Zbynek Pospisil/istockphoto
Like many mental health conditions, post-traumatic stress disorder is widely known, but little understood. The National Institute for Mental Health estimates that some 8% of all people will experience the disorder at some point in their lives, with the source of their trauma varying widely from military combat to sexual assault. We got expert advice and looked at studies and other reports to get a sense of how common PTSD is and what can be done about it.
PTSD is an anxiety disorder resulting from extremely stressful, frightening or dangerous experiences that get relived through hyperarousal, nightmares, and disruptive thoughts because they haven't been sufficiently processed — in essence, a reaction to trauma that's normal but lasts an extended period of time. "The normal process of adaptational extinction doesn't happen in these folks," explains USC psychologist Albert "Skip" Rizzo, whose work focuses on developing virtual reality treatment and assessment tools for PTSD. Symptoms will usually begin within three months of a trauma, though sometimes they can start much later, and must persist for more than a month and be severe enough to interfere with work or relationships to be diagnosed as PTSD.
Anyone can develop PTSD at any age. Around 70% of Americans have endured trauma, and up to 20% of those go on to experience PTSD, though researchers have yet to pinpoint what causes it in some people versus others. According to a 2005 survey from the National Institute of Mental Health, PTSD affects about 7.7 million U.S. adults in a given year, and about 5% of adolescents. It's more likely to affect women than men, with about 10% of females developing the disorder sometime in their lives compared with just 4% of males.
Previous traumas can increase the chances of developing PTSD after an incident, because each depletes a brain hormone that helps handle stress. Personality is another potential factor, if you have an avoidant personality that ignores trauma instead of confronting it. Lack of education and a history of childhood abuse or neglect can also make development of PTSD more likely.
Conversely, optimists and people who are more resourceful in problem-solving tend to be more resilient to traumatic experiences, as do those with college educations and even positive relationships with their fathers. In the same vein, perhaps the most telling indicator of whether someone develops PTSD is the strength of their social support system. Sometimes referred to as a "trauma membrane," a strong network of close relationships has been shown to decrease one's likelihood of developing PTSD and improve outcomes for those who already have it.
Despite its higher prevalence among women, PTSD is still most commonly associated with male veterans of military combat, in large part due to its history. PTSD was first coined as "shell shock" to describe the lingering trauma experienced by soldiers returning home from World War I, but it wasn't added to the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders until 1980. "I think it was really after the Vietnam War, when a group of activists and veterans really pushed for the idea that this is not just weak will," Rizzo says. "This is a condition." Though few mental health professionals or members of the public doubt the condition's seriousness today, the association with combat service remains strong.
Combat exposure isn't the only common cause of PTSD in veterans. Military sexual trauma results from physical assault and unwanted touching of a sexual nature experienced by service members whether during training or active duty. According to a U.S. Department of Veterans Affairs' national screening program, about one in every four women and one in every 100 men surveyed experienced MST at some point. Because there are significantly more men than women in the military, this suggests both groups are affected in great numbers.
Like military personnel, first responders to emergency or disaster situations such as police, firefighters, and emergency medical technicians are at high risk of developing PTSD or related symptoms. Rizzo says the trauma, chronic fatigue, and exposure to death, destruction, and terror these occupations can entail have become widely recognized in recent decades. "They may have only a couple of symptoms, but not enough to be diagnosed," he says. "As a cop, you may start to look at certain racial groups as different. You're numbed to their experience and, at the same time, you're hypervigilant about threats — that's a toxic combination for pulling the trigger."
Millions of women develop PTSD not from being in a war zone, but from giving birth. Postnatal PTSD was only formally recognized in the '90s, after psychiatrists recognized formally that the disorder results not just from events "outside the range of usual human experience," but anywhere the person "witnessed or confronted serious physical threat or injury ... and responded with feelings of fear, helplessness or horror." But childbirth causes the deaths of 803 women worldwide every day, and studies estimate that 4% of all births and one-third of all "traumatic delivery" experiences lead to the development of PTSD in mothers, in some cases affecting partners or midwives as well. This can affect the parent-baby bond, especially when women feel a stigma that speaking openly about the event will make them seem ungrateful or like a bad mother.
One common thread of traumatic experiences is a sense of helplessness, something victims of sexual or intimate partner abuse may feel regarding their own bodies, especially if the exposure becomes long-term. "Getting beat up by a stranger in some alley is going to have a different load than if your husband or wife really beats the crap out of you," Rizzo says, "because you know that person."
Just as routine exposure to death in war zones can affect soldiers, recurring violence closer to home can cause trauma in civilian populations, including teens, children, and even babies. It's not just poorer inner-city (predominantly nonwhite) areas with high crime rates that are at risk, but also suburban and rural neighborhoods where kids may be exposed to school shootings, car accidents, assaults, and domestic violence at home.
"If you gave everybody a diagnostic interview for PTSD the day after their house was blown away by a hurricane, everybody would be diagnosed with it," Rizzo says. Trauma symptoms are a natural reaction to disasters such as earthquakes and manmade incidents such as terrorism; whether they persist depends on a variety of factors, including access to treatment. In general, up to one-third of children who lived through a natural disaster will develop chronic PTSD symptoms within a year. A study within a year of Hurricane Maria found that more than 7% of public-school students in Puerto Rico reported PTSD symptoms.
It isn't always a case of exceptional violence that causes PTSD; sometimes it's just the loss of someone close to us. Unexpected deaths raise the odds of experiencing PTSD, panic disorder, and depressive episodes at any age or income level. Though psychiatrically speaking you must have seen the death to qualify for a PTSD diagnosis, research suggests it's more about the relationship.
A gray area is whether subjective experiences of trauma may justify a diagnosis. Patients with other mental conditions may be just as traumatized by hallucinations or being forcibly sedated in the hospital due to psychosis as others are by more objectively life-threatening experiences. Though the sense of stress and danger they experience may be just as extreme, long-lasting, and disruptive to everyday life, the subjective nature and commonness of the triggering incident can detract from recognition and treatment. Some researchers propose a new categorization of "psychosis-related PTSD."
For an adult to be diagnosed with PTSD under official guidelines, their symptoms must last for longer than one month and include the following: at least one re-experiencing symptom (the flashbacks, nightmares, and disruptive thoughts most people imagine when they think of PTSD); one avoidance symptom (the tendency to steer clear of situations or subjects relating to the traumatic event); and at least two of both arousal and reactivity symptoms (constant feelings of tension or hyperarousal that may cause anger issues or trouble sleeping) and cognitive and mood symptoms (relating to one's personal conscious thoughts and feelings, including a negative outlook on the world or oneself, guilt, and loss of interest in previously enjoyable activities).
PTSD can manifest in unique symptoms for younger populations, especially children 6 or younger. These can include bedwetting, clinginess to parents or other adults, drawing or acting out the traumatic event during playtime, and being unable or unwilling to speak. Older children and teens show symptoms more similar to those seen in adults, but may also develop destructive behaviors, have thoughts of revenge, and feel especially guilty for not preventing a death or other incident.
Contrary to some antiquated stigmas, PTSD has less to do with character than with brain chemistry, as has been recorded by fMRI studies. Most memories are filed away in the brain's hippocampus, but traumatic experiences can instead trigger and become stuck in a more primitive region called the amygdala, activating our fight-or-flight mode and interrupting the process of fear extinction. One University of California study showed that the part of the amygdala responsible for controlling fear and aversion to stimuli was an average 6% larger in the brains of military members with PTSD. "The brain is tuned to be vigilant — that's part of what keeps us alive," Rizzo say. "People with PTSD end up having these symptoms that make it so they're always vigilant." Someone with PTSD may feel just as terrified by certain triggers despite logical awareness that they're not in danger.
When people experiencing trauma start avoiding thoughts, people, or situations that trigger their fear, they get a temporary sense of relief that can end up reinforcing their continued avoidance. "Sometimes the avoidance starts to generalize," Rizzo says. "You stop participating in life in a general way. You become emotionally numb, because you try to avoid having any emotion toward another person, good or bad. It isn't just the negative stuff that you avoid."
Like most diagnosable mental health conditions, PTSD's impacts can range from mild to severe. The most common experience is a "shrinking of active participation in daily life," Rizzo says. Avoidance causes mounting withdrawal from social and professional activities, while hyperarousal can lead to angry outbursts or substance abuse to manage the constant stress. Perhaps most crucially, these symptoms can hurt even one's closest relationships, so friends and family become alienated and unsure how to relate to people with PTSD — compounding their isolation.
Related: Could Your Words Be Hurting Someone with a Mental Health Issue?
Traumatic exposure can result in not just mental disorders, but respiratory impairments as well. PTSD has been reported as a risk factor for contracting asthma and enhancing the severity of existing asthma. Though little is known about the mechanisms driving this correlation, it shows that psychological trauma and stress are connected intimately to physical health in ways we're only beginning to understand.
There are many treatment routes available to those with PTSD, but also factors that may keep people from getting help. While some cases are overlooked due to lack of awareness (such as childbirth and other instances of PTSD in women), even well-known trauma sources such as combat carry stigma that health professionals struggle to overcome. "The military has tried over the last 10 to 12 years to institute programs that say, if you're gonna be a good soldier, you gotta take care of your mental health, and if you're having issues, you need to get them addressed," Rizzo says. "They're trying to normalize seeking help. When it comes to anxiety and other PTSD-related pain, people go years and decades without seeking help because of the stigma, including self-stigma — looking at yourself as less of a person."
Because PTSD is a condition of avoidance that "very rarely just resolves on its own," the person's own lack of awareness or negativity can become barriers to treatment and positive outcomes. Rizzo also points to discomfort with seeking help or talking about mental issues as an impediment. "It's not like getting shot in the arm, where you get treated and maybe it becomes a funny story," he says. "People don't look at talking about their psychological problems as a fun story — there's still a societal view of weakness."
The course of PTSD varies, but it's not a life sentence — effective treatments are available. One crucial element is a comprehensive approach of "treating the whole person," with various types of therapy and social support to help process their experiences as well as medications to manage symptoms. "They're not a magic bullet," Rizzo cautions. "I think a key is to have patients have more agency in making decisions about their treatment, so they can pick things and have more options."
Trauma-focused psychotherapy is the type of treatment most highly recommended by the VA. It centers around regular personalized interaction and sessions with a specialized therapist to help people confront and process difficult emotional memories in a safe setting. "Studies show that if you just say, ‘We're going to give you supportive counseling and not deal with [what] happened and focus on your future,' that doesn't work," Rizzo says. "Eventually, hopefully you get a feeling of empowerment, as people are confronting the things they thought they could never handle before."
Also used for phobias and other anxiety-based disorders, prolonged exposure entails facing negative feelings and subjects and activities one has avoided. There are different techniques to accomplish this, so patients may simply talk about their trauma, visualize them, or even play virtual reality video games tailored to them. Prolonged exposure usually runs about eight to 16 sessions, Rizzo says.
While prolonged exposure has patients confront their trauma and negative feelings repeatedly, cognitive processing therapy encourages them to reframe it in their minds, usually by talking with a provider or completing short writing assignments. They work together, with PE operating on the level of brain activation and fear extinction and CP helping in a deeper, emotional fashion. A key element is education, helping patients understand the physiological sources of their problems, letting them feel secure in their reactions, and teaching strategies to cope with them. "People that are educated and aware of what they're going through are going to have better outcomes," Rizzo says.
The last form of trauma-based therapy with the strongest evidence it helps, EMDR has patients process trauma while paying close attention to a recurring sound or back-and-forth movement, mimicking REM sleep. Similar to controlled breathing and meditation, which have also been found to improve PTSD outcomes, this approach seems to help by making patients feel safe and present while confronting past fears.
The most prescribed pharmaceuticals for PTSD symptoms are antidepressant selective serotonin reuptake inhibitors such as Zoloft and Paxil, but there's emerging evidence supporting the use of MDMA, a common recreational drug. When administered before psychotherapy, MDMA can reduce anxiety and hypervigilance, making the patient more motivated in confronting their trauma and engaging with the therapist. There's also anecdotal support for medical cannabis and CBD use for symptom relief, with a pilot study on its effectiveness in progress.
Additional factors that help recovery from trauma and PTSD include seeking out help, developing a positive coping strategy, and finding a social support group. "I've always said when people are coming back from war and returning to civilian life, they need to take up a team sport," Rizzo says. "It gives them more purpose in everyday life." Other general recommendations from NIMH include engaging in mild physical activities and exercise, breaking up large tasks into smaller ones, and seeking out comforting people, places, and situations.
New research shows that PTSD symptoms can also be reduced by a cutting-edge type of transcranial magnetic stimulation called Intermittent theta-burst stimulation. By mimicking hippocampal memory systems, the theta waves can induce synaptic connections and activity in a region of the brain crucial to processing and fear extinction, limiting the intrusive impacts of traumatic memories, investigators say. fMRI scans were used successfully to predict which patients would respond most favorably to the treatment.
Overcoming PTSD means taking control of a situation that makes you feel helpless. There's no scientific way to know which treatment will work best for which person, so motivation and shared decision-making between a patient and their provider is essential to achieving positive outcomes. "You're always going to have bad memories of what you went through; we're not in the business of erasing memories," Rizzo says. "There are treatments out there and you shouldn't just give up and think it's not for you." The World Health Organization put out a report recently that estimated nearly two-thirds of the world population with mental health issues never seeks treatment, he says. "We need to start looking at mental health the same way we look at physical health."
