asp |archive-url=https://web.archive.org/web/20090730103610/http://www.ptsd.va.gov/professional/pages/ptsd-physical-health.asp |url-status=dead |archive-date=30 July 2009 |work=Information on trauma and PTSD for professionals, National Center for PTSD |publisher=U.S. Department of Veterans Affairs |access-date=8 June 2013}}</ref> The U.S. National Center for PTSD recommends moderate exercise as a way to distract from disturbing emotions, build self-esteem and increase feelings of being in control again. They recommend a discussion with a doctor before starting an exercise program.<ref name=VA-Lifestylerecs>{{cite web |last=U.S. Department of Veterans Affairs |title=Lifestyle Changes Recommended for PTSD Patients |url=http://www.ptsd.va.gov/public/pages/coping-ptsd-lifestyle-changes.asp |archive-url=https://web.archive.org/web/20090731100807/http://www.ptsd.va.gov/public/pages/coping-ptsd-lifestyle-changes.asp |url-status=dead |archive-date=31 July 2009 |work=Information on trauma and PTSD for veterans, general public and family from the National Center for PTSD |publisher=U.S. Department of Veterans Affairs |access-date=8 June 2013}}</ref>
+Physical activity, including [[sports]] and [[exercise]], can enhance people's psychological and physical well-being. The U.S. National Center for PTSD recommends moderate exercise as a way to distract from disturbing [[emotion]]s, build [[self-esteem]], and increase feelings of being in control again. They recommend a discussion with a doctor before starting an exercise program.<ref>[https://www.mirecc.va.gov/cih-visn2/Documents/Patient_Education_Handouts/Coping_with_PTSD_and_Recommended_Lifestyle_Changes_Version_3.pdf Lifestyle Changes Recommended for PTSD Patients] ''National Center for PTSD''. Retrieved October 12, 2023. </ref>
 ====Play therapy for children====
-Play is thought to help children link their inner thoughts with their outer world, connecting real experiences with abstract thought.<ref name=Wethington2008>{{cite journal | vauthors = Wethington HR, Hahn RA, Fuqua-Whitley DS, Sipe TA, Crosby AE, Johnson RL, Liberman AM, Mościcki E, Price LN, Tuma FK, Kalra G, Chattopadhyay SK | title = The effectiveness of interventions to reduce psychological harm from traumatic events among children and adolescents: a systematic review | journal = American Journal of Preventive Medicine | volume = 35 | issue = 3 | pages = 287–313 | date = September 2008 | pmid = 18692745 | doi = 10.1016/j.amepre.2008.06.024 | url = https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0026074 | archive-url = https://web.archive.org/web/20140203040225/http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0026074/ | url-status = live | archive-date = 3 February 2014 }}</ref> Repetitive play can also be one way a child relives traumatic events, and that can be a symptom of trauma in a child or young person.<ref name=Fletcher2003>{{cite book|editor-last=Mash|editor-first=Eric J. |last1=Fletcher |first1=K. E. |last2=Barkley |first2=Russell A. | name-list-style = vanc |title=Child psychopathology |url=https://archive.org/details/childpsychopatho00mash_735|url-access=limited|year=2003 |chapter=7 |publisher=Guilford Press |location=New York |isbn=978-1-57230-609-7 |pages=[https://archive.org/details/childpsychopatho00mash_735/page/n342 330]–371 |edition=2nd}}</ref> Although it is commonly used, there have not been enough studies comparing outcomes in groups of children receiving and not receiving [[play therapy]], so the effects of play therapy are not yet understood.<ref name=UK2005/><ref name=Wethington2008 />
+[[Play (activity)|Play]] is thought to help children link their inner thoughts with their outer world, connecting real experiences with abstract thought. Repetitive play can be one way a child relives traumatic events, and that can be a symptom of trauma in a child or young person.<ref> Eric J. Mash and Russell A. Barkley (eds.), ''Child Psychopathology'' (The Guilford Press, 2002, ISBN 978-1572306097). </ref> [[Play therapy]] is a form of psychotherapy which uses play to help overcome challenges andto reduce psychological harm from traumatic events.
 ====Military programs====
-Many veterans of the wars in [[Iraq War|Iraq]] and [[War in Afghanistan (2001–present)|Afghanistan]] have faced significant physical, emotional, and relational disruptions. In response, the [[United States Marine Corps]] has instituted programs to assist them in re-adjusting to civilian life, especially in their relationships with spouses and loved ones, to help them communicate better and understand what the other has gone through.<ref name=Marriagetherapy>{{cite news |url=http://www.foxnews.com/story/0,2933,344991,00.html |title=Marine Corps Offers Yoga, Massages to Marriages Strained by War |agency=Associated Press |date=2008-04-02 |access-date=2008-04-03 |publisher=Fox News Channel |url-status=live |archive-url=https://web.archive.org/web/20080405164223/http://www.foxnews.com/story/0,2933,344991,00.html |archive-date=2008-04-05 }}</ref> [[Walter Reed Army Institute of Research]] (WRAIR) developed the [[Battlemind]] program to assist service members avoid or ameliorate PTSD and related problems. [[Wounded Warrior Project]] partnered with the US Department of Veterans Affairs to create [[Warrior Care Network]], a national health system of PTSD treatment centers.<ref>{{Cite news|url=http://www.military.com/daily-news/2015/11/06/private-hospital-network-to-help-va-mental-health-care-vets.html|title=Private Hospital Network to Help VA with Mental Health Care for Vets|last=Sweeney|first=Heather | name-list-style = vanc |date=November 6, 2015|work=Military.com|access-date=2017-03-29|url-status=live|archive-url=https://web.archive.org/web/20170330085254/http://www.military.com/daily-news/2015/11/06/private-hospital-network-to-help-va-mental-health-care-vets.html|archive-date=March 30, 2017}}</ref><ref>{{Cite news|url=https://www.bostonglobe.com/metro/massachusetts/2016/05/02/changing-culture/CAjKLHyN6c5xobx8sdgKCO/story.html|title=Covering all the bases for veterans|last=Cullen|first=Kevin | name-list-style = vanc |date=May 2, 2016|work=[[The Boston Globe]]|access-date=2017-03-29|url-status=live|archive-url=https://web.archive.org/web/20170330174306/https://www.bostonglobe.com/metro/massachusetts/2016/05/02/changing-culture/CAjKLHyN6c5xobx8sdgKCO/story.html|archive-date=March 30, 2017}}</ref>
+Many veterans of the wars in [[Iraq War|Iraq]] and [[War in Afghanistan (2001–present)|Afghanistan]] have faced significant physical, emotional, and relational disruptions. In response, the [[United States Marine Corps]] has instituted programs to assist them in re-adjusting to civilian life, especially in their relationships with spouses and loved ones, to help them communicate better and understand what the other has gone through. [[Walter Reed Army Institute of Research]] (WRAIR) developed the [[Battlemind]] program to assist service members avoid or ameliorate PTSD and related problems. [[Wounded Warrior Project]] partnered with the US Department of Veterans Affairs to create [[Warrior Care Network]], a national health system of PTSD treatment centers.<ref>Kevin Cullen, [https://www.bostonglobe.com/metro/massachusetts/2016/05/02/changing-culture/CAjKLHyN6c5xobx8sdgKCO/story.html Covering all the bases for veterans] ''The Boston Globe'' (May 2, 2016). Retrieved October 12, 2023.</ref>
-====Nightmares====
-In 2020, the United States [[Food and Drug Administration]] granted marketing approval for an [[Apple Watch]] app call NightWare. The app aims to improve sleep for people suffering from PTSD-related nightmares, by vibrating when it detects a nightmare in progress based on monitoring heart rate and body movement.<ref>[https://kyma.com/videor/2020/11/11/fda-approves-apple-watch-app-nightware-to-treat-ptsd-nightmares/  FDA approves Apple Watch app NightWare to treat PTSD nightmares]</ref>
-== Epidemiology ==
-[[File:Post-traumatic stress disorder world map - DALY - WHO2004.svg|thumb|[[Disability-adjusted life year]] rates for post-traumatic stress disorder per 100,000&nbsp;inhabitants in 2004<ref>{{cite web |url=https://www.who.int/entity/healthinfo/global_burden_disease/gbddeathdalycountryestimates2004.xls |title=Mortality and Burden of Disease Estimates for WHO Member States in 2004 |work=World Health Organization}}</ref>{{refbegin|2}}
-{{legend|#b3b3b3|no data}}
-{{legend|#ffff65|< 43.5}}
-{{legend|#fff200|43.5–45}}
-{{legend|#ffdc00|45–46.5}}
-{{legend|#ffc600|46.5–48}}
-{{legend|#ffb000|48–49.5}}
-{{legend|#ff9a00|49.5–51}}
-{{legend|#ff8400|51–52.5}}
-{{legend|#ff6e00|52.5–54}}
-{{legend|#ff5800|54–55.5}}
-{{legend|#ff4200|55.5–57}}
-{{legend|#ff2c00|57–58.5}}
-{{legend|#cb0000|> 58.5}}
-{{refend}}]]
-There is debate over the rates of PTSD found in populations, but, despite changes in diagnosis and the criteria used to define PTSD between 1997 and 2013, [[Epidemiology|epidemiological]] rates have not changed significantly.<ref name="Brunet2">{{cite journal | vauthors = Brunet A, Akerib V, Birmes P | title = Don't throw out the baby with the bathwater (PTSD is not overdiagnosed) | journal = Canadian Journal of Psychiatry | volume = 52 | issue = 8 | pages = 501–2; discussion 503 | date = August 2007 | pmid = 17955912 | doi = 10.1177/070674370705200805 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Kilpatrick DG, Resnick HS, Milanak ME, Miller MW, Keyes KM, Friedman MJ | title = National estimates of exposure to traumatic events and PTSD prevalence using DSM-IV and DSM-5 criteria | journal = Journal of Traumatic Stress | volume = 26 | issue = 5 | pages = 537–47 | date = October 2013 | pmid = 24151000 | pmc = 4096796 | doi = 10.1002/jts.21848 }}</ref> Most of the current reliable data regarding the epidemiology of PTSD is based on DSM-IV criteria, as the DSM-5 was not introduced until 2013.
-The United Nations' World Health Organization publishes estimates of PTSD impact for each of its member states; the latest data available are for 2004. Considering only the 25 most populated countries ranked by overall [[Age adjustment|age-standardized]] [[Disability-adjusted life year|Disability-Adjusted Life Year]] (DALY) rate, the top half of the ranked list is dominated by Asian/Pacific countries, the US, and Egypt.<ref name=WHO2004>{{cite web |url=https://www.who.int/entity/healthinfo/global_burden_disease/gbddeathdalycountryestimates2004.xls |title=Mortality and Burden of Disease Estimates for WHO Member States: Persons, all ages (2004) |format=xls |work=World Health Organization |year=2004 |access-date=2009-11-12}}</ref> Ranking the countries by the male-only or female-only rates produces much the same result, but with less meaningfulness, as the score range in the single-sex rankings is much-reduced (4 for women, 3 for men, as compared with 14 for the overall score range), suggesting that the differences between female and male rates, within each country, is what drives the distinctions between the countries.<ref name=WHO2004f>{{cite web |url=https://www.who.int/entity/healthinfo/global_burden_disease/gbddeathdalycountryestimates_female_2004.xls |title=Mortality and Burden of Disease Estimates for WHO Member States: Females, all ages (2004) |format=xls |work=World Health Organization |year=2004 |access-date=2009-11-12}}</ref><ref name=WHO2004m>{{cite web |url=https://www.who.int/entity/healthinfo/global_burden_disease/gbddeathdalycountryestimates_male_2004.xls |title=Mortality and Burden of Disease Estimates for WHO Member States: Males, all ages (2004) |format=xls |work=World Health Organization |year=2004 |access-date=2009-11-12}}</ref>
-As of 2017, the cross-national lifetime prevalence of PTSD was 3.9%, based on a survey were 5.6% had been exposed to trauma.<ref name=":6">{{cite journal | vauthors = Koenen KC, Ratanatharathorn A, Ng L, McLaughlin KA, Bromet EJ, Stein DJ, Karam EG, Meron Ruscio A, Benjet C, Scott K, Atwoli L, Petukhova M, Lim CC, Aguilar-Gaxiola S, Al-Hamzawi A, Alonso J, Bunting B, Ciutan M, de Girolamo G, Degenhardt L, Gureje O, Haro JM, Huang Y, Kawakami N, Lee S, Navarro-Mateu F, Pennell BE, Piazza M, Sampson N, Ten Have M, Torres Y, Viana MC, Williams D, Xavier M, Kessler RC | title = Posttraumatic stress disorder in the World Mental Health Surveys | journal = Psychological Medicine | volume = 47 | issue = 13 | pages = 2260–2274 | date = October 2017 | pmid = 28385165 | pmc = 6034513 | doi = 10.1017/S0033291717000708 }}</ref> The primary factor impacting treatment-seeking behavior, which can help to mitigate PTSD development after trauma was income, while being younger, female, and having less social status (less education, lower individual income, and being unemployed) were all factors associated with less treatment-seeking behaviour.<ref name=":6" />
-{| class="wikitable sortable"
-|+ [[Age adjustment|Age-standardized]] [[Disability-adjusted life year]] (DALY) rates for PTSD, per 100,000 inhabitants, in 25 most populous countries, ranked by overall rate (2004)
-! Region !!  Country !!  PTSD DALY rate,<br />overall<ref name=WHO2004 /> !! PTSD DALY rate,<br />females<ref name=WHO2004f /> !! PTSD DALY rate,<br />males<ref name=WHO2004m />
-|-
-| Asia / Pacific || Thailand || 59 || 86 || 30
-|-
-| Asia / Pacific || Indonesia || 58 || 86 || 30
-|-
-| Asia / Pacific || Philippines || 58 || 86 || 30
-|-
-| Americas || USA || 58 || 86 || 30
-|-
-| Asia / Pacific || Bangladesh || 57 || 85 || 29
-|-
-| Africa || Egypt || 56 || 83 || 30
-|-
-| Asia / Pacific || India || 56 || 85 || 29
-|-
-| Asia / Pacific || Iran || 56 ||83 || 30
-|-
-| Asia / Pacific || Pakistan || 56 || 85 || 29
-|-
-| Asia / Pacific || Japan || 55 || 80 || 31
-|-
-| Asia / Pacific || Myanmar || 55 || 81 || 30
-|-
-| Europe || Turkey || 55 || 81 || 30
-|-
-| Asia / Pacific || Vietnam || 55 || 80 || 30
-|-
-| Europe || France || 54 || 80 || 28
-|-
-| Europe || Germany || 54 || 80 || 28
-|-
-| Europe || Italy || 54 || 80 || 28
-|-
-| Asia / Pacific || Russian Federation || 54 || 78 || 30
-|-
-| Europe || United Kingdom || 54 || 80 || 28
-|-
-| Africa || Nigeria || 53 || 76 || 29
-|-
-| Africa || Dem. Republ. of Congo || 52 || 76 || 28
-|-
-| Africa || Ethiopia || 52 || 76 || 28
-|-
-| Africa || South Africa || 52 || 76 || 28
-|-
-| Asia / Pacific || China || 51 || 76 || 28
-|-
-| Americas || Mexico || 46 || 60 || 30
-|-
-| Americas || Brazil || 45 || 60 || 30
-|}
-=== United States ===
-The [[National Comorbidity Survey|National Comorbidity Survey Replication]] has estimated that the [[lifetime prevalence]] of PTSD among adult Americans is 6.8%, with women (9.7%) more than twice as likely as men<ref name="Olszewski 2005 40" />  (3.6%) to have PTSD at some point in their lives.<ref name=Kessler95>{{cite journal | vauthors = Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB | title = Posttraumatic stress disorder in the National Comorbidity Survey | journal = Archives of General Psychiatry | volume = 52 | issue = 12 | pages = 1048–60 | date = December 1995 | pmid = 7492257 | doi = 10.1001/archpsyc.1995.03950240066012 }}</ref> More than 60% of men and more than 60% of women experience at least one traumatic event in their life. The most frequently reported traumatic events by men are rape, combat, and childhood neglect or physical abuse. Women most frequently report instances of rape, sexual molestation, physical attack, being threatened with a weapon and childhood physical abuse.<ref name="Olszewski 2005 40" /> 88% of men and 79% of women with lifetime PTSD have at least one [[comorbid]] psychiatric disorder. Major depressive disorder, 48% of men and 49% of women, and lifetime alcohol use disorder or dependence, 51.9% of men and 27.9% of women, are the most common comorbid disorders.<ref>{{cite journal | vauthors = Sher L | s2cid = 5900319 | title = Neurobiology of suicidal behavior in post-traumatic stress disorder | journal = Expert Review of Neurotherapeutics | volume = 10 | issue = 8 | pages = 1233–5 | date = August 2010 | pmid = 20662745 | doi = 10.1586/ern.10.114 }}</ref>
-==== Military combat ====
-The [[United States Department of Veterans Affairs]] estimates that 830,000 Vietnam War veterans had symptoms of PTSD.<ref>{{cite web | vauthors = Mintz S |year=2007 |url=http://www.digitalhistory.uh.edu/database/article_display.cfm?HHID=513 |archive-url=https://web.archive.org/web/20030907033319/http://www.digitalhistory.uh.edu/database/article_display.cfm?HHID=513 |archive-date=2003-09-07 |title=The War's Costs |website=Digital History}}</ref>  The ''National Vietnam Veterans' Readjustment Study'' (NVVRS) found 15% of male and 9% of female Vietnam veterans had PTSD at the time of the study. Life-time prevalence of PTSD was 31% for males and 27% for females. In a reanalysis of the NVVRS data, along with analysis of the data from the Matsunaga Vietnam Veterans Project, Schnurr, Lunney, Sengupta, and Waelde found that, contrary to the initial analysis of the NVVRS data, a large majority of Vietnam veterans had PTSD symptoms (but not the disorder itself). Four out of five reported recent symptoms when interviewed 20–25 years after Vietnam.<ref name="autogenerated2">{{cite web |last=Price |first=Jennifer L. | name-list-style = vanc |title=Findings from the National Vietnam Veterans' Readjustment Study – Factsheet |work=United States Department of Veterans Affairs |publisher=National Center for PTSD |url=http://ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_nvvrs.html?printable-template=factsheet |archive-url=https://web.archive.org/web/20090430104839/http://www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_nvvrs.html |archive-date=2009-04-30 |url-status=dead }}</ref>
-A 2011 study from [[Georgia State University]] and [[San Diego State University]] found that rates of PTSD diagnosis increased significantly when troops were stationed in combat zones, had tours of longer than a year, experienced combat, or were injured. Military personnel serving in combat zones were 12.1 percentage points more likely to receive a PTSD diagnosis than their active-duty counterparts in non-combat zones. Those serving more than 12 months in a combat zone were 14.3 percentage points more likely to be diagnosed with PTSD than those having served less than one year.  Experiencing an enemy firefight was associated with an 18.3 percentage point increase in the probability of PTSD, while being wounded or injured in combat was associated with a 23.9 percentage point increase in the likelihood of a PTSD diagnosis. For the 2.16&nbsp;million U.S. troops deployed in combat zones between 2001 and 2010, the total estimated two-year costs of treatment for combat-related PTSD are between $1.54&nbsp;billion and $2.69&nbsp;billion.<ref>{{cite web |url=http://journalistsresource.org/studies/government/federalstate/psychological-costs-war-military-combat-mental-health/ |title=Psychological Costs of War: Military Combat and Mental Health |publisher=Journalistsresource.org |access-date=2014-01-29 |url-status=live |archive-url=https://web.archive.org/web/20140202140609/http://journalistsresource.org/studies/government/federalstate/psychological-costs-war-military-combat-mental-health/ |archive-date=2014-02-02 |date=2012-02-27 }}</ref>
-As of 2013, rates of PTSD have been estimated at up to 20% for veterans returning from Iraq and Afghanistan.<ref name="VAscreen">{{cite book | vauthors = Spoont M, Arbisi P, Fu S, Greer N, Kehle-Forbes S, Meis L, Rutks I, Wilt TJ | title = Screening for Post-Traumatic Stress Disorder (PTSD) in Primary Care: A Systematic Review | date = January 2013 | pmid = 23487872 | url = https://www.ncbi.nlm.nih.gov/books/NBK126691/ | publisher = Department of Veterans Affairs | series = VA Evidence-based Synthesis Program Reports }}</ref>  As of 2013 13% of veterans returning from Iraq were [[unemployed]].<ref>{{Cite news|url = http://www.medscape.com/viewarticle/781380_2|title = Mission Critical: Getting Vets With PTSD Back to Work|last1 = Meade|first1 = Barbara J.|last2 = Glenn|first2 = Margaret K.|last3 = Wirth|first3 = Oliver | name-list-style = vanc |date = March 29, 2013|work = NIOSH: Workplace Safety and Health|publisher = Medscape & NIOSH|url-status = live|archive-url = https://web.archive.org/web/20160316003216/http://www.medscape.com/viewarticle/781380_2|archive-date = March 16, 2016}}</ref>
-==== Man-made disasters ====
-The [[Trauma and first responders|September 11 attacks]] took the lives of nearly 3,000 people, leaving 6,000 injured.<ref name=":2">{{cite journal | vauthors = Lowell A, Suarez-Jimenez B, Helpman L, Zhu X, Durosky A, Hilburn A, Schneier F, Gross R, Neria Y | title = 9/11-related PTSD among highly exposed populations: a systematic review 15 years after the attack | journal = Psychological Medicine | volume = 48 | issue = 4 | pages = 537–553 | date = March 2018 | pmid = 28805168 | pmc = 5805615 | doi = 10.1017/S0033291717002033 }}</ref> [[Trauma and first responders|First responders]] ([[police]], [[firefighters]], and [[emergency medical technicians]]), sanitation workers, and [[volunteering|volunteers]] were all involved in the recovery efforts. The [[prevalence]] of probable PTSD in these highly exposed populations was estimated across several studies using in-person, telephone, and online [[interview]]s and [[questionnaire]]s.<ref name=":2" /><ref name=":3">{{cite journal | vauthors = Perrin MA, DiGrande L, Wheeler K, Thorpe L, Farfel M, Brackbill R | title = Differences in PTSD prevalence and associated risk factors among World Trade Center disaster rescue and recovery workers | journal = The American Journal of Psychiatry | volume = 164 | issue = 9 | pages = 1385–94 | date = September 2007 | pmid = 17728424 | doi = 10.1176/appi.ajp.2007.06101645 | s2cid = 22476443 }}</ref><ref name=":5">{{cite journal | vauthors = Stellman JM, Smith RP, Katz CL, Sharma V, Charney DS, Herbert R, Moline J, Luft BJ, Markowitz S, Udasin I, Harrison D, Baron S, Landrigan PJ, Levin SM, Southwick S | title = Enduring mental health morbidity and social function impairment in world trade center rescue, recovery, and cleanup workers: the psychological dimension of an environmental health disaster | journal = Environmental Health Perspectives | volume = 116 | issue = 9 | pages = 1248–53 | date = September 2008 | pmid = 18795171 | pmc = 2535630 | doi = 10.1289/ehp.11164 }}</ref> Overall prevalence of PTSD was highest immediately following the attacks and decreased over time. However, disparities were found among the different types of recovery workers.<ref name=":2" /><ref name=":3" /> The rate of probable PTSD for first responders was lowest directly after the attacks and increased from ranges of 4.8-7.8% to 7.4-16.5% between the 5-6 year follow-up and a later assessment.<ref name=":2" /> When comparing traditional responders to non-traditional responders (volunteers), the probable PTSD prevalence 2.5 years after the initial visit was greater in volunteers with estimates of 11.7% and 17.2% respectively.<ref name=":2" /> Volunteer participation in tasks atypical to the defined occupational role was a significant risk factor for PTSD.<ref name=":3" /> Other risk factors included exposure intensity, earlier start date, duration of time spent on site, and constant, negative reminders of the trauma.<ref name=":2" /><ref name=":3" /> Additional research has been performed to understand the social consequences of the September 11 attacks. Alcohol consumption was assessed in a cohort of [[World Trade Center (1973–2001)|World Trade Center]] workers using the [[CAGE questionnaire|cut-annoyed-guilty-eye (CAGE) questionnaire]] for [[alcohol use disorder]]. Almost 50% of World Trade Center workers who self-identified as alcohol users reported drinking more during the rescue efforts.<ref name=":5" /> Nearly a quarter of these individuals reported drinking more following the recovery.<ref name=":5" /> If determined to have probable PTSD status, the risk of developing an alcohol problem was double compared to those without psychological [[morbidity]].<ref name=":5" /> Social disability was also studied in this cohort as a social consequence of the September 11 attacks. Defined by the disruption of family, work, and social life, the risk of developing social disability increased 17-fold when categorized as having probable PTSD.<ref name=":5" />
-== Veterans ==
-[[File:Vietnam War Memorial Washington DC Maya Lin-editA.jpg|thumb|[[Vietnam Veterans Memorial]], [[Washington, D.C.]]]]
-=== United States ===
-{{See also|Benefits for US Veterans with PTSD}} <!-- Please see the Talk page for this article for a discussion about this section. —>
-The United States provides a range of benefits for veterans that the [[United States Department of Veterans Affairs|VA]] has determined have PTSD, which developed during, or as a result of, their military service. These benefits may include tax-free cash payments,<ref>{{cite web|title=VA Compensation Rate Table|url=http://www.vba.va.gov/bln/21/Rates/comp01.htm|work=Department of Veterans Affairs|access-date=20 October 2012|url-status=dead|archive-url=https://web.archive.org/web/20121103153745/http://www.vba.va.gov/bln/21/rates/comp01.htm|archive-date=3 November 2012}}</ref> free or low-cost mental health treatment and other healthcare,<ref>{{cite web|title=Access VA Health Benefits|url=http://www.va.gov/healthbenefits/access/|work=Department of Veterans Affairs|access-date=20 October 2012|url-status=live|archive-url=https://web.archive.org/web/20121016204408/http://www.va.gov/healthbenefits/access/|archive-date=16 October 2012}}</ref> vocational rehabilitation services,<ref>{{cite web|title=VA Vocational Rehabilitation|url=http://www.vba.va.gov/bln/vre/|work=Department of Veterans Affairs|access-date=20 October 2012|url-status=live|archive-url=https://web.archive.org/web/20121019193548/http://www.vba.va.gov/bln/vre/|archive-date=19 October 2012}}</ref> employment assistance,<ref>{{cite web|title=Vet Success|url=http://vetsuccess.gov|work=Department of Veterans Affairs + State Government Veterans Agencies|access-date=20 October 2012|url-status=dead|archive-url=https://web.archive.org/web/20121019193551/http://vetsuccess.gov/|archive-date=19 October 2012}}</ref> and independent living support.<ref>{{cite web|title=Independent Living Support for Veterans|url=http://www.vba.va.gov/bln/vre/ilp.htm|work=Department of Veterans Affairs|access-date=20 October 2012|url-status=live|archive-url=https://web.archive.org/web/20121024180323/http://www.vba.va.gov/bln/vre/ilp.htm|archive-date=24 October 2012}}</ref><ref>{{cite web|title=Veterans Benefits|url=http://www.vba.va.gov/VBA/|publisher=Veterans Benefits Administration|access-date=30 November 2012|url-status=dead|archive-url=https://web.archive.org/web/20121126185724/http://www.vba.va.gov/VBA/|archive-date=26 November 2012}}</ref>
-=== Iraq ===
-Young [[Iraqis]] have high rates of post-traumatic stress disorder due to the [[2003 invasion of Iraq]].<ref>{{cite web |url= https://www.austinpublishinggroup.com/community-medicine/fulltext/jcmhc-v2-id1010.php|title= Posttraumatic Stress Disorder among Youth in Iraq, Short Systemic Reviews |last= al-Shawi|first= Ameel | name-list-style = vanc |date= February 2017|website= austinpublishinggroup.com|publisher= Journal of Community Medicine And Healthcare |access-date= 5 July 2019}}</ref>
-=== United Kingdom ===
-In the UK, there are various charities and service organisations dedicated to aiding veterans in readjusting to civilian life. [[The Royal British Legion]] and the more recently established [[Help for Heroes]] are two of Britain's more high-profile veterans' organisations which have actively advocated for veterans over the years. There has been some controversy that the [[National Health Service|NHS]] has not done enough in tackling mental health issues and is instead "dumping" veterans on charities such as [[Combat Stress]].<ref>{{cite news |url=http://www.timesonline.co.uk/tol/news/politics/article5819059.ece |title=Lance Corporal Johnson Beharry accuses Government of neglecting soldiers |work=The Times |date=February 28, 2009 |access-date=2009-08-29 |location=London |first=Laura |last=Dixon | name-list-style = vanc }} {{subscription required}}</ref><ref>{{cite news |url=http://news.bbc.co.uk/1/hi/uk/7916852.stm |archive-url=https://web.archive.org/web/20140219060821/http://news.bbc.co.uk/2/hi/uk_news/7916852.stm |archive-date=2014-02-19 |title=UK &#124; Full interview: L/Cpl Johnson Beharry |work=BBC News |date=2009-02-28 |access-date=2009-08-29 |url-status=live}}</ref>
-===Canada===
-[[Veterans Affairs Canada]] offers a new program that includes rehabilitation, financial benefits, job placement, health benefits program, disability awards, [[peer support]]<ref>{{cite web |url=http://www.osiss.ca/engraph/index_e.asp |title=The Operational Stress Injury Social Support (OSISS) Program for Canadian Veterans |url-status=dead |archive-url=https://web.archive.org/web/20110706192633/http://www.osiss.ca/engraph/index_e.asp |archive-date=6 July 2011 }} See also {{cite web |url=http://www.veterans.gc.ca/pdf/deptReports/OSISS-Eval-Final-Rpt-Jan05(Nov04-05)-eng.pdf |title=Evaluation of the OSISS Peer Support Network |publisher=Dept. of National Defence and Veterans Affairs Canada |date=January 2005 |url-status=live |archive-url=https://web.archive.org/web/20140130040959/http://www.veterans.gc.ca/pdf/deptReports/OSISS-Eval-Final-Rpt-Jan05(Nov04-05)-eng.pdf |archive-date=2014-01-30 }}</ref><ref>{{cite web |url=http://www.dtic.mil/cgi-bin/GetTRDoc?Location=U2&doc=GetTRDoc.pdf&AD=ADA472725 |format=PDF | vauthors = Heber A, Grenier S, Richardson D, Darte K |year=2006 |title=Combining Clinical Treatment and Peer Support: A Unique Approach to Overcoming Stigma and Delivering Care |work=Human Dimensions in Military Operations – Military Leaders' Strategies for Addressing Stress and Psychological Support |place=Neuilly-sur-Seine, France |publisher=Canadian Department Of National Defence |access-date=2014-01-30 |url-status=dead |archive-url=https://web.archive.org/web/20121007035651/http://www.dtic.mil/cgi-bin/GetTRDoc?Location=U2&doc=GetTRDoc.pdf&AD=ADA472725 |archive-date=2012-10-07 }}</ref><ref>{{cite journal |url=http://www.journal.forces.gc.ca/vo9/no1/09-richardson-eng.asp |year=2008 |title=Operational Stress Injury Social Support: a Canadian innovation in professional peer support |journal=Canadian Military Journal |volume=9 |issue=1 |pages=57–64 |access-date=2014-01-30 | first1 = J Don | last1 = Richardson | first2 = Kathy | last2 = Darte | first3 = Stéphane | last3 = Grenier | first4 = Allan | last4 = English | first5 = Joe | last5 = Sharpe | name-list-style = vanc |url-status=live |archive-url=https://web.archive.org/web/20131221173442/http://www.journal.forces.gc.ca/vo9/no1/09-richardson-eng.asp |archive-date=2013-12-21 }}</ref> and family support.<ref>{{cite web |url=http://www.vac-acc.gc.ca/clients/sub.cfm?source=Forces/nvc&CFID=9295860&CFTOKEN=39698927 |archive-url=https://web.archive.org/web/20060619065006/http://www.vac-acc.gc.ca/clients/sub.cfm?source=Forces%2Fnvc&CFID=661705&CFTOKEN=25812540 |archive-date=2006-06-19 |title=The New Veterans Charter for CF Veterans and their Families |publisher=Vac-Acc.Gc.Ca |date=2006-07-12 |access-date=2009-08-29 |url-status=dead }}</ref>
-== History ==
-The 1952 edition of the DSM-I includes a diagnosis of "gross stress reaction", which has similarities to the modern definition and understanding of PTSD.<ref name="Posttraumatic stress disorder: a history and a critique">{{cite journal | vauthors = Andreasen NC | title = Posttraumatic stress disorder: a history and a critique | journal = Annals of the New York Academy of Sciences | volume = 1208 | issue = Psychiatric and Neurologic Aspects of War | pages = 67–71 | date = October 2010 | pmid = 20955327 | doi = 10.1111/j.1749-6632.2010.05699.x | bibcode = 2010NYASA1208...67A | s2cid = 42645212 }}</ref> Gross stress reaction is defined as a normal personality using established patterns of reaction to deal with overwhelming fear as a response to conditions of great stress.<ref name= "DSM-I">{{cite book|last1=American Psychiatric Association|title=Diagnostic and Statistical Manual|date=1952|publisher=American Psychiatric Association Mental Hospital Service|isbn=978-0890420171|page=326.3}}</ref> The diagnosis includes language which relates the condition to combat as well as to "civilian catastrophe".<ref name=DSM-I />
-A USAF study carried out in 1979 focused on individuals (civilian and military) who had worked to recover or identify the remains of those who died in [[Jonestown]]. The bodies had been dead for several days, and a third of them had been children. The study used the term "dysphoria" to describe PTSD-like symptoms.<ref>{{Cite web|url=https://apps.dtic.mil/dtic/tr/fulltext/u2/a115592.pdf|archive-url=https://web.archive.org/web/20190608170611/https://apps.dtic.mil/dtic/tr/fulltext/u2/a115592.pdf|url-status=live|archive-date=8 June 2019|title=Emotional Effects on USAF Personnel of Recovering and Identifying Victims from Jonestown, Guyana|last1=Jones|first1=David R.|last2=Fischer|first2=Joseph R. | name-list-style = vanc |date=1982-04-01}}</ref>
-Early in 1978, the diagnosis term "post-traumatic stress disorder" was first recommended in a working group finding presented to the Committee of Reactive Disorders.<ref name="IHHRT" /> The condition was described in the [[DSM-III]] (1980) as posttraumatic stress disorder.<ref name="Posttraumatic stress disorder: a history and a critique" /><ref name="IHHRT">{{cite book | last1 = Shalev | first1 = Arieh Y. | last2 = Yehuda | first2 = Rachel | first3 = Alexander C. | last3 = McFarlane | name-list-style = vanc  |title=International handbook of human response to trauma |publisher=Kluwer Academic/Plenum Press |location=New York |year=2000 |isbn=978-0-306-46095-1}}{{page needed|date=January 2014}};[https://web.archive.org/web/20070617045846/http://www.istss.org/what/history2.cfm on-line].</ref> In the [[DSM-IV]], the spelling "posttraumatic stress disorder" is used, while in the [[ICD-10]], the spelling is "post-traumatic stress disorder".<ref name="icd10-2007">{{cite web |url=http://apps.who.int/classifications/apps/icd/icd10online2007/index.htm?gf40.htm+F431 |title=International Statistical Classification of Diseases and Related Health Problems 10th Revision Version for 2007 |publisher=World Health Organization (UN) |year=2007 |access-date=October 3, 2011 |url-status=dead |archive-url=https://web.archive.org/web/20141205050052/http://apps.who.int/classifications/apps/icd/icd10online2007/index.htm?gf40.htm+F431 |archive-date=December 5, 2014 }}</ref>
-The addition of the term to the DSM-III was greatly influenced by the experiences and conditions of U.S. military veterans of the [[Vietnam War]].<ref name="AllInTheMind">{{cite web |url=http://www.abc.net.au/rn/allinthemind/stories/2004/1214098.htm |title=When trauma tips you over: PTSD Part 1 |series=All in the Mind |publisher=Australian Broadcasting Commission |date=9 October 2004 |url-status=live |archive-url=https://web.archive.org/web/20080603155139/http://www.abc.net.au/rn/allinthemind/stories/2004/1214098.htm |archive-date=3 June 2008 }}</ref> Owing to its association with the war in Vietnam, PTSD has become synonymous with many historical war-time diagnoses such as [[railway spine]], stress syndrome, [[homesickness|nostalgia]], soldier's heart, [[shell shock]], [[Combat stress reaction|battle fatigue]], [[combat stress reaction]], or traumatic war neurosis.<ref>{{cite book |title=Brave New Brain: Conquering Mental Illness in the Era of the Genome |last=Andreasen |first=Nancy C. | name-list-style = vanc |author-link=Nancy Coover Andreasen |date=Feb 19, 2004 |publisher=Oxford University Press |location=New York |isbn=978-0-19-516728-3 |page=303}}</ref><ref>{{cite journal | vauthors = Jones JA | title = From Nostalgia to Post-Traumatic Stress Disorder: A Mass Society Theory of Psychological Reactions to Combat. | journal = Inquiries Journal | date = 2013 | volume = 5 | issue = 2 | pages =1–3 | url = http://www.studentpulse.com/articles/727/from-nostalgia-to-post-traumatic-stress-disorder-a-mass-society-theory-of-psychological-reactions-to-combat | archive-url = https://web.archive.org/web/20140217051451/http://www.studentpulse.com/articles/727/from-nostalgia-to-post-traumatic-stress-disorder-a-mass-society-theory-of-psychological-reactions-to-combat | archive-date=2014-02-17 }}</ref> Some of these terms date back to the 19th century, which is indicative of the universal nature of the condition. In a similar vein, psychiatrist [[Jonathan Shay]] has proposed that [[Lady Percy]]'s [[soliloquy]] in the [[William Shakespeare]] play ''[[Henry IV, Part 1]]'' (act 2, scene 3, lines 40–62<ref>{{cite web |url=http://www.opensourceshakespeare.org/views/plays/play_view.php?WorkID=henry4p1&Act=2&Scene=3&Scope=scene |title=Henry IV, Part I, Act II, Scene 3 {{colon}} &#124;{{colon}} Open Source Shakespeare |publisher=Opensourceshakespeare.org |access-date=2014-01-30 |url-status=live |archive-url=https://web.archive.org/web/20140327183019/http://opensourceshakespeare.org/views/plays/play_view.php?WorkID=henry4p1&Act=2&Scene=3&Scope=scene |archive-date=2014-03-27 }}</ref>), written around 1597, represents an unusually accurate description of the symptom constellation of PTSD.<ref>{{cite book |last=Shay |first=Jonathan | name-list-style = vanc |title=Achilles in Vietnam: Combat Trauma and the Undoing of Character |publisher=Scribner |year=1994 |pages=165–66}}</ref>
-[[File:Statue Three Servicemen Vietnam Veterans Memorial-editA.png|thumb|Statue, ''Three Servicemen'', Vietnam Veterans Memorial]]
-The correlations between combat and PTSD are undeniable; according to Stéphane Audoin-Rouzeau and Annette Becker, "One-tenth of mobilized American men were hospitalized for mental disturbances between 1942 and 1945, and, after thirty-five days of uninterrupted combat, 98% of them manifested psychiatric disturbances in varying degrees."<ref>{{cite web | url = http://www.ralphmag.org/CG/world-war-one2.html | title = World War One – A New Kind of War, Part II | archive-url = https://web.archive.org/web/20160303191857/http://www.ralphmag.org/CG/world-war-one2.html | archive-date=2016-03-03 | work = www.ralphmag.org }}, From ''14 – 18 Understanding the Great War'', by Stéphane Audoin-Rouzeau, Annette Becker{{incomplete short citation|date=January 2014}}</ref> In fact, much of the available published research regarding PTSD is based on studies done on veterans of the war in Vietnam.  A study based on personal letters from soldiers of the 18th-century [[Prussian Army]] concludes that combatants may have had PTSD.<ref>{{cite magazine |title=Im Kugelhagel der Musketen |language=de |first=Sascha |last=Möbius | name-list-style = vanc |magazine=[[Damals]] |pages=64–69 |volume=47 |issue=12 |year=2015}}</ref> Aspects of PTSD in soldiers of ancient [[Assyria]] have been identified using written sources from 1300 to 600 B.C.E. These Assyrian soldiers would undergo a three-year rotation of combat before being allowed to return home, and were reported to have faced immense challenges in reconciling their past actions in war with their civilian lives.<ref>{{cite web | url=https://www.smithsonianmag.com/smart-news/ancient-assyrian-soldiers-were-haunted-war-too-180954022/ | title=Ancient Assyrian Soldiers Were Haunted by War, Too}}</ref> Connections between the actions of Viking [[berserkers]] and the hyperarousal of post-traumatic stress disorder have also been drawn.<ref>{{cite book | vauthors = Shay J | date = 2000 | chapter = Killing rage: physis or nomos—or both | pages = 31–56 | title = War and Violence in Ancient Greece | publisher = Duckworth and the Classical Press of Wales | isbn = 0715630466 }}</ref>
-The researchers from the Grady Trauma Project highlight the tendency people have to focus on the combat side of PTSD: "less public awareness has focused on civilian PTSD, which results from trauma exposure that is not combat related... " and "much of the research on civilian PTSD has focused on the sequelae of a single, disastrous event, such as the [[Oklahoma City bombing]], [[September 11th attacks]], and [[Hurricane Katrina]]".<ref>{{cite journal|title=Civilian PTSD Symptoms and Risk for Involvement in the Criminal Justice System|journal=Journal of the Academy of Psychiatry and the Law|date=2012-12-01|volume=40|issue=4|pages=522–529|url=http://www.jaapl.org/content/40/4/522.full?sid=b7a23ae3-d147-48af-b8fc-310fa08605e7|access-date=2014-11-29|issn=1093-6793}}</ref> Disparity in the focus of PTSD research affects the already popular perception of the exclusive interconnectedness of combat and PTSD. This is misleading when it comes to understanding the implications and extent of PTSD as a neurological disorder.  Dating back to the definition of Gross stress reaction in the DSM-I, civilian experience of catastrophic or high stress events is included as a cause of PTSD in medical literature. The 2014 National Comorbidity Survey reports that "the traumas most commonly associated with PTSD are combat exposure and witnessing among men and rape and sexual molestation among women."<ref name="Kessler95"/>
-Because of the initial overt focus on PTSD as a combat related disorder when it was first fleshed out in the years following the war in Vietnam, in 1975 Ann Wolbert Burgess and Lynda Lytle Holmstrom defined rape trauma syndrome (RTS) in order to draw attention to the striking similarities between the experiences of soldiers returning from war and of rape victims.<ref>{{cite book |last1=Holmstrom |first1=Lynda Lyttle |last2=Burgess |first2=Ann Wolbert |name-list-style=vanc |title=The Victim of Rape: Institutional Reactions |publisher=Wiley-Interscience |isbn=978-0471407850 |year=1978 |url-access=registration |url=https://archive.org/details/victimo_hol_1978_00_0399}}</ref> This paved the way for a more comprehensive understanding of causes of PTSD.
-After PTSD became an official psychiatric diagnosis with the publication of DSM-III (1980), the number of [[personal injury]]lawsuits ([[tort]] claims) asserting the plaintiff suffered from PTSD increased rapidly. However, [[Trier of fact|triers of fact]] (judges and juries) often regarded the PTSD diagnostic criteria as imprecise, a view shared by legal scholars, trauma specialists, [[forensic psychology|forensic psychologists]], and [[forensic psychiatry|forensic psychiatrists]]. Professional discussions and debates in academic journals, at conferences, and between thought leaders, led to a more clearly-defined set of diagnostic criteria in DSM-IV, particularly the definition of a "traumatic event".<ref>{{Cite web|url=http://www.psychiatrictimes.com/ptsd-traumatic-principle-and-lawsuits|title=PTSD, the Traumatic Principle and Lawsuits|work=Psychiatric Times | vauthors = Scrignar CB |access-date=2018-06-25}}</ref>
-The DSM-IV classified PTSD under anxiety disorders, but the DSM-5 created a new category called "trauma and stressor-related disorders", in which PTSD is now classified.<ref name="DSM5" />
-== Terminology ==
-{{Redirect-distinguish|PTSS|Post Traumatic Slave Syndrome}}
-The ''[[Diagnostic and Statistical Manual of Mental Disorders]]'' does not hyphenate "post" and "traumatic", thus, the [[DSM-5]] lists the disorder as ''posttraumatic stress disorder''. However, many scientific journal articles and other scholarly publications do hyphenate the name of the disorder, ''viz.'', "post-traumatic stress disorder".<ref>{{cite web|title=Search results: 'post-traumatic stress disorder' in the title of a journal article|url=https://www.ncbi.nlm.nih.gov/pubmed?term=post-traumatic%20stress%20disorder%5BTitle%5D|publisher=U.S. National Library of Medicine|access-date=21 January 2015|url-status=live|archive-url=https://web.archive.org/web/20160514050330/http://www.ncbi.nlm.nih.gov/pubmed?term=post-traumatic%20stress%20disorder%5BTitle%5D|archive-date=14 May 2016}}</ref> Dictionaries also differ with regard to the preferred spelling of the disorder with the ''Collins English Dictionary – Complete and Unabridged'' using the hyphenated spelling, and the ''American Heritage Dictionary of the English Language, Fifth Edition'' and the ''Random House Kernerman Webster's College Dictionary'' giving the non-hyphenated spelling.<ref>{{cite web|title=PTSD|url=http://www.thefreedictionary.com/PTSD|website=[[TheFreeDictionary.com]]|publisher=Farlex, Inc.|access-date=21 January 2015}}</ref>
-Some authors have used the terms "'''post-traumatic stress syndrome'''" or "'''post-traumatic stress symptoms'''" ("'''PTSS'''"),{{Citation needed|date=September 2021}} or simply "post-traumatic stress" ("PTS") in the case of the  [[U.S. Department of Defense]],<ref>{{cite news |last1=Thompson |first1=Mark | name-list-style = vanc |title=The Disappearing 'Disorder': Why PTSD is becoming PTS |url=http://nation.time.com/2011/06/05/the-disappearing-disorder-why-ptsd-is-becoming-pts/ |access-date=3 October 2018 |magazine=Time |date=2011 |url-access=limited}}</ref> to avoid stigma associated with the word "disorder".
-The comedian [[George Carlin]] criticized the [[euphemism treadmill]] which led to progressive change of the way PTSD was referred to over the course of the 20th century, from "shell shock" in the [[World War I|First World War]] to the "battle fatigue" in the [[World War II|Second World War]], to "operational exhaustion" in the [[Korean War]], to the current "post-traumatic stress disorder", coined during the [[Vietnam War]], which "added a hyphen" and which, he commented, "completely burie[s] [the pain] under [[jargon]]". He also stated that the name given to the condition has had a direct effect on the way veteran soldiers with PTSD were treated and perceived by civilian populations over time.<ref>{{cite web |url=https://www.mcsweeneys.net/articles/george-carlin-euphemism-fighter-supreme |title=George Carlin: Euphemism Fighter Supreme |last=Peters |first=Mark | name-list-style = vanc |date= 19 May 2017|website=McSweeny's |access-date=3 April 2019}}</ref>
-== Research ==
-{{Contradicts other|MDMA#Research| 4 = section
-| 5 = section
-| date = April 2021
-}}
-Most knowledge regarding PTSD comes from studies in high-income countries.<ref name="FodorUnterhitzenberger2014">{{cite journal | vauthors = Fodor KE, Unterhitzenberger J, Chou CY, Kartal D, Leistner S, Milosavljevic M, Nocon A, Soler L, White J, Yoo S, Alisic E | title = Is traumatic stress research global? A bibliometric analysis | journal = European Journal of Psychotraumatology | volume = 5 | issue = 1 | pages = 23269 | year = 2014 | pmid = 24563730 | pmc = 3930940 | doi = 10.3402/ejpt.v5.23269 }}</ref>
-To recapitulate some of the neurological and neurobehavioral symptoms experienced by the [[veteran]] population of recent conflicts in Iraq and Afghanistan, researchers at the [[Roskamp Institute]] and the James A Haley Veteran's Hospital (Tampa) have developed an animal model to study the consequences of [[mild traumatic brain injury]] (mTBI) and PTSD.<ref name="Ojo2014">{{cite journal | vauthors = Ojo JO, Greenberg MB, Leary P, Mouzon B, Bachmeier C, Mullan M, Diamond DM, Crawford F | title = Neurobehavioral, neuropathological and biochemical profiles in a novel mouse model of co-morbid post-traumatic stress disorder and mild traumatic brain injury | journal = Frontiers in Behavioral Neuroscience | volume = 8 | pages = 213 | date = December 2014 | pmid = 25002839 | pmc = 4067099 | doi = 10.3389/fnbeh.2014.00213 | doi-access = free }}</ref> In the laboratory, the researchers exposed mice to a repeated session of unpredictable stressor (i.e. predator odor while restrained), and physical trauma in the form of inescapable foot-shock, and this was also combined with a mTBI. In this study, PTSD animals demonstrated recall of traumatic memories, anxiety, and an impaired social behavior, while animals subject to both mTBI and PTSD had a pattern of disinhibitory-like behavior. mTBI abrogated both contextual fear and impairments in social behavior seen in PTSD animals. In comparison with other animal studies,<ref name="Ojo2014" /><ref name="Poulos 2014">{{cite journal | vauthors = Poulos AM, Reger M, Mehta N, Zhuravka I, Sterlace SS, Gannam C, Hovda DA, Giza CC, Fanselow MS | title = Amnesia for early life stress does not preclude the adult development of posttraumatic stress disorder symptoms in rats | journal = Biological Psychiatry | volume = 76 | issue = 4 | pages = 306–14 | date = August 2014 | pmid = 24231200 | pmc = 3984614 | doi = 10.1016/j.biopsych.2013.10.007 }}</ref> examination of [[Neuroendocrine cell|neuroendocrine]] and [[neuroimmune system|neuroimmune]] responses in plasma revealed a trend toward increase in [[corticosterone]] in PTSD and combination groups.
-[[Stellate ganglion]] block is an experimental procedure for the treatment of PTSD.<ref name="StatPearls SGBs">{{cite journal | vauthors = Piraccini E, Munakomi S, Chang KV | title = Stellate Ganglion Blocks | year = 2020 | pmid = 29939575 | url = https://www.ncbi.nlm.nih.gov/books/NBK507798/ | journal = StatPearls | publisher = StatPearls Publishing LLC }}</ref>
-Researchers are investigating a number of experimental FAAH and MAGL-inhibiting drugs of hopes of finding a better treatment for anxiety and stress-related illnesses.<ref name="ECS_Stress_Related">{{cite journal | vauthors = Hill MN, Patel S | title = Translational evidence for the involvement of the endocannabinoid system in stress-related psychiatric illnesses | journal = Biology of Mood & Anxiety Disorders | volume = 3 | issue = 1 | pages = 19 | date = October 2013 | pmid = 24286185 | pmc = 3817535 | doi = 10.1186/2045-5380-3-19 }}</ref> In 2016, the FAAH-inhibitor drug [[BIA 10-2474]] was withdrawn from human trials in France due to adverse effects.<ref name="BIA_10_2474">{{cite web |title=New clues to why a French drug trial went horribly wrong |url=https://www.sciencemag.org/news/2017/06/new-clues-why-french-drug-trial-went-horribly-wrong|publisher=Science| first = Hinnerk | last = Feldwisch-Drentrup | name-list-style = vanc |access-date=11 December 2019 |date=July 2002}}</ref>
-Preliminary evidence suggests that [[MDMA-assisted psychotherapy]] might be an effective treatment for PTSD.<ref>{{cite journal|title=MDMA-assisted therapy for severe PTSD: a randomized, double-blind, placebo-controlled phase 3 study |journal=Nature Medicine |volume=27 |pages=1025–1033 |date=2021 |doi=10.1038/s41591-021-01336-3 |vauthors= Mitchell JM, Bogenschutz M, Lilienstein A, etal|issue=6 |pmid=33972795 |pmc=8205851 }}</ref> However, it is important to note that the results in clinical trials of MDMA-assisted psychotherapy might be substantially influenced by expectancy effects given the unblinding of participants.<ref>{{Cite journal|last1=Muthukumaraswamy|first1=Suresh D.|last2=Forsyth|first2=Anna|last3=Lumley|first3=Thomas|date=2021-09-02|title=Blinding and expectancy confounds in psychedelic randomized controlled trials|url=https://www.tandfonline.com/doi/full/10.1080/17512433.2021.1933434|journal=Expert Review of Clinical Pharmacology|language=en|volume=14|issue=9|pages=1133–1152|doi=10.1080/17512433.2021.1933434|pmid=34038314|s2cid=235215630|issn=1751-2433}}</ref><ref>{{Cite journal|last1=Burke|first1=Matthew J.|last2=Blumberger|first2=Daniel M.|date=October 2021|title=Caution at psychiatry's psychedelic frontier|url=https://www.nature.com/articles/s41591-021-01524-1|journal=Nature Medicine|language=en|volume=27|issue=10|pages=1687–1688|doi=10.1038/s41591-021-01524-1|pmid=34635858|s2cid=238635462|issn=1078-8956}}</ref> Furthermore, there is a conspicuous lack of trials comparing MDMA-assisted psychotherapy to existent first-line treatments for PTSD, such as trauma-focused psychological treatments, which seems to achieve similar or even better outcomes than MDMA-assisted psychotherapy.<ref>{{Cite journal|last1=Halvorsen|first1=Joar Øveraas|last2=Naudet|first2=Florian|last3=Cristea|first3=Ioana A.|date=October 2021|title=Challenges with benchmarking of MDMA-assisted psychotherapy|url=https://www.nature.com/articles/s41591-021-01525-0|journal=Nature Medicine|language=en|volume=27|issue=10|pages=1689–1690|doi=10.1038/s41591-021-01525-0|pmid=34635857|s2cid=238636360|issn=1078-8956}}</ref>
-=== Psychotherapy ===
-Trauma-focused psychotherapies for PTSD (also known as "exposure-based" or "exposure" psychotherapies), such as prolonged exposure therapy (PE), eye movement desensitization and reprocessing (EMDR), and cognitive-reprocessing therapy (CPT) have the most evidence for efficacy and are recommended as first-line treatment for PTSD by almost all clinical practice guidelines.<ref name="Examining military population and t">{{cite journal | vauthors = Straud CL, Siev J, Messer S, Zalta AK | title = Examining military population and trauma type as moderators of treatment outcome for first-line psychotherapies for PTSD: A meta-analysis | journal = Journal of Anxiety Disorders | volume = 67 | pages = 102133 | date = October 2019 | pmid = 31472332 | pmc = 6739153 | doi = 10.1016/j.janxdis.2019.102133 }}</ref><ref>{{cite journal | vauthors = Hamblen JL, Norman SB, Sonis JH, Phelps AJ, Bisson JI, Nunes VD, Megnin-Viggars O, Forbes D, Riggs DS, Schnurr PP | display-authors = 6 | title = A guide to guidelines for the treatment of posttraumatic stress disorder in adults: An update | journal = Psychotherapy | volume = 56 | issue = 3 | pages = 359–373 | date = September 2019 | pmid = 31282712 | doi = 10.1037/pst0000231 | s2cid = 195829939 | url = http://orca.cf.ac.uk/131829/1/CPG%20Review%20of%20Guidelines%20111218.%20CC%20edit%2003_02_19%20revision%20clean.pdf }}</ref><ref>{{cite journal | vauthors = Kline AC, Cooper AA, Rytwinksi NK, Feeny NC | title = Long-term efficacy of psychotherapy for posttraumatic stress disorder: A meta-analysis of randomized controlled trials | journal = Clinical Psychology Review | volume = 59 | pages = 30–40 | date = February 2018 | pmid = 29169664 | pmc = 5741501 | doi = 10.1016/j.cpr.2017.10.009 }}</ref> Exposure-based psychotherapies demonstrate efficacy for PTSD caused by different trauma "types", such as combat, sexual-assault, or natural disasters.<ref name="Examining military population and t"/> At the same time, many trauma-focused psychotherapies evince high drop-out rates.<ref>{{cite journal | vauthors = Goetter EM, Bui E, Ojserkis RA, Zakarian RJ, Brendel RW, Simon NM | title = A Systematic Review of Dropout From Psychotherapy for Posttraumatic Stress Disorder Among Iraq and Afghanistan Combat Veterans | journal = Journal of Traumatic Stress | volume = 28 | issue = 5 | pages = 401–9 | date = October 2015 | pmid = 26375387 | doi = 10.1002/jts.22038 }}</ref>
-Most systematic reviews and clinical guidelines indicate that psychotherapies for PTSD, most of which are trauma-focused therapies, are more effective than pharmacotherapy (medication),<ref>{{cite journal | vauthors = Merz J, Schwarzer G, Gerger H | title = Comparative Efficacy and Acceptability of Pharmacological, Psychotherapeutic, and Combination Treatments in Adults With Posttraumatic Stress Disorder: A Network Meta-analysis | journal = JAMA Psychiatry | volume = 76 | issue = 9 | pages = 904–913 | date = June 2019 | pmid = 31188399 | pmc = 6563588 | doi = 10.1001/jamapsychiatry.2019.0951 }}</ref> although there are reviews that suggest exposure-based psychotherapies for PTSD and pharmacotherapy are equally effective.<ref>{{Cite book | vauthors = Forman-Hoffman V, Middleton JC, Feltner C, Gaynes BN, Weber RP, Bann C, Viswanathan M, Lohr KN, Baker C, Green J | display-authors = 6  |url=http://www.ncbi.nlm.nih.gov/books/NBK525132/|title=Psychological and Pharmacological Treatments for Adults With Posttraumatic Stress Disorder: A Systematic Review Update |date=2018|publisher=Agency for Healthcare Research and Quality (US)|series=AHRQ Comparative Effectiveness Reviews|location=Rockville (MD)|pmid=30204376}}</ref> Interpersonal psychotherapy shows preliminary evidence of probable efficacy, but more research is needed to reach definitive conclusions.<ref>{{cite journal | vauthors = Althobaiti S, Kazantzis N, Ofori-Asenso R, Romero L, Fisher J, Mills KE, Liew D | title = Efficacy of interpersonal psychotherapy for post-traumatic stress disorder: A systematic review and meta-analysis | journal = Journal of Affective Disorders | volume = 264 | pages = 286–294 | date = March 2020 | pmid = 32056763 | doi = 10.1016/j.jad.2019.12.021 | s2cid = 211111940 }}</ref>
-==Complex PTSD==
-{{Infobox medical condition (new)
-| name          = Complex post-traumatic stress disorder (C-PTSD)
-| synonym      = Disorders of extreme stress not otherwise specified (DESNOS)
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-| specialty    = [[Psychiatry]], [[clinical psychology]]
-| symptoms      = Problems in affect regulation; beliefs about oneself as diminished, defeated or worthless, accompanied by feelings of shame, guilt or failure related to the traumatic event; difficulties in sustaining relationships and in feeling close to others.
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-}}
-'''Complex post-traumatic stress disorder''' ('''C-PTSD'''; also known as '''complex trauma disorder''')<ref name="Cook2005" /> is a psychological disorder that can develop in response to exposure to a series of [[Psychological trauma|traumatic]] events in a context in which the individual perceives little or no chance of escape, and particularly where the exposure is prolonged or repetitive.{{r|ICD11}} In addition to the symptoms of [[post-traumatic stress disorder]] (PTSD), an individual with C-PTSD experiences [[emotional dysregulation]], negative self-beliefs and feelings of shame, guilt or failure regarding the trauma, and interpersonal difficulties.<ref name=ICD11>''World Health Organisation''. 2020. "{{ICD11|6B41|585833559}} Complex post traumatic stress disorder". ''International Classification of Diseases, 11th Revision''.</ref> C-PTSD relates to the [[trauma model of mental disorders]] and is associated with chronic [[Child sexual abuse|sexual]], [[Psychological abuse|psychological]], and [[physical abuse]] or [[Child neglect|neglect]], or chronic [[intimate partner violence]], victims of kidnapping and hostage situations, [[indentured servitude|indentured servants]], victims of [[slavery]] and [[human trafficking]], [[sweatshop]] workers, [[prisoner of war|prisoners of war]], [[concentration camp]] survivors, [[Canadian Indian residential school system|residential school]] survivors and prisoners kept in [[solitary confinement]] for a long period of time, or defectors from authoritarian religions. Situations involving captivity/entrapment (a situation lacking a viable escape route for the victim or a perception of such) can lead to C-PTSD-like symptoms, which can include prolonged feelings of terror, worthlessness, helplessness, and deformation of one's identity and sense of self.<ref name="TAR" />
-C-PTSD has also been referred to as ''disorders of extreme stress not otherwise specified'' or ''DESNOS''.<ref>{{Cite journal |last1=Luxenberg |first1=Toni |last2=Spinazzola |first2=Joseph |last3=Van der Kolk |first3=Bessel |name-list-style=vanc |date=November 2001 |title=Complex Trauma and Disorders of Extreme Stress (DESNOS) Diagnosis, Part One: Assessment |journal=Directions in Psychiatry |volume=21 |pages=22 |url=https://complextrauma.org/wp-content/uploads/2019/01/CPTSD-1-Joseph-Spinazzola.pdf }}</ref>
-Some researchers believe that C-PTSD is distinct from, but similar to, PTSD, [[somatization disorder]], [[dissociative identity disorder]], and [[borderline personality disorder]].<ref name="TAR">{{cite book |first=Judith L. |last=Herman |name-list-style=vanc |title=Trauma and Recovery: The Aftermath of Violence—From Domestic Abuse to Political Terror |url=https://archive.org/details/traumarecovery00herm_0 |url-access=registration |access-date=29 October 2012 |date=30 May 1997 |publisher=Basic Books |isbn=978-0-465-08730-3 }}</ref> Its main distinctions are a distortion of the person's core identity and significant [[emotional dysregulation]].<ref name = "Brewin_2017">{{cite journal | vauthors = Brewin CR, Cloitre M, Hyland P, Shevlin M, Maercker A, Bryant RA, Humayun A, Jones LM, Kagee A, Rousseau C, Somasundaram D, Suzuki Y, Wessely S, van Ommeren M, Reed GM | display-authors = 6 | title = A review of current evidence regarding the ICD-11 proposals for diagnosing PTSD and complex PTSD | journal = Clinical Psychology Review | volume = 58 | pages = 1–15 | date = December 2017 | pmid = 29029837 | doi = 10.1016/j.cpr.2017.09.001 | url = http://mural.maynoothuniversity.ie/11577/1/Hyland_Review_2017.pdf }}</ref> It was first described in 1992 by American psychiatrist and scholar [[Judith Lewis Herman]] in her book ''Trauma & Recovery'' and an accompanying article.<ref name="TAR" /><ref name="Herman1992">{{Cite journal |vauthors=Herman JL |title=Complex PTSD: A Syndrome in Survivors of Prolonged and Repeated Trauma |doi=10.1007/BF00977235 |journal=Journal of Traumatic Stress |volume=5 |issue=3 |pages=377–391 |year=1992 |s2cid=189943097 |url=http://202.68.89.83/NR/rdonlyres/D4D172A3-372C-4EC9-B27C-16CC2FF079C7/119065/49SCJE_EVI_00DBHOH_BILL9236_1_A15599_CooperLegalBa.pdf }}{{Dead link|date=July 2019 |bot=InternetArchiveBot |fix-attempted=yes }}</ref><ref>{{cite journal |vauthors=van der Hart O, Nijenhuis ER, Steele K |title=Dissociation: An Insufficiently Recognized Major Feature of Complex Posttraumatic Stress Disorder |journal=Journal of Traumatic Stress |volume=18 |issue=5 |pages=413–23 |date=October 2005 |pmid=16281239 |doi=10.1002/jts.20049 |url=http://www.onnovdhart.nl/wp-content/uploads/2008/09/jts_complex_%20ptsd.pdf }}</ref>
-The disorder is included in the [[World Health Organization]]'s (WHO) eleventh revision of the [[International Statistical Classification of Diseases and Related Health Problems]] ([[ICD-11]]). The C-PTSD criteria has not yet gone through the private approval board of the [[American Psychiatric Association]] (APA) for inclusion in the ''[[Diagnostic and Statistical Manual of Mental Disorders]]'' (''DSM''). Complex PTSD is also recognized by the [[United States Department of Veterans Affairs]] (VA), [[Healthdirect Australia]] (HDA), and the British [[National Health Service]] (NHS).
-== Symptoms ==
-=== Children and adolescents ===
-The diagnosis of PTSD was originally developed for adults who had suffered from a single-event trauma, such as rape, or a traumatic experience during a war.<ref name = traumacenter>{{cite web | url=http://www.wmich.edu/traumacenter/pdf/Complex%20Trauma%20and%20Developmental%20Trauma%20Disorder1%5D.pdf | title=Complex Trauma And Developmental Trauma Disorder | publisher=National Child Traumatic Stress Network | access-date=14 November 2013 | archive-url=https://web.archive.org/web/20131205105733/http://www.wmich.edu/traumacenter/pdf/Complex%20Trauma%20and%20Developmental%20Trauma%20Disorder1%5D.pdf | archive-date=5 December 2013 | url-status=dead }}</ref> However, the situation for many children is quite different. Children can suffer chronic trauma such as maltreatment, family violence, dysfunction, or a disruption in attachment to their primary caregiver.<ref name = Ford/> In many cases, it is the child's caregiver who causes the trauma.<ref name = traumacenter/> The diagnosis of PTSD does not take into account how the developmental stages of children may affect their symptoms and how trauma can affect a child's development.<ref name = traumacenter/>
-The term ''developmental trauma disorder'' (''DTD'') has been proposed as the childhood equivalent of C-PTSD.<ref name = Ford>{{cite journal | vauthors = Ford JD, Grasso D, Greene C, Levine J, Spinazzola J, van der Kolk B | title = Clinical significance of a proposed developmental trauma disorder diagnosis: results of an international survey of clinicians | journal = The Journal of Clinical Psychiatry | volume = 74 | issue = 8 | pages = 841–9 | date = August 2013 | pmid = 24021504 | doi = 10.4088/JCP.12m08030 }}</ref> This developmental form of trauma places children at risk for developing psychiatric and medical disorders.<ref name = Ford/> [[Bessel van der Kolk]] explains DTD as numerous encounters with interpersonal trauma such as physical assault, sexual assault, violence or death. It can also be brought on by subjective events such as abandonment, betrayal, defeat or shame.<ref name=":0" />
-Repeated traumatization during childhood leads to symptoms that differ from those described for PTSD.<ref name=":0">{{cite web | url=http://www.traumacenter.org/products/Developmental_Trauma_Disorder.pdf | title=Developmental trauma disorder | publisher=Psychiatric Annals | year=2005 | access-date=14 November 2013 | vauthors = van der Kolk B | pages=401–408}}</ref> Cook and others describe symptoms and behavioural characteristics in seven domains:<ref name="NCTSNWhitePaper">{{Cite book| editor-last = Cook | editor-first = Alexandra | editor2-last = Blaustein | editor2-first = Margaret | editor3-last = Spinazzola | editor3-first = Joseph | editor4-last = van der Kolk | editor4-first = Bessel| name-list-style = vanc | date = 2003 | title = Complex Trauma in Children and Adolescents: White Paper from the National Child Traumatic Stress Network, Complex Trauma Task Force | publisher = National Child Traumatic Stress Network | url = http://nursebuddha.files.wordpress.com/2011/12/complex-trauma-in-children.pdf | access-date = 2013-11-14}}</ref><ref name="Cook2005" />
-* Attachment – "problems with relationship boundaries, lack of trust, social isolation, difficulty perceiving and responding to others' emotional states"
-* Biology – "sensory-motor developmental dysfunction, sensory-integration difficulties, somatization, and increased medical problems"
-* Affect or [[emotional regulation]] – "poor affect regulation, difficulty identifying and expressing emotions and internal states, and difficulties communicating needs, wants, and wishes"
-* Dissociation – "amnesia, [[depersonalization]], discrete [[Dissociative identity disorder|states of consciousness]] with discrete memories, affect, and functioning, and impaired memory for state-based events"
-* Behavioural control – "problems with [[impulse control]], [[aggression]], pathological self-soothing, and [[Sleep disorder|sleep problems]]"
-* Cognition – "difficulty regulating [[attention]]; problems with a variety of '[[executive functions]]' such as planning, judgement, initiation, use of materials, and self-monitoring; difficulty [[Information processing|processing new information]]; difficulty focusing and completing tasks; poor [[object constancy]]; problems with 'cause-effect' thinking; and language developmental problems such as a gap between receptive and expressive communication abilities."
-* Self-concept – "fragmented and disconnected autobiographical narrative, disturbed [[body image]], low [[self-esteem]], excessive [[shame]], and negative internal working models of self".
-=== Adults ===
-Adults with C-PTSD have sometimes experienced prolonged interpersonal traumatization beginning in childhood, rather than, or as well as, in adulthood. These early injuries interrupt the development of a robust sense of self and of others. Because physical and emotional pain or neglect was often inflicted by attachment figures such as caregivers or older siblings, these individuals may develop a sense that they are fundamentally flawed and that others cannot be relied upon.<ref name="Herman1992" /><ref name="Zlotnick1996">{{cite journal | vauthors = Zlotnick C, Zakriski AL, Shea MT, Costello E, Begin A, Pearlstein T, Simpson E | title = The long-term sequelae of sexual abuse: support for a complex posttraumatic stress disorder | journal = Journal of Traumatic Stress | volume = 9 | issue = 2 | pages = 195–205 | date = April 1996 | pmid = 8731542 | doi = 10.1007/BF02110655 | s2cid = 189939468 }}</ref> This can become a pervasive way of relating to others in adult life, described as [[insecure attachment]]. This symptom is neither included in the diagnosis of dissociative disorder nor in that of PTSD in the current [[DSM-5]] (2013). Individuals with Complex PTSD also demonstrate lasting personality disturbances with a significant risk of [[revictimization]].<ref name="Ide2000">{{cite journal | vauthors = Ide N, Paez A | title = Complex PTSD: a review of current issues | journal = International Journal of Emergency Mental Health | volume = 2 | issue = 1 | pages = 43–9 | year = 2000 | pmid = 11232103 }}</ref>
-Six clusters of symptoms have been suggested for diagnosis of C-PTSD:<ref name="Roth_1997">{{cite journal | vauthors = Roth S, Newman E, Pelcovitz D, van der Kolk B, Mandel FS | title = Complex PTSD in victims exposed to sexual and physical abuse: results from the DSM-IV Field Trial for Posttraumatic Stress Disorder | journal = Journal of Traumatic Stress | volume = 10 | issue = 4 | pages = 539–55 | date = October 1997 | pmid = 9391940 | doi = 10.1002/jts.2490100403 }}</ref><ref name="Pelcovitz1997">{{cite journal | vauthors = Pelcovitz D, van der Kolk B, Roth S, Mandel F, Kaplan S, Resick P | title = Development of a criteria set and a structured interview for disorders of extreme stress (SIDES) | journal = Journal of Traumatic Stress | volume = 10 | issue = 1 | pages = 3–16 | date = January 1997 | pmid = 9018674 | doi = 10.1002/jts.2490100103 }}</ref>
-* Alterations in regulation of affect and impulses
-* Alterations in attention or consciousness
-* Alterations in self-perception
-* Alterations in relations with others
-* [[Somatization]]
-* Alterations in systems of meaning<ref name="Pelcovitz1997" />
-Experiences in these areas may include:<ref name="TAR" />{{rp|199–122}}<ref name="NCPTSD" />
-* Changes in emotional regulation, including experiences such as persistent [[dysphoria]], chronic suicidal preoccupation, [[self-injury]], explosive or extremely [[cognitive inhibition|inhibited anger]] (may alternate), and compulsive or extremely inhibited sexuality (may alternate).
-* Variations in consciousness, such as [[psychogenic amnesia|amnesia]] or [[hypermnesia|improved recall]] for traumatic events, episodes of [[Dissociation (psychology)|dissociation]], [[depersonalization]]/[[derealization]], and reliving experiences (either in the form of intrusive PTSD symptoms or in ruminative preoccupation).
-* Changes in self-perception, such as a sense of [[Helplessness, learned|helplessness]] or paralysis of initiative, shame, guilt and self-blame, a sense of defilement or stigma, and a sense of being completely different from other human beings (may include a sense of specialness, utter aloneness, a belief that no other person can understand, or a feeling of nonhuman identity).
-* Varied changes in perception of the perpetrators, such as a preoccupation with the relationship with a perpetrator (including a preoccupation with revenge), an unrealistic attribution of total power to a perpetrator (though the individual's assessment may be more realistic than the clinician's), [[Idealization and devaluation|idealization]] or paradoxical gratitude, a sense of a special or supernatural relationship with a perpetrator, and acceptance of a perpetrator's belief system or rationalizations.
-* Alterations in relations with others, such as isolation and withdrawal, disruption in intimate relationships, a repeated search for a rescuer (may alternate with isolation and withdrawal), persistent distrust, and repeated failures of self-protection.
-* Changes in systems of meaning, such as a loss of sustaining faith and a sense of hopelessness and despair.
-== Diagnostics ==
-C-PTSD was considered for inclusion in the DSM-IV but was not included when the DSM-IV was published in 1994.<ref name="TAR" /> It was also not included in the [[DSM-5]], though post-traumatic stress disorder continues to be listed as a disorder.<ref>{{cite web |title=American Psychiatric Association Board of Trustees Approves DSM-5 |url=http://dsmfacts.org/materials/american-psychiatric-association-board-of-trustees-approves-dsm-5/ |location=[[Arlington, Virginia]] |publisher=American Psychiatric Association |archive-url=https://web.archive.org/web/20130504075409/http://dsmfacts.org/materials/american-psychiatric-association-board-of-trustees-approves-dsm-5/ |date=1 December 2012 |archive-date=4 May 2013 |access-date=2 November 2021 }}</ref>
-=== Differential diagnosis ===
-==== Post-traumatic stress disorder ====
-{{main|Post-traumatic stress disorder}}
-Post-traumatic stress disorder (PTSD) was included in the [[Diagnostic and Statistical Manual of Mental Disorders#DSM-III .281980.29|DSM-III]] (1980), mainly due to the relatively large numbers of American combat veterans of the [[Vietnam War]] who were seeking treatment for the lingering effects of combat stress. In the 1980s, various researchers and clinicians suggested that PTSD might also accurately describe the [[sequelae]] of such traumas as child sexual abuse and domestic abuse.<ref name="Courtois2004">{{Cite journal | vauthors = Courtois DA | title = Complex Trauma, Complex Reactions: Assessment and Treatment | doi = 10.1037/0033-3204.41.4.412 | journal = Psychotherapy: Theory, Research, Practice, Training | volume = 41 | issue = 4 | pages = 412–425| year = 2004 | url = http://www.dhss.delaware.gov/dhss/DSAMH/files/si10_1396_article1.pdf| citeseerx = 10.1.1.600.157 }}</ref> However, it was soon suggested that PTSD failed to account for the cluster of symptoms that were often observed in cases of prolonged abuse, particularly that which was perpetrated against [[children]] by [[caregiver]]s during multiple [[childhood development|childhood]] and [[adolescent development]]al stages. Such patients were often extremely difficult to treat with established methods.<ref name="Courtois2004" />
-PTSD descriptions fail to capture some of the core characteristics of C-PTSD. These elements include captivity, psychological fragmentation, the loss of a sense of safety, trust, and self-worth, as well as the tendency to be [[revictimized]]. Most importantly, there is a loss of a coherent sense of self: this loss, and the ensuing symptom profile, most pointedly differentiates C-PTSD from PTSD.<ref name="TAR" />{{rp|199–122}}
-C-PTSD is also characterized by [[attachment disorder]], particularly the [[Insecure attachment|pervasive insecure]], or [[Disorganized attachment|disorganized-type attachment]].<ref name="vanderKolkRoth2005">{{cite journal | vauthors = van der Kolk BA, Roth S, Pelcovitz D, Sunday S, Spinazzola J | title = Disorders of extreme stress: The empirical foundation of a complex adaptation to trauma | journal = Journal of Traumatic Stress | volume = 18 | issue = 5 | pages = 389–99 | date = October 2005 | pmid = 16281237 | doi = 10.1002/jts.20047 | url = http://www.traumacenter.org/products/pdf_files/specialissuecomplextraumaoct2006jts3.pdf }}</ref> [[Diagnostic and Statistical Manual of Mental Disorders#DSM-IV .281994.29|DSM-IV]] (1994) [[dissociative disorder]]s and PTSD do not include insecure attachment in their criteria. As a consequence of this aspect of C-PTSD, when some adults with C-PTSD become parents and confront their own children's [[Attachment theory|attachment]] needs, they may have particular difficulty in responding sensitively especially to their infants' and young children's routine distress – such as during routine separations, despite these parents' best intentions and efforts.<ref name="Schechter2008">{{cite journal | vauthors = Schechter DS, Coates SW, Kaminer T, Coots T, Zeanah CH, Davies M, Schonfeld IS, Marshall RD, Liebowitz MR, Trabka KA, McCaw JE, Myers MM | display-authors = 6 | title = Distorted maternal mental representations and atypical behavior in a clinical sample of violence-exposed mothers and their toddlers | journal = Journal of Trauma & Dissociation | volume = 9 | issue = 2 | pages = 123–47 | year = 2008 | pmid = 18985165 | pmc = 2577290 | doi = 10.1080/15299730802045666 }}, pp. 123-149</ref> Although the great majority of survivors do not abuse others,<ref name="Kaufman1987">{{cite journal | vauthors = Kaufman J, Zigler E | title = Do abused children become abusive parents? | journal = The American Journal of Orthopsychiatry | volume = 57 | issue = 2 | pages = 186–192 | date = April 1987 | pmid = 3296775 | doi = 10.1111/j.1939-0025.1987.tb03528.x }}</ref> this difficulty in parenting may have adverse repercussions for their children's social and emotional development if parents with this condition and their children do not receive appropriate treatment.<ref name="Schechter2009">{{cite journal | vauthors = Schechter DS, Willheim E | title = Disturbances of attachment and parental psychopathology in early childhood | journal = Child and Adolescent Psychiatric Clinics of North America | volume = 18 | issue = 3 | pages = 665–86 | date = July 2009 | pmid = 19486844 | pmc = 2690512 | doi = 10.1016/j.chc.2009.03.001 }}</ref><ref name="Schechter2007">{{cite journal | vauthors = Schechter DS, Zygmunt A, Coates SW, Davies M, Trabka K, McCaw J, Kolodji A, Robinson J | display-authors = 6 | title = Caregiver traumatization adversely impacts young children's mental representations on the MacArthur Story Stem Battery | journal = Attachment & Human Development | volume = 9 | issue = 3 | pages = 187–205 | date = September 2007 | pmid = 18007959 | pmc = 2078523 | doi = 10.1080/14616730701453762 }}</ref>
-Thus, a differentiation between the diagnostic category of C-PTSD and that of PTSD has been suggested. C-PTSD better describes the pervasive negative impact of chronic repetitive trauma than does PTSD alone.<ref name="NCPTSD">{{cite web |url=http://www.ptsd.va.gov/professional/PTSD-overview/complex-ptsd.asp |title=Complex PTSD |year=2007 |publisher=[[United States Department of Veterans Affairs]] |work=www.ptsd.va.gov (National Center for PTSD)}}</ref> PTSD can exist alongside C-PTSD, however a sole diagnosis of PTSD often does not sufficiently encapsulate the breadth of symptoms experienced by those who have experienced prolonged traumatic experience, and therefore C-PTSD extends beyond the PTSD parameters.<ref name="Herman1992" />
-C-PTSD also differs from continuous traumatic stress disorder (CTSD), which was introduced into the trauma literature by Gill Straker (1987).<ref>{{cite journal|last=Straker|first=Gillian| name-list-style = vanc |title=The Continuous Traumatic Stress Syndrome. The Single Therapeutic Interview|journal=Psychology in Society|year=1987|issue=8 |pages=46–79}}</ref> It was originally used by South African clinicians to describe the effects of exposure to frequent, high levels of violence usually associated with [[Civil war|civil conflict]] and [[political repression]]. The term is also applicable to the effects of exposure to contexts in which [[gang violence]] and [[crime]] are endemic as well as to the effects of ongoing exposure to life threats in [[Occupational safety and health|high-risk occupations]] such as [[Emergency service|police, fire and emergency services]].
-==== Traumatic grief ====
-{{main|Grief|Grief counseling}}
-Traumatic grief<ref>{{Cite journal | vauthors = Bonanno GA | title = Is Complicated Grief a Valid Construct? | doi = 10.1111/j.1468-2850.2006.00014.x | journal = Clinical Psychology: Science and Practice | volume = 13 | issue = 2 | pages = 129–134 | year = 2006 }}</ref><ref>{{cite journal | vauthors = Jacobs S, Mazure C, Prigerson H | title = Diagnostic criteria for traumatic grief | journal = Death Studies | volume = 24 | issue = 3 | pages = 185–99 | year = 2000 | pmid = 11010626 | doi = 10.1080/074811800200531 }}</ref><ref name="Ambrose">{{cite web |url=http://www.restoringconnections.ca/assets/pdf/ambrose_traumatic_grief.pdf |title=Traumatic Grief: What We Need to Know as Trauma Responders | last = Ambrose | first = Jeannette | name-list-style = vanc }}</ref><ref name="Figley1997">{{cite book| first = Charles | last = Figley | name-list-style = vanc |title=Death And Trauma: The Traumatology Of Grieving|url=https://books.google.com/books?id=oxwdm5tA59EC|access-date=28 October 2012|date=1 April 1997|publisher=Taylor & Francis|isbn=978-1-56032-525-3}}</ref> or complicated mourning<ref name="Rando1993">{{cite book| first = Therese A. | last = Rando | name-list-style = vanc |title=Treatment of complicated mourning|url=https://books.google.com/books?id=wXBHAAAAMAAJ|access-date=28 October 2012|date=February 1993|publisher=Research Press|isbn=978-0-87822-329-9}}</ref> are conditions<ref name="Rando1994">{{Cite book|last=Rando|first=Therese A.| name-list-style = vanc |title=Dying, death, and bereavement: theoretical perspectives and other ways of knowing|url=https://books.google.com/books?id=6Q3XAAAAMAAJ|access-date=28 October 2012|date=1 January 1994|publisher=Jones and Bartlett|isbn=978-0-86720-631-9|pages=253–271|contribution=Complications in Mourning Traumatic Death. | editor-last = Corless | editor-first =Inge B. | editor2-last =Germino | editor2-first = Barbara B. |editor3-last= Pittman |editor3-first=Mary }}</ref> where both trauma and [[grief]] coincide. There are conceptual links between trauma and bereavement since loss of a loved one is inherently traumatic.<ref name="Green2000">{{Cite journal | vauthors = Green BL | doi = 10.1080/10811440008407845 | title = Traumatic Loss: Conceptual and Empirical Links Between Trauma and Bereavement | journal = Journal of Personal and Interpersonal Loss | volume = 5 | pages = 1–17| year = 2000 | s2cid = 144608897 }}</ref> If a traumatic event was [[Lethality|life-threatening]], but did not result in a [[death]], then it is more likely that the survivor will experience post-traumatic stress symptoms. If a person dies, and the survivor was close to the person who died, then it is more likely that symptoms of grief will also develop. When the death is of a loved one, and was sudden or violent, then both symptoms often coincide. This is likely in children exposed to community violence.<ref name="PynoosNader1988">{{Cite journal | vauthors = Pynoos RS, Nader K | doi = 10.1002/jts.2490010406 | title = Psychological first aid and treatment approach to children exposed to community violence: Research implications | journal = Journal of Traumatic Stress | volume = 1 | issue = 4 | pages = 445–473 | year = 1988 }}</ref><ref name = "NCTSNFirstAid">{{cite web |url=http://nctsnet.org/nctsn_assets/pdfs/edu_materials/psychological_1st_aid.pdf |title=Psychological First Aid |publisher=National Child Traumatic Stress Network |work=Adapted from Pynoos RS, Nader K (1988) |access-date=2012-10-29 |archive-url=https://web.archive.org/web/20160304033259/http://nctsnet.org/nctsn_assets/pdfs/edu_materials/psychological_1st_aid.pdf |archive-date=2016-03-04 |url-status=dead }}</ref>
-For C-PTSD to manifest traumatic grief, the violence would occur under conditions of captivity, loss of control and disempowerment, coinciding with the death of a friend or loved one in life-threatening circumstances. This again is most likely for children and stepchildren who experience prolonged domestic or chronic community violence that ultimately results in the death of friends and loved ones. The phenomenon of the increased risk of violence and death of [[stepchild]]ren is referred to as the [[Cinderella effect]].
-====Borderline personality disorder====
-{{main|Attachment theory|Borderline personality disorder}}
-C-PTSD may share some symptoms with both PTSD and borderline personality disorder (BPD).<ref name="vanderKolkCourtois2005">{{cite journal | vauthors = van der Kolk BA, Courtois CA | title = Editorial comments: Complex developmental trauma | journal = Journal of Traumatic Stress | volume = 18 | issue = 5 | pages = 385–8 | date = October 2005 | pmid = 16281236 | doi = 10.1002/jts.20046 | url = http://afosterdissertation.wikispaces.com/file/view/van+der+Kolk_Editorial+Comments_2005.pdf }}</ref> However, there is enough evidence to also differentiate C-PTSD from borderline personality disorder.
-It may help to understand the intersection of attachment theory with C-PTSD and BPD if one reads the following opinion of [[Bessel van der Kolk|Bessel A. van der Kolk]] together with an understanding drawn from a description of BPD:
-{{blockquote|
-Uncontrollable disruptions or distortions of attachment bonds precede the development of post-traumatic stress syndromes. People seek increased attachment in the face of danger. Adults, as well as children, may develop strong emotional ties with people who intermittently [[harassment|harass]], beat, and, threaten them. The persistence of these attachment bonds leads to confusion of pain and love. Trauma can be repeated on behavioural, emotional, [[physiology|physiologic]], and [[Neuroendocrinology|neuroendocrinologic]] levels. Repetition on these different levels causes a large variety of individual and social suffering.
-}}
-However, C-PTSD and BPD have been found by some researchers to be distinctive disorders with different features. Those with C-PTSD do not fear abandonment or have unstable patterns of relations; rather, they withdraw. There are distinct and notably large differences between BPD and C-PTSD and while there are some similarities – predominantly in terms of issues with attachment (though this plays out in different ways) and trouble regulating strong emotional affects – the disorders are different in nature{{Citation needed|date=April 2021}}.
-{{blockquote|
-While the individuals in the BPD reported many of the symptoms of PTSD and CPTSD, the BPD class was clearly distinct in its endorsement of symptoms unique to BPD. The RR ratios presented in Table 5 revealed that the following symptoms were highly indicative of placement in the BPD rather than the CPTSD class: (1) frantic efforts to avoid real or imagined abandonment, (2) unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation, (3) markedly and persistently unstable self-image or sense of self, and (4) impulsiveness. Given the gravity of suicidal and self-injurious behaviors, it is important to note that there were also marked differences in the presence of suicidal and self-injurious behaviors with approximately 50% of individuals in the BPD class reporting this symptom but much fewer and an equivalent number doing so in the CPTSD and PTSD classes (14.3 and 16.7%, respectively). The only BPD symptom that individuals in the BPD class did not differ from the CPTSD class was chronic feelings of emptiness, suggesting that in this sample, this symptom is not specific to either BPD or CPTSD and does not discriminate between them.
-Overall, the findings indicate that there are several ways in which complex PTSD and BPD differ, consistent with the proposed diagnostic formulation of CPTSD. BPD is characterized by fears of abandonment, unstable sense of self, unstable relationships with others, and impulsive and self-harming behaviors. In contrast, in CPTSD as in PTSD, there was little endorsement of items related to instability in self-representation or relationships. Self-concept is likely to be consistently negative and relational difficulties concern mostly avoidance of relationships and sense of alienation.<ref name = "Cloitre_2014">{{cite journal | vauthors = Cloitre M, Garvert DW, Weiss B, Carlson EB, Bryant RA | title = Distinguishing PTSD, Complex PTSD, and Borderline Personality Disorder: A latent class analysis | journal = European Journal of Psychotraumatology | volume = 5 | pages = 25097 | date = 15 September 2014 | pmid = 25279111 | pmc = 4165723 | doi = 10.3402/ejpt.v5.25097 }}</ref>}}
-In addition, 25% of those diagnosed with BPD have no known history of childhood neglect or abuse and individuals are six times as likely to develop BPD if they have a relative who was so diagnosed{{Citation needed|date=March 2009}} compared to those who do not. One conclusion is that there is a genetic predisposition to BPD unrelated to trauma. Researchers conducting a longitudinal investigation of identical twins found that "genetic factors play a major role in individual differences of borderline personality disorder features in Western society."<ref name ="Distel2008">{{cite journal | vauthors = Distel MA, Trull TJ, Derom CA, Thiery EW, Grimmer MA, Martin NG, Willemsen G, Boomsma DI | display-authors = 6 | title = Heritability of borderline personality disorder features is similar across three countries | journal = Psychological Medicine | volume = 38 | issue = 9 | pages = 1219–29 | date = September 2008 | pmid = 17988414 | doi = 10.1017/S0033291707002024 | url = http://dare.ubvu.vu.nl/bitstream/handle/1871/17379/Distel_Psychological%20Medicine_38%289%29_2008_u.pdf | hdl = 1871/17379 | s2cid = 17447787 }}</ref> A 2014 study published in European Journal of Psychotraumatology was able to compare and contrast C-PTSD, PTSD, Borderline Personality Disorder and found that it could distinguish between individual cases of each and when it was co-morbid, arguing for a case of separate diagnoses for each.<ref name = "Cloitre_2014" /> BPD may be confused with C-PTSD by some without proper knowledge of the two conditions because those with BPD also tend to have PTSD or to have some history of trauma.
-In ''Trauma and Recovery,'' Herman expresses the additional concern that patients with C-PTSD frequently risk being misunderstood as inherently '[[Dependent personality disorder|dependent]]', '[[Sadomasochism|masochistic]]', or '[[Self-defeating personality disorder|self-defeating]]', comparing this attitude to the historical misdiagnosis of [[female hysteria]].<ref name="TAR" /> However, those who develop C-PTSD do so as a result of the intensity of the [[Traumatic bonding|traumatic bond]] – in which someone becomes tightly biolo-chemically bound to someone who abuses them and the responses they learned to survive, navigate and deal with the abuse they suffered then become automatic responses, imbedded in their personality over the years of trauma – a normal reaction to an abnormal situation.<ref>{{cite web |url=http://www.healing-arts.org/healing_trauma_therapy/traumabonding-traumaticbonds.htm#abuse_and_traumatic_bonds |title=Trauma Therapy Articles: Descilo: Understanding and Treating Traumatic Bonds |website=Healing-Arts.org }}</ref>
-== Treatment ==
-While standard evidence-based treatments may be effective for treating [[post traumatic stress disorder]], treating complex PTSD often involves addressing interpersonal relational difficulties and a different set of symptoms which make it more challenging to treat. According to the [[United States Department of Veteran Affairs]]:
-{{blockquote|
-The current PTSD diagnosis often does not fully capture the severe psychological harm that occurs with prolonged, repeated trauma. People who experience chronic trauma often report additional symptoms alongside formal PTSD symptoms, such as changes in their self-concept and the way they adapt to stressful events.<ref>{{cite web |title=Complex PTSD - PTSD: National Center for PTSD |url=https://www.ptsd.va.gov/professional/treat/essentials/complex_ptsd.asp |website=www.ptsd.va.gov |publisher=US Department of Veteran Affairs |access-date=1 January 2020 |language=en}} {{PD-notice}}</ref>
-}}
-The utility of PTSD-derived psychotherapies for assisting children with C-PTSD is uncertain. This area of diagnosis and treatment calls for caution in use of the category C-PTSD. Dr. Julian Ford and Dr. [[Bessel van der Kolk]] have suggested that C-PTSD may not be as useful a category for diagnosis and treatment of children as a proposed category of [[developmental trauma disorder]] (DTD).<ref name= "Ford_2009" />{{rp|60}} According to Courtois & Ford, for DTD to be diagnosed it requires a
-{{blockquote|
-history of exposure to early life developmentally adverse interpersonal trauma such as sexual abuse, physical abuse, violence, traumatic losses or other significant disruption or betrayal of the child's relationships with primary caregivers, which has been postulated as an etiological basis for complex traumatic stress disorders. Diagnosis, treatment planning and outcome are always relational.<ref name= "Ford_2009">{{cite book | first1 = Julian D. | last1 = Ford | first2 = Marylene | last2 = Cloitre | chapter = Chapter 3: Best Practices in Psychotherapy for Children and Adolescents |editor-last1=Courtois |editor-first1=Christine A. |editor-last2=Herman |editor-first2=Judith Lewis | name-list-style = vanc |title=Treating complex traumatic stress disorders : an evidence-based guide |date=2009 |publisher=Guilford Press |isbn=978-1-60623-039-8 |page=60 |edition=1st}}</ref>
-}}
-Since C-PTSD or DTD in children is often caused by chronic maltreatment, neglect or abuse in a care-giving relationship the first element of the biopsychosocial system to address is that relationship. This invariably involves some sort of child protection agency. This both widens the range of support that can be given to the child but also the complexity of the situation, since the agency's statutory legal obligations may then need to be enforced.
-A number of practical, therapeutic and ethical principles for assessment and intervention have been developed and explored in the field:<ref name= "Ford_2009" />{{rp|67}}
-* Identifying and addressing threats to the child's or family's safety and stability are the first priority.
-* A relational bridge must be developed to engage, retain and maximize the benefit for the child and caregiver.
-* Diagnosis, treatment planning and outcome monitoring are always relational (and) strengths based.
-* All phases of treatment should aim to enhance self-regulation competencies.
-* Determining with whom, when and how to address traumatic memories.
-* Preventing and managing relational discontinuities and psychosocial crises.
-=== Adults ===
-====Trauma recovery model====
-Judith Lewis Herman, in her book, ''Trauma and Recovery'', proposed a complex trauma recovery model that occurs in three stages:
-# Establishing safety
-# Remembrance and mourning for what was lost
-# Reconnecting with community and more broadly, society
-Herman believes recovery can only occur within a healing relationship and only if the survivor is empowered by that relationship. This healing relationship need not be romantic or sexual in the colloquial sense of "relationship", however, and can also include relationships with friends, co-workers, one's relatives or children, and the [[therapeutic relationship]].<ref name="TAR" />
-Complex trauma means complex reactions and this leads to complex treatments. {{Citation needed|date=February 2022}} Hence, treatment for C-PTSD requires a multi-modal approach.<ref name="Cook2005">{{cite journal | vauthors = Cook A, Blaustein M, Spinazzola J, Van Der Kolk B | s2cid = 141684244 | year = 2005 | title = Complex trauma in children and adolescents | journal = Psychiatric Annals | volume = 35 | issue = 5 | pages = 390–398 |doi=10.3928/00485713-20050501-05 }}</ref>
-It has been suggested that treatment for complex PTSD should differ from treatment for PTSD by focusing on problems that cause more functional impairment than the PTSD symptoms. These problems include emotional dysregulation, [[Dissociation (psychology)|dissociation]], and interpersonal problems.<ref name="vanderKolkRoth2005" /> Six suggested core components of complex trauma treatment include:<ref name="Cook2005" />
-* Safety
-* Self-regulation
-* Self-reflective information processing
-* Traumatic experiences integration
-* Relational engagement
-* Positive affect enhancement
-The above components can be conceptualized as a model with three phases. Every case will not be the same, but one can expect the first phase to consist of teaching adequate coping strategies and addressing safety concerns. The next phase would focus on decreasing avoidance of traumatic stimuli and applying coping skills learned in phase one. The care provider may also begin challenging assumptions about the trauma and introducing alternative narratives about the trauma. The final phase would consist of solidifying what has previously been learned and transferring these strategies to future stressful events.<ref>{{Cite journal|first=David|last=Lawson| name-list-style = vanc |date=July 2017|title=Treating Adults With Complex Trauma: An Evidence-Based Case Study|journal=Journal of Counseling and Development|volume=95|issue=3|pages=288–298|doi=10.1002/jcad.12143}}</ref>
-====Neuroscientific and trauma informed interventions====
-In practice, the forms of treatment and intervention varies from individual to individual since there is a wide spectrum of childhood experiences of developmental trauma and symptomatology and not all survivors respond positively, uniformly, to the same treatment. Therefore, treatment is generally tailored to the individual.<ref>|{{cite journal | vauthors = Schnyder U, Ehlers A, Elbert T, Foa EB, Gersons BP, Resick PA, Shapiro F, Cloitre M | display-authors = 6 | title = Psychotherapies for PTSD: what do they have in common? | journal = European Journal of Psychotraumatology | volume = 6 | pages = 28186 | date = 2015 | pmid = 26290178 | pmc = 4541077 | doi = 10.3402/ejpt.v6.28186 }}</ref> Recent neuroscientific research has shed some light on the impact that severe childhood abuse and neglect (trauma) has on a child's developing brain, specifically as it relates to the development in brain structures, function and connectivity among children from infancy to adulthood. This understanding of the neurophysiological underpinning of complex trauma phenomena is what currently is referred to in the field of traumatology as 'trauma informed' which has become the rationale which has influenced the development of new treatments specifically targeting those with childhood developmental trauma.<ref name = "Anda_2006">{{cite journal | vauthors = Anda RF, Felitti VJ, Bremner JD, Walker JD, Whitfield C, Perry BD, Dube SR, Giles WH | display-authors = 6 | title = The enduring effects of abuse and related adverse experiences in childhood. A convergence of evidence from neurobiology and epidemiology | journal = European Archives of Psychiatry and Clinical Neuroscience | volume = 256 | issue = 3 | pages = 174–86 | date = April 2006 | pmid = 16311898 | pmc = 3232061 | doi = 10.1007/s00406-005-0624-4 }}</ref><ref>{{cite journal | vauthors = Teicher MH, Samson JA, Anderson CM, Ohashi K | title = The effects of childhood maltreatment on brain structure, function and connectivity | journal = Nature Reviews. Neuroscience | volume = 17 | issue = 10 | pages = 652–66 | date = September 2016 | pmid = 27640984 | doi = 10.1038/nrn.2016.111 | s2cid = 27336625 | url = https://www.researchgate.net/publication/308303380 }}</ref>
-Dr. Martin Teicher, a Harvard psychiatrist and researcher, has suggested that the development of specific complex trauma related symptomatology (and in fact the development of many adult onset psychopathologies) may be connected to gender differences and at what stage of childhood development trauma, abuse or neglect occurred.<ref name = "Anda_2006" /> For example, it is well established that the development of [[dissociative identity disorder]] among women is often associated with early childhood sexual abuse.
-====Use of evidence-based treatment and its limitations====
-One of the current challenges faced by many survivors of complex trauma (or developmental trauma disorder) is support for treatment since many of the current therapies are relatively expensive and not all forms of [[therapy]] or [[psychological intervention|intervention]] are reimbursed by insurance companies who use [[evidence-based practice]] as a criteria for reimbursement. [[Cognitive behavioral therapy]], [[prolonged exposure therapy]] and [[dialectical behavioral therapy]] are well established forms of evidence-based intervention. These treatments are approved and endorsed by the [[American Psychiatric Association]], the [[American Psychological Association]] and the Veteran's Administration.
-While standard evidence-based treatments may be effective for treating standard [[post-traumatic stress disorder]], treating complex PTSD often involves addressing interpersonal relational difficulties and a different set of symptoms which make it more challenging to treat. The [[United States Department of Veterans Affairs]] acknowledges,
-{{blockquote|
-the current PTSD diagnosis often does not fully capture the severe psychological harm that occurs with prolonged, repeated trauma. People who experience chronic trauma often report additional symptoms alongside formal PTSD symptoms, such as changes in their self-concept and the way they adapt to stressful events.<ref>{{cite news|url=https://www.ptsd.va.gov/professional/treat/essentials/complex_ptsd.asp|title=Complex PTSD |date=2019|publisher=U.S. Department of Veterans Affairs}}</ref>}}
-For example, "Limited evidence suggests that predominantly [Cognitive behavioral therapy] CBT [evidence-based] treatments are effective, but do not suffice to achieve satisfactory end states, especially in Complex PTSD populations."<ref>{{cite journal | vauthors = Dorrepaal E, Thomaes K, Hoogendoorn AW, Veltman DJ, Draijer N, van Balkom AJ | title = Evidence-based treatment for adult women with child abuse-related Complex PTSD: a quantitative review | journal = European Journal of Psychotraumatology | volume = 5 | pages = 23613 | date = 2014 | pmid = 25563302 | pmc = 4199330 | doi = 10.3402/ejpt.v5.23613 }}</ref>
-====Treatment challenges====
-It is widely acknowledged by those who work in the trauma field that there is no one single, standard, 'one size fits all' treatment for complex PTSD.{{cn|date=June 2022}} There is also no clear consensus regarding the best treatment among the greater mental health professional community which included clinical psychologists, social workers, licensed therapists MFTs) and psychiatrists. Although most trauma neuroscientifically informed practitioners understand the importance of utilizing a combination of both 'top down' and 'bottom up' interventions as well as including somatic interventions (sensorimotor psychotherapy or somatic experiencing or yoga) for the purposes of processing and integrating trauma memories.
-Survivors with complex trauma often struggle to find a mental health professional who is properly trained in trauma informed practices. They can also be challenging to receive adequate treatment and services to treat a mental health condition which is not universally recognized or well understood by general practitioners.
-Allistair and Hull echo the sentiment of many other trauma neuroscience researchers (including [[Bessel van der Kolk]] and [[Bruce D. Perry]]) who argue:
-{{blockquote|
-Complex presentations are often excluded from studies because they do not fit neatly into the simple nosological categorisations required for research power. This means that the most severe disorders are not studied adequately and patients most affected by early trauma are often not recognised by services. Both historically and currently, at the individual as well as the societal level, "dissociation from the acknowledgement of the severe impact of childhood abuse on the developing brain leads to inadequate provision of services. Assimilation into treatment models of the emerging affective neuroscience of adverse experience could help to redress the balance by shifting the focus from top-down regulation to bottom-up, body-based processing."<ref>{{cite journal | vauthors = Corrigan FM, Hull AM | title = Neglect of the complex: why psychotherapy for post-traumatic clinical presentations is often ineffective | journal = BJPsych Bulletin | volume = 39 | issue = 2 | pages = 86–9 | date = April 2015 | pmid = 26191439 | pmc = 4478904 | doi = 10.1192/pb.bp.114.046995 }}</ref>
-}}
-Complex post trauma stress disorder is a long term mental health condition which is often difficult and relatively expensive to treat and often requires several years of psychotherapy, modes of intervention and treatment by highly skilled, mental health professionals who specialize in trauma informed modalities designed to process and integrate childhood trauma memories for the purposes of mitigating symptoms and improving the survivor's quality of life. Delaying therapy for people with complex PTSD, whether intentionally or not, can exacerbate the condition.<ref>{{cite journal | vauthors = De Jongh A, Resick PA, Zoellner LA, van Minnen A, Lee CW, Monson CM, Foa EB, Wheeler K, Broeke ET, Feeny N, Rauch SA, Chard KM, Mueser KT, Sloan DM, van der Gaag M, Rothbaum BO, Neuner F, de Roos C, Hehenkamp LM, Rosner R, Bicanic IA | display-authors = 6 | title = Critical Analysis of the Current Treatment Guidelines for Complex Ptsd in Adults | journal = Depression and Anxiety | volume = 33 | issue = 5 | pages = 359–69 | date = May 2016 | pmid = 26840244 | doi = 10.1002/da.22469 | s2cid = 25010506 }}</ref>
-====Recommended treatment modalities and interventions====
-There is no one treatment which has been designed specifically for use with the adult complex PTSD population (with the exception of component based psychotherapy <ref>{{cite journal | vauthors = Grossman FK, Spinazzola J, Zucker M, Hopper E | title = Treating adult survivors of childhood emotional abuse and neglect: A new framework | journal = The American Journal of Orthopsychiatry | volume = 87 | issue = 1 | pages = 86–93 | date = 2017 | pmid = 28080123 | doi = 10.1037/ort0000225 | s2cid = 4486624 }}</ref>) there are many therapeutic interventions used by mental health professionals to treat PTSD. {{as of|2017|February|}}, the American Psychological Association PTSD Guideline Development Panel (GDP) strongly recommends the following for the treatment of PTSD:<ref>{{cite web|author=American Psychological Association Guideline Developmental Panel|title=Clinical Practice Guideline for the Treatment of PTSD|url=https://www.apa.org/ptsd-guideline/ptsd.pdf|date=February 2017}}</ref>
-# [[Cognitive behavioral therapy]] (CBT) and trauma focused CBT
-# Cognitive processing therapy (CPT)
-# Cognitive therapy (CT)
-# [[Prolonged exposure therapy]] (PE)
-The American Psychological Association also conditionally recommends<ref>{{cite web|url=https://www.apa.org/ptsd-guideline/treatments/eye-movement-reprocessing|title=Eye Movement Desensitization and Reprocessing (EMDR) Therapy|website=American Psychological Association}}</ref>
-# [[Eclectic psychotherapy|Brief eclectic psychotherapy]] (BEP)
-# [[Eye movement desensitization and reprocessing]] (EMDR) <ref>{{cite journal | vauthors = van der Kolk BA, Spinazzola J, Blaustein ME, Hopper JW, Hopper EK, Korn DL, Simpson WB | title = A randomized clinical trial of eye movement desensitization and reprocessing (EMDR), fluoxetine, and pill placebo in the treatment of posttraumatic stress disorder: treatment effects and long-term maintenance | journal = The Journal of Clinical Psychiatry | volume = 68 | issue = 1 | pages = 37–46 | date = January 2007 | pmid = 17284128 | doi = 10.4088/jcp.v68n0105 | url = http://www.besselvanderkolk.net/uploads/3/4/9/8/34980287/emdrjcpfinalpage_proofspdf.pdf }}</ref><ref>{{cite journal | vauthors = Korn DL, Leeds AM | title = Preliminary evidence of efficacy for EMDR resource development and installation in the stabilization phase of treatment of complex posttraumatic stress disorder | journal = Journal of Clinical Psychology | volume = 58 | issue = 12 | pages = 1465–87 | date = December 2002 | pmid = 12455016 | doi = 10.1002/jclp.10099 | url = http://www.traumacenter.org/products/pdf_files/Korn_&_Leeds_RDI_article_1.pdf | publisher = Wiley }}</ref><ref>{{cite news|last1=Fisher|first1=Janina | name-list-style = vanc |title=Modified EMDR Resource Development and Installation Protocol|url=https://janinafisher.com/pdfs/modemdr.pdf|publisher=Trauma Center Boston, MA |date=2001}}</ref><ref>{{cite book|last=Parnell|first=Laura | name-list-style = vanc |title=EMDR in the Treatment of Adults Abused as Children|url=https://books.google.com/books?id=n7pcHAAACAAJ |publisher=Norton Professional Books|isbn=978-0-393-70298-9|date=1999}}</ref><ref>{{cite book|last1=Parnell|first1=Laura|last2=Felder|first2=Elaine | name-list-style = vanc |title=Attachment-Focused EMDR: Healing Relational Trauma|url=https://books.google.com/books?id=Pc3IZSD2OBIC|publisher=W.W.Norton and Company|isbn=978-0-393-70745-8|date=1999}}</ref>
-# [[Narrative exposure therapy]] (NET)
-While these treatments have been recommended, there is still on-going debate regarding the best and most efficacious treatment for complex PTSD. Many commonly used treatments are considered complementary or alternative since there still is a lack of research to classify these approaches as evidenced based. Some of these additional interventions and modalities include:
-* [[biofeedback]]
-* dyadic resourcing (used with EMDR)<ref>{{cite book |last=Manfield|first=Phil | name-list-style = vanc |title=Dyadic Resourcing: Creating a Foundation for Processing Trauma |url= https://books.google.com/books?id=_P-ccQAACAAJ&q=Phil+manfield+dyadic+resourcing |publisher=Create Space Independent |date=2010|isbn=978-1-4537-3813-9 }}</ref>
-* [[emotionally focused therapy]]
-* emotional freedom technique (EFT) or tapping<ref>{{cite book|last=Parnell|first=Laura | name-list-style = vanc |title=Tapping In: A Step-by-Step Guide to Activating Your Healing Resources Through Bilateral Stimulation|url=https://archive.org/details/tappinginstepbys0000parn|url-access=registration|quote=Laurel Parnell.|publisher=Sounds True|isbn=978-1-59179-788-3|date=2008}}</ref>
-* [[equine-assisted therapy]]<ref>{{cite news|last=Dorotik-Nana|first=Claire| name-list-style = vanc |title=Is Equine Therapy Supported By Research?|url=https://blogs.psychcentral.com/equine-therapy/2011/02/is-equine-therapy-supported-by-research|publisher=PsychCentral|date= February 2011}}</ref>
-* expressive arts therapy
-* [[Internal Family Systems Model|internal family systems therapy]]<ref>{{cite book |last1=Anderson |first1=Frank |last2=Schwartz |first2=Richard |last3=Sweezy |first3=Martha | name-list-style = vanc |title=Internal Family Systems Skills Training Manual: Trauma-Informed Treatment for Anxiety, Depression, PTSD & Substance Abuse|publisher=PESI Publishing and Media |date=2017 |isbn=978-1-68373-087-3 |url=https://books.google.com/books?id=Sba6tAEACAAJ&q=frank+anderson+internal+family+systems }}</ref>
-* [[dialectical behavior therapy]] (DBT)
-* [[family therapy|family systems therapy]]
-* [[Group psychotherapy|group therapy]]<ref name = "Ford_2009" />
-* [[neurofeedback]]<ref>{{cite journal | vauthors = van der Kolk BA, Hodgdon H, Gapen M, Musicaro R, Suvak MK, Hamlin E, Spinazzola J | title = A Randomized Controlled Study of Neurofeedback for Chronic PTSD | journal = PLOS ONE | volume = 11 | issue = 12 | pages = e0166752 | date = April 2019 | pmid = 27992435 | pmc = 5161315 | doi = 10.1371/journal.pone.0166752 | doi-access = free }}</ref><ref>{{Cite book|last=Fisher|first=Sebern| name-list-style = vanc |title=Neurofeedback in the Treatment of Developmental Trauma: Calming the Fear-Driven Brain|publisher= W.W. Norton and Company|isbn = 978-0-393-70786-1 |date=2014-04-21}}</ref><ref>{{cite journal|last1=Othmer|first1=Siegfried Othmer|last2=Othmer|first2=Susan| name-list-style = vanc |title=Post Traumatic Stress Disorder: The Neurofeedback Remedy|url=https://www.eeginfo.com/research/articles/PTSD-NeurofeedbackRemedy.pdf|journal=Biofeedback|publisher=Association for Applied Psychophysiology & Biofeedback|date=Spring 2009|volume=37|number=1|pages=24–31|doi=10.5298/1081-5937-37.1.24}}</ref>
-* [[psychodynamic therapy]]
-* [[sensorimotor psychotherapy]]<ref>{{cite book|last1=Odgen|first1=Pat|last2=Minton|first2=Kekuni|last3=Pain|first3=Clare| name-list-style = vanc |title= Sensorimotor Psychotherapy: Interventions for Trauma and Attachment|publisher=W.W. Norton and Company|url=https://books.google.com/books?id=ixzha85iwPQC|isbn=978-0-393-70613-0 |date=2015}}</ref>
-* [[somatic experiencing]]
-* [[yoga]], specifically [[trauma-sensitive yoga]]<ref>{{cite journal | vauthors = van der Kolk BA, Stone L, West J, Rhodes A, Emerson D, Suvak M, Spinazzola J | title = Yoga as an adjunctive treatment for posttraumatic stress disorder: a randomized controlled trial | journal = The Journal of Clinical Psychiatry | volume = 75 | issue = 6 | pages = e559-65 | date = June 2014 | pmid = 25004196 | doi = 10.4088/JCP.13m08561 | url = https://besselvanderkolk.net/uploads/3/4/9/8/34980287/yoga_f_j_clin_psychiat___1_.pdf }}</ref>
-=== Arguments against diagnosis ===
-Though acceptance of the idea of complex PTSD has increased with mental health professionals, the fundamental research required for the proper validation of a new disorder is insufficient as of 2013.<ref>{{cite journal | vauthors = Keane TM | title = Interview: does complex trauma exist? A "long view" based on science and service in the trauma field. Interview by Lisa M Najavits | journal = Journal of Clinical Psychology | volume = 69 | issue = 5 | pages = 510–5 | date = May 2013 | pmid = 23564601 | doi = 10.1002/jclp.21991 }}</ref> The disorder was proposed under the name DES-NOS (Disorder of Extreme Stress Not Otherwise Specified) for inclusion in the [[DSM-IV]] but was rejected by members of the [[Diagnostic and Statistical Manual of Mental Disorders]] (DSM) committee of the [[American Psychiatric Association]] for lack of sufficient diagnostic validity research. Chief among the stated limitations was a study which showed that 95% of individuals who could be diagnosed with the proposed DES-NOS were also diagnosable with PTSD, raising questions about the added usefulness of an additional disorder.<ref name="Roth_1997" />
-Following the failure of DES-NOS to gain formal recognition in the DSM-IV, the concept was re-packaged for children and adolescents and given a new name, developmental trauma disorder.<ref name="vanderKolk2005">{{cite journal| vauthors = van der Kolk BA |s2cid=75373197|title=Developmental trauma disorder: toward a rational diagnosis for children with complex trauma histories.|journal=Psychiatric Annals |date=2005|volume=35|issue=5|pages=401–408|doi=10.3928/00485713-20050501-06}}</ref> Supporters of DTD appealed to the developers of the DSM-5 to recognize DTD as a new disorder. Just as the developers of DSM-IV refused to included DES-NOS, the developers of [[DSM-5]] refused to include DTD due to a perceived lack of sufficient research.
-One of the main justifications offered for this proposed disorder has been that the current system of diagnosing PTSD plus comorbid disorders does not capture the wide array of symptoms in one diagnosis.<ref name="Herman1992" /> Because individuals who suffered repeated and prolonged traumas often show PTSD plus other concurrent psychiatric disorders, some researchers have argued that a single broad disorder such as C-PTSD provides a better and more parsimonious diagnosis than the current system of PTSD plus concurrent disorders.<ref>{{cite journal | vauthors = D'Andrea W, Ford J, Stolbach B, Spinazzola J, van der Kolk BA | title = Understanding interpersonal trauma in children: why we need a developmentally appropriate trauma diagnosis | journal = The American Journal of Orthopsychiatry | volume = 82 | issue = 2 | pages = 187–200 | date = April 2012 | pmid = 22506521 | doi = 10.1111/j.1939-0025.2012.01154.x | url = http://www.traumacenter.org/research/AJOP_why_we_need_a_complex_trauma_dx.pdf }}</ref> Conversely, an article published in [[BioMed Central]] has posited there is no evidence that being labeled with a single disorder leads to better treatment than being labeled with PTSD plus concurrent disorders.<ref name="Schmid2013">{{cite journal | vauthors = Schmid M, Petermann F, Fegert JM | title = Developmental trauma disorder: pros and cons of including formal criteria in the psychiatric diagnostic systems | journal = BMC Psychiatry | volume = 13 | pages = 3 | date = January 2013 | pmid = 23286319 | pmc = 3541245 | doi = 10.1186/1471-244X-13-3 }}</ref>
-Complex PTSD embraces a wider range of symptoms relative to PTSD, specifically emphasizing problems of emotional regulation, negative self-concept, and interpersonal problems. Diagnosing complex PTSD can imply that this wider range of symptoms is caused by traumatic experiences, rather than acknowledging any pre-existing experiences of trauma which could lead to a higher risk of experiencing future traumas. It also asserts that this wider range of symptoms and higher risk of traumatization are related by hidden confounder variables and there is no causal relationship between symptoms and trauma experiences.<ref name="Schmid2013"/>
-In the diagnosis of PTSD, the definition of the stressor event is narrowly limited to life-threatening events, with the implication that these are typically sudden and unexpected events. Complex PTSD vastly widened the definition of potential stressor events by calling them adverse events, and deliberating dropping reference to life-threatening, so that experiences can be included such as neglect, emotional abuse, or living in a war zone without having specifically experienced life-threatening events.<ref name = "Brewin_2017" /> By broadening the stressor criterion, an article published by the [[Child and Youth Care Forum]] claims this has led to confusing differences between competing definitions of complex PTSD, undercutting the clear operationalization of symptoms seen as one of the successes of the DSM.<ref>{{cite journal |vauthors=Scheeringa MS |title=Untangling Psychiatric Comorbidity in Young Children Who Experienced Single, Repeated, or Hurricane Katrina Traumatic Events |journal=Child & Youth Care Forum |volume=44 |issue=4 |pages=475–492 |date=August 2015 |pmid=26213455 |pmc=4511493 |doi=10.1007/s10566-014-9293-7 }}</ref>
-There are no known case reports with prospective repeated assessments to clearly demonstrate that the alleged symptoms followed the adverse events. Instead, supporters of complex PTSD have pushed for recognition of a disorder before conducting any of the prospective repeated assessments that are needed.<ref>{{Cite book |chapter=Chapter 8. Facing the Disinformation Critics of the DSM-5 |title=They'll Never Be the Same: A Parent's Guide to PTSD in Youth |last=Scheeringa |first=Michael S. |name-list-style=vanc |isbn=978-1-942094-61-6 |publisher=Central Recovery Press |date=2017-10-10 }}</ref>
-== References ==
-* {{cite book|last1=Anderson|first1=Frank|last2=Schwartz|first2=Richard|last3=Sweezy|first3=Martha | name-list-style = vanc |title=Internal Family Systems Skills Training Manual: Trauma-Informed Treatment for Anxiety, Depression, PTSD & Substance Abuse|publisher=PESI Publishing and Media|date=2017|isbn=978-1-68373-087-3|url=https://books.google.com/books?id=Sba6tAEACAAJ&q=frank+anderson+internal+family+systems}}
-* {{Cite journal | vauthors = Appleyard K, Osofsky JD | doi = 10.1002/imhj.10050 | title = Parenting after trauma: Supporting parents and caregivers in the treatment of children impacted by violence | journal = Infant Mental Health Journal | volume = 24 | issue = 2 | pages = 111–125 | year = 2003 | url = http://www.futureunlimited.org/pdf/imh_.3_03.}}
-* {{cite book|last=Bannit|first=Susan Pease| name-list-style = vanc |title=The Trauma Tool Kit: Healing PTSD from the Inside Out|publisher=Quest Books|date=2012|isbn=978-0-8356-0896-1|url=https://books.google.com/books?id=6Yrv2ugNUnEC}}
-* {{cite book|last1=Briere|first1=John|last2=Scott|first2=Catherine | name-list-style = vanc |title=Principles of Trauma Therapy: A Guide to Symptoms, Evaluation, and Treatment|url=https://books.google.com/books?id=W_G0ygAACAAJ|access-date=29 October 2012|date=30 August 2012|publisher=SAGE Publications|isbn=978-1-4129-8143-9}}
-* {{Cite book|last=Courtois|first=Christine| name-list-style = vanc |title=It's Not You, It's What Happened to You: Complex Trauma and Treatment|url=https://books.google.com/books?id=ZycVogEACAAJ&q=Courtois+christine+its+not+what|publisher=Elements Behavioral Health|date=October 12, 2014|isbn=978-1-941536-55-1}}
-* {{Cite book|last1=Fisher|first1=Janina|title=Healing the Fragmented Selves of Trauma Survivors: Overcoming Internal Self-Alienation|publisher=Routledge|url=https://books.google.com/books?id=NJ40DgAAQBAJ&q=Healing+the+fragmented+selves|date=2017|isbn=978-0-415-70823-4}}
-* {{Cite journal|last=Fisher|first=Sebern| name-list-style = vanc |title=Arousal and Identity: Thoughts on Neurofeedback in the Treatment of Developmental Trauma|journal=Biofeedback|volume=38|issue=1|pages=6–8|date=2010|doi=10.5298/1081-5937-38.1.6|url=https://www.aapb.org/files/publications/biofeedback/2010/biof-38-01-6-8.pdf}}
-* {{Cite book|last=Fisher|first=Sebern| name-list-style = vanc |title=Neurofeedback in the Treatment of Developmental Trauma: Calming the Fear-Driven Brain|publisher=W.W. Norton and Company|date=2014|url=https://books.google.com/books?id=OgBZAwAAQBAJ|isbn=978-0-393-70786-1}}
-* {{cite journal | vauthors = Ford JD | title = Disorders of extreme stress following war-zone military trauma: associated features of posttraumatic stress disorder or comorbid but distinct syndromes? | journal = Journal of Consulting and Clinical Psychology | volume = 67 | issue = 1 | pages = 3–12 | date = February 1999 | pmid = 10028203 | doi = 10.1037/0022-006X.67.1.3 | url = http://www.trauma-pages.com/a/ford99.php }}
-* {{Cite book|last1=Frewen|first1=Paul|last2=Lanius|first2=Ruth| name-list-style = vanc |title=Healing the Traumatized Self: Consciousness, Neuroscience, Treatment | series = Norton Series on Interpersonal Neurobiology |publisher=W.W. Norton and Company|date=2015|url=https://books.google.com/books?id=zRN0AwAAQBAJ|isbn=978-0-393-70849-3}}
-* {{cite journal | title = Guidelines for treating dissociative identity disorder in adults, third revision | journal = Journal of Trauma & Dissociation | volume = 12 | issue = 2 | pages = 115–87 | date = 2011 | pmid = 21391103 | doi = 10.1080/15299732.2011.537247 | url = https://www.isst-d.org/wp-content/uploads/2019/02/GUIDELINES_REVISED2011.pdf | last1 = International Society For The Study }}
-* {{Cite book|last1=Odgen|first1=Pat|last2=Minton|first2=Kekuni|last3=Pain|first3=Clare | name-list-style = vanc |title=Sensorimotor Psychotherapy: Interventions for Trauma and Attachment|url=https://books.google.com/books?id=ixzha85iwPQC|publisher=W.W. Norton and Company|date=2015|isbn=978-0-393-70613-0}}
-* {{cite journal | vauthors = Teicher MH, Samson JA, Anderson CM, Ohashi K | title = The effects of childhood maltreatment on brain structure, function and connectivity | journal = Nature Reviews. Neuroscience | volume = 17 | issue = 10 | pages = 652–66 | date = September 2016 | pmid = 27640984 | doi = 10.1038/nrn.2016.111 | s2cid = 27336625 | url = https://www.researchgate.net/publication/308303380 }}
-* {{Cite journal|last1=van der Hart|first1=Onno|last2=Mosquera|first2=Delores|last3=Gonzales|first3=Anabel| name-list-style = vanc |title=Borderline Personality Disorder, Developmental Trauma and Structural Dissociation of the Personality|journal=Persona|volume=2|pages=44–73|date=2008|url=http://www.onnovdhart.nl/wp-content/uploads/2008/09/persona2.pdf}}
-* {{Cite book | last1 = van der Hart | first1 = Onno | last2 = Nijenhuis | first2 = Ellert R.S. | last3 = Steele | first3 = Kathy | name-list-style = vanc | title = The Haunted Self: Structural Dissociation and the Treatment of Chronic Traumatization | url = https://books.google.com/books?id=PPpxN70YLQEC | publisher = W.W. Norton | date = 2006 | isbn = 978-0-393-70401-3 }}
-* {{Cite book|last1=van der Hart|first1=Onno|last2=Boon|first2=Suzanne|last3=Steele|first3=Kathy| name-list-style = vanc |title=Treating Trauma-Related Dissociation: A Practical, Integrative Approach | series = Norton Series on Interpersonal Neurobiology |publisher=Norton Publishing|date=2016|url=https://books.google.com/books?id=l_B_DQAAQBAJ&q=Dissociation+boon|isbn=978-0-393-70759-5}}
-* {{Cite book |last=van der Kolk|first=Bessel| name-list-style = vanc |title=The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma|url=https://books.google.com/books?id=vHnZCwAAQBAJ|publisher=Penguin|date=2015|isbn=978-0-14-312774-1}}
-* {{cite journal | vauthors = van der Kolk BA | s2cid = 28935850 | title = Clinical implications of neuroscience research in PTSD | journal = Annals of the New York Academy of Sciences | volume = 1071 | issue = 1 | pages = 277–93 | date = July 2006 | pmid = 16891578 | doi = 10.1196/annals.1364.022 | bibcode = 2006NYASA1071..277V }}
-*{{Cite news|last=van der Kolk|first=Bessel| name-list-style = vanc |url=http://www.traumacenter.org/products/Developmental_Trauma_Disorder.pdf | title=Developmental trauma disorder | publisher=Psychiatric Annals | year=2005| pages=401–408}}
-* {{cite journal | vauthors = van der Kolk BA, Stone L, West J, Rhodes A, Emerson D, Suvak M, Spinazzola J | title = Yoga as an adjunctive treatment for posttraumatic stress disorder: a randomized controlled trial | journal = The Journal of Clinical Psychiatry | volume = 75 | issue = 6 | pages = e559-65 | date = June 2014 | pmid = 25004196 | doi = 10.4088/JCP.13m08561 | url = https://besselvanderkolk.net/uploads/3/4/9/8/34980287/yoga_f_j_clin_psychiat___1_.pdf }}
-* {{cite book | last = Walker | first = Pete | name-list-style = vanc | date = December 2013 | url = https://booksgoogle.ca/books?id=32AQnwEACAAJ | title = Complex PTSD: From Surviving to Thriving: A Guide and Map for Recovering from Childhood Trauma | publisher = CreateSpace Independent Publishing Platform | isbn = 978-1-4928-7184-2 }}
-{{refend}}
 == Notes ==
@@ Line 688: / Line 214: @@
 ==References==
+* American Psychiatric Association. ''DSM I: Diagnostic and Statistical Manual Mental Disorders''. American Psychiatric Publishing, 1952. ISBN 978-0890420171
+* American Psychiatric Association. ''Diagnostic and Statistical Manual of Mental Disorders: DSM-IV''. American Psychiatric Association, 1994. ISBN 0890420610
+* American Psychiatric Association. ''Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5''. American Psychiatric Publishing, 2013. ISBN 978-0890425558
+* Andreasen, Nancy C. ''Brave New Brain: Conquering Mental Illness in the Era of the Genome''. Oxford University Press, 2001. ISBN 978-0195145090
+* Audoin-Rouzeau, Stéphane, and Annette Becker. ''1914-1918 Understanding the Great War''. Profile Books, 2002. ISBN 978-1861973528
+* Carlstedt, Roland. ''Handbook of Integrative Clinical Psychology, Psychiatry, and Behavioral Medicine Perspectives, Practices, and Research''. Springer Publishing Company, 2009. ISBN 0826110940
+* First, Michael B. ''DSM-5® Handbook of Differential Diagnosis''. American Psychiatric Publishing, 2013. ISBN 978-1585624621
+* Forbes, David, Jonathan I. Bisson, Candice M. Monson, and Lucy Berliner (eds.). ''Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies''. The Guilford Press, 2020. ISBN 978-1462543564
+* Holmstrom, Lynda Lytle, and Ann Wolbert Burgess. ''The Victim of Rape: Institutional Reactions''. Routledge, 1983. ISBN 978-0878559329
+* Kennedy, Sidney H., Jerrold S. Maxmen, and Roger S. McIntyre. ''Psychotropic Drugs: Fast facts''. W. W. Norton & Company, 2008. ISBN 978-0393705201
+* de Kloet, E. Ronald, Melly S. Oitzl, and Eric Vermetten (eds.). ''Stress Hormones and Post Traumatic Stress Disorder: Basic Studies and Clinical Perspectives''. Elsevier Science, 2008. ISBN 978-0444531407
+* Klykylo, William M., Jerald Kay, and David Rube. ''Clinical Child Psychiatry''. Saunders, 1998. ISBN 978-0721638409
+* Mash, Eric J., and Russell A. Barkley (eds.). ''Child Psychopathology''. The Guilford Press, 2002. ISBN 978-1572306097
+* National Collaborating Centre for Mental Health. ''Post-Traumatic Stress Disorder: The Management of PTSD in Adults and Children in Primary and Secondary Care''. British Psychological Society and RCPsych Publications, 2005. ISBN 978-1904671251
+* O'Brien, L. Stephen. ''Traumatic Events and Mental Health''. Cambridge University Press, 1998. ISBN 978-0521578868
+* Rothschild, Babette. ''The Body Remembers: The Psychophysiology of Trauma and Trauma Treatment''. W. W. Norton & Company, 2000. ISBN 978-0393703276
+* Shalev, Arieh Y., Rachel Yehuda, and Alexander C. McFarlane (eds.). ''International Handbook of Human Response to Trauma''. Springer, 2012 (original 1999). ISBN 978-1461368731
+* Shay, Jonathan. ''Achilles in Vietnam: Combat Trauma and the Undoing of Character''. Simon & Schuster, 1995. ISBN 978-0684813219
+* Sloan, Denise M., and Brian P. Marx. ''Written Exposure Therapy for PTSD: A Brief Treatment Approach for Mental Health Professionals''. Washington DC: American Psychological Association, 2019. ISBN 978-1433830129
+* Spitzer, Robert L. (ed.). ''Diagnostic and Statistical Manual of Mental Disorders: DSM-III''. American Psychiatric Association, 1980. {{ASIN|B000P1A7CK}}
+* Taylor,Steven (ed.). ''Advances in the Treatment of Posttraumatic Stress Disorder: Cognitive-behavioral perspectives''. Springer Publishing Company, 2004. ISBN 978-0826120472
+* U.S. Department of Health and Human Services. ''Interventions for the Prevention of Posttraumatic Stress Disorder (PTSD) in Adults After Exposure to Psychological Trauma''. Agency for Healthcare Research and Quality (US), 2013. ISBN 978-1490363608
+* van Wees, Hans (ed.). ''War and Violence in Ancient Greece''. Classical Press of Wales, 2009., ISBN 978-1905125340
 == External links ==
+All links retrieved
-* [https://www.newmethodwellness.com/complex-ptsd-cptsd-test/ Understanding Complex PTSD]
+* [https://www.samhsa.gov/mental-health/post-traumatic-stress-disorder Post-Traumatic Stress Disorder (PTSD)] ''SAMHSA''
+* [https://www.apa.org/ptsd-guideline/ Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults (2017)] ''APA''
-* {{Curlie|Health/Mental_Health/Disorders/Anxiety/Post-traumatic_Stress}}
+* [https://www.ptsd.va.gov/ PTSD: National Center for PTSD] ''U.S. Department of Veterans Affairs''
-* [http://www.nctsn.org/resources Post traumatic stress disorder information from The National Child Traumatic Stress Network]
+* [https://www.mayoclinic.org/diseases-conditions/post-traumatic-stress-disorder/symptoms-causes/syc-20355967 Post-traumatic stress disorder (PTSD) ] ''Mayo Clinic''
-* [https://web.archive.org/web/20130425020526/http://www.som.uq.edu.au/ptsd Information resources from The University of Queensland School of Medicine]
+* [https://www.newmethodwellness.com/complex-ptsd-cptsd-test/ Understanding Complex PTSD] ''New Method Wellness''
-* [http://www.apa.org/ptsd-guideline/ APA practice parameters for assessment and treatment for PTSD (Updated 2017)]
+* [https://www.psychiatry.org/patients-families/ptsd/what-is-ptsd What is Posttraumatic Stress Disorder (PTSD)?] ''American Psychiatric Association''
-* [http://www.ptsd.va.gov/professional/index.asp Resources for professionals from the VA National PTSD Center]
+* [https://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd Post-Traumatic Stress Disorder] ''National Institute of Mental Health''
-* [https://www.apa.org/ptsd-guideline/ APA practice parameters for assessment and treatment for PTSD (Updated 2017)]
+[[Category:Psychology]]
+[[Category:Health and disease]]
 {{Credits|Post-traumatic_stress_disorder|1091628040|Complex_post-traumatic_stress_disorder|1096428644}}