Posttraumatic Stress Disorder (PTSD)

The traumatic event may repeatedly reappear in the form of involuntary, unwanted memories or recurrent nightmares. Some people have flashbacks, in which they relive events as if they were actually happening rather than simply being remembered.

People may also experience intense reactions to reminders of the event. A combat veteran's symptoms might be triggered by fireworks, for example, whereas those of a robbery victim may be triggered by seeing a gun in a movie.

People persistently avoid things—activities, situations, or people—that are reminders of the trauma. For example, they may avoid entering a park or an office building where they were assaulted or avoid speaking to people of the same race as their assailant. They may even attempt to avoid thoughts, feelings, or conversations about the traumatic event.

People may be unable to remember significant parts of the traumatic event (called dissociative amnesia).

People may feel emotionally numb or disconnected from other people. Depression is common, and people show less interest in previously enjoyed activities.

How people think about the event may become distorted, leading them to blame themselves or others for what happened. Feelings of guilt are also common. For example, they may feel guilty that they survived when other people did not. They may feel only negative emotions, such as fear, horror, anger, or shame, and may be unable to feel happy or satisfied or to love.

People may have difficulty falling asleep or concentrating.

They may become excessively vigilant for warning signs of risk. They may be easily startled.

People may become less able to control their reactions, resulting in reckless behavior or angry outbursts.

Some people develop ritual activities to help reduce their anxiety. For example, people who were sexually assaulted may bathe repeatedly to try to remove the sense of being unclean.

Many people with PTSD try to relieve their symptoms with alcohol or illicit drugs and develop a substance use disorder.

A dissociative subtype of PTSD has now been recognized. A person with this disorder has all the symptoms mentioned above, plus depersonalization (feeling detached from one's self or body) and/or derealization (experiencing the world as unreal or dreamlike).

Self-care is crucial during and after a crisis or trauma. Self-care can be divided into 3 components:

• Personal safety

• Physical health

• Mindfulness

Personal safety is fundamental. After a single traumatic episode, people are better able to process the experience when they know that they and their loved ones are safe. It can be difficult, however, to gain complete safety during ongoing crises such as domestic abuse, war, or an infectious pandemic. During such ongoing difficulties, people should seek the guidance of experts on how they and their loved ones can be as safe as possible.

Physical health can be put at risk during and after traumatic experiences. Everyone should try to maintain a healthy schedule of eating, sleeping, and exercise. Drugs that sedate and intoxicate (for example, alcohol) should be used sparingly, if at all.

A mindful approach to self-care aims to reduce the feelings of stress, boredom, anger, sadness, and isolation that traumatized people normally experience. If circumstances allow, at-risk individuals should make and follow a normal daily schedule, for example, get up, shower, get dressed, go outside and take a walk, and prepare and eat regular meals.

It is useful to practice familiar hobbies as well as activities that sound fun and distracting: draw a picture, watch a movie, or cook.

Community involvement can be crucial, even if it is difficult to maintain human connection during a crisis.

Stretching and exercise are beneficial, but it can be equally helpful to sit still and count one's own breaths or listen carefully for surrounding sounds. People can become preoccupied with the trauma or crisis, so it is useful to choose to think of other things: read a novel or get engaged with a puzzle. Unpleasant emotions may typically feel "frozen" during and after a trauma, and it can be a relief to find activities that shift the feeling state: laugh, watch a fun movie, do something silly, or draw with crayons. Under stress, people can become short-tempered, even with people they care about.

Spontaneous kindness can be a win/win solution for everyone: sending a nice note, making someone cookies, and offering up a smile may not only be a nice surprise for the recipient, but they can reduce the hopelessness and passivity that tends to be part of the sender's experience of trauma.

Psychotherapy is central to the treatment of PTSD.

Education about PTSD can be an important early step in therapy. The symptoms of PTSD can feel overwhelmingly confusing, and it is often very useful for people and loved ones to understand how PTSD can include seemingly unrelated symptoms.

Trauma-focused cognitive-behavioral therapy is the most effective treatment for PTSD. This form of therapy, which is also effective for acute stress disorder, includes education about the nature of stress and the body/mind's response to it, modifying one's thinking about the traumatic event and responses to it (or putting things into perspective), and undergoing carefully guided therapeutic exposure to memories of the traumatic experience.

It is important to find a mental health professional who expresses warmth, reassurance, and empathy to help people with PTSD who often suffer from shame, avoidance, hypervigilance, and detachment.

Stress management techniques, such as breathing and relaxation, are important. Exercises that reduce and control anxiety (for example, yoga, meditation) can relieve symptoms and also prepare people for treatment that involves stress-inducing exposure to memories of the trauma.

The strongest current evidence favors structured, focused psychotherapy, usually a type of cognitive-behavioral therapy called exposure therapy that helps to extinguish the fear left over from the traumatic event.

In exposure therapy, the therapist has people imagine being in situations associated with prior trauma. For example, they may be asked to imagine visiting a park where they were assaulted. The therapist may help people reimagine the traumatic event itself. Because of the often intense anxiety associated with traumatic memories, it is important for people in therapy to feel supported and for the exposure to proceed at the right pace. People who have been traumatized may be especially sensitive and vulnerable to the threat of being traumatized again, so treatment can get stalled if it goes too quickly. Often, treatment may shift from exposure to a more supportive, open-ended treatment, to help people be more comfortable with exposure therapy.

Broader and more exploratory psychotherapy may also ease return to a happier life, such as by focusing on relationships that may have been fractured by PTSD. Other types of supportive and psychodynamic psychotherapy can also be useful as long as they do not shift the focus of treatment away from exposure therapy.

Eye movement desensitization and reprocessing (EMDR) is treatment in which people are asked to follow the therapist's moving finger while they imagine being exposed to the trauma. Some experts think that the eye movements themselves help with desensitization, but EMDR probably works mainly because of the exposure, not the eye movements.

Antidepressants may also be an effective treatment for PTSD, even in people who do not also have major depression

A variety of other medications are used in people with PTSD. Often, they are used to target specific moods, thoughts, and behaviors that are part of an episode of PTSD or are part of a co-occurring disorder.

antipsychotic drugs