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'''Posttraumatic stress disorder''' (also known as '''post-traumatic stress disorder''' or '''PTSD''') is a severe [[anxiety disorder]] that can develop after exposure to any event that results in [[psychological trauma]].<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|pages= |isbn=0890420610}}</ref><ref name="surgeon42">{{cite book | year=1999| chapter=Chapter 4.2 | author=[[David Satcher|Satcher D]] et al.| title=Mental Health: A Report of the Surgeon General | publisher = [[Surgeon General of the United States]] | url=http://www.surgeongeneral.gov/library/mentalhealth/chapter4/sec2.html}}</ref><ref name="Brunet"/> This event may involve the threat of death to oneself or to someone else, or to one's own or someone else's physical, sexual, or psychological integrity,<ref name=DSM4/> overwhelming the individual's [[coping (psychology)|ability to cope]]. As an effect of [[psychological trauma]], PTSD is less frequent and more enduring than the more commonly seen [[acute stress reaction|acute stress response]].

Diagnostic symptoms for PTSD include re-experiencing the original trauma(s) through [[Flashback (psychology)|flashback]]s or [[nightmare]]s, avoidance of stimuli associated with the trauma, and increased [[arousal]] – such as difficulty falling or staying asleep, [[anger]], and [[hypervigilance]]. Formal diagnostic criteria (both [[DSM-IV-TR]] and [[International Statistical Classification of Diseases and Related Health Problems|ICD-10]]) require that the symptoms last more than one month and cause significant impairment in social, occupational, or other important areas of functioning.<ref name=DSM4/>

==Classification==

Posttraumatic stress disorder is classified as an [[anxiety disorder]], characterized by aversive anxiety-related experiences, behaviors, and physiological responses that develop after exposure to a psychologically traumatic event (sometimes months after). Its features persist for longer than 30 days, which distinguishes it from the briefer [[acute stress disorder]]. These persisting posttraumatic stress symptoms cause significant disruptions of one or more important areas of life function.<ref>{{Cite book | last = Kaplan | first =HI | coauthors =Sadock, BJ, Grebb, JA | title =Kaplan and Sadock's synopsis of psychiatry: Behavioral sciences, clinical psychiatry, 7th ed. | publisher =Williams & Williams | year =1994 | location =Baltimore | pages =606–609 | isbn = }}</ref> It has three sub-forms: acute, chronic, and delayed-onset.<ref name="surgeon4">{{cite book | year=1999| chapter=Chapter 4 | author=[[David Satcher|Satcher D]] et al.| title=Mental Health: A Report of the Surgeon General | publisher =[[Surgeon General of the United States]] | url=http://www.surgeongeneral.gov/library/mentalhealth/toc.html#chapter4}}</ref>

==Causes==
===Psychological trauma===
PTSD is believed to be caused by either [[physical trauma]] or [[psychological trauma]], or more frequently a combination of both.<ref name=DSM4/> According to Atkinson ''et al.'' (2000){{Citation needed|date=November 2010}} PTSD is more likely to be caused by physical or psychological trauma caused by humans such as rape, war, or terrorist attack than trauma caused by natural disasters. Possible sources of trauma include experiencing or witnessing childhood or adult [[physical abuse|physical]], [[emotional abuse|emotional]] or [[sexual abuse]].<ref name=DSM4/> In addition, experiencing or witnessing an event perceived as life-threatening such as physical [[assault]], adult experiences of [[sexual assault]], accidents, [[drug addiction]], illnesses, [[complication (medicine)|medical complications]], or employment in occupations exposed to war (such as soldiers) or disaster (such as [[emergency service]] workers).{{Citation needed|date=July 2009}}

Traumatic events that may cause PTSD symptoms to develop include violent assault, kidnapping, sexual assault, torture, being a hostage, prisoner of war or concentration camp victim, experiencing a disaster, violent automobile accidents or getting a diagnosis of a life-threatening illness.<ref name=DSM4/> Children or adults may develop PTSD symptoms by experiencing [[bullying]] or [[mobbing]].<ref>{{cite journal |author=Kelleher I, Harley M, Lynch F, Arseneault L, Fitzpatrick C, Cannon M |title=Associations between childhood trauma, bullying and psychotic symptoms among a school-based adolescent sample |journal=Br J Psychiatry |volume=193 |issue=5 |pages=378–82 |year=2008 |month=November |pmid=18978317 |doi=10.1192/bjp.bp.108.049536 |url=}}</ref><ref>["Are they really out to get your patient?" http://www.innovations-training.com/0804CP_Article4.pdf] ''Current Psychiatry'' Volume 8 Number 4</ref> Preliminary research suggests that child abuse may interact with mutations in a stress-related gene to increase the risk of PTSD in adults.<ref>{{cite journal |author=Binder EB, Bradley RG, Liu W, ''et al.'' |title=Association of FKBP5 polymorphisms and childhood abuse with risk of posttraumatic stress disorder symptoms in adults |journal=JAMA |volume=299 |issue=11 |pages=1291–305 |year=2008 |month=March |pmid=18349090 |pmc=2441757 |doi=10.1001/jama.299.11.1291 |url=}}</ref>{{MEDRS|date=August 2010}}<ref>{{MEDRS|date=August 2010}}{{cite news|url=http://www.medpagetoday.com/Genetics/GeneticTesting/dh/8824  |title=Genes May Affect Lifelong Impact of Child Abuse |author=Peggy Peck, Executive Editor |publisher=MedPage Today |date=2008-03-09}}</ref>{{MEDRS|date=August 2010}}<ref>{{MEDRS|date=August 2010}}{{cite news|url=http://sciencenow.sciencemag.org/cgi/content/full/2008/318/2?etoc  |title=Seeds of PTSD Planted in Childhood  |author=Constance Holden|publisher=ScienceNOW Daily News |date=2008-03-18}}</ref>

Multiple studies show that parental PTSD and other posttraumatic disturbances in parental psychological functioning can, despite a traumatized parent's best efforts, interfere with their response to their child as well as their child's response to trauma.{{MEDRS|date=August 2010}}<ref>{{MEDRS|date=August 2010}}{{cite journal |author=[[Daniel Schechter|Schechter DS]], [[Susan Coates|Coates SW]], Kaminer T, ''et al.'' |title=Distorted maternal mental representations and atypical behavior in a clinical sample of violence-exposed mothers and their toddlers |journal=J Trauma Dissociation |volume=9 |issue=2 |pages=123–47 |year=2008 |pmid=18985165 |pmc=2577290 |doi=10.1080/15299730802045666}}</ref>{{MEDRS|date=August 2010}}<ref>{{MEDRS|date=August 2010}}{{cite journal |doi=10.1080/14616730701453762 |author=[[Daniel Schechter|Schechter DS]], Zygmunt A, Coates SW, ''et al.'' |title=Caregiver traumatization adversely impacts young children's mental representations on the MacArthur Story Stem Battery |journal=Attach Hum Dev |volume=9 |issue=3 |pages=187–205 |year=2007 |month=September |pmid=18007959 |pmc=2078523}}</ref> Parents with violence-related PTSD may, for example, inadvertently expose their children to developmentally inappropriate violent media due to their need to manage their own emotional dysregulation.{{MEDRS|date=August 2010}}<ref>{{MEDRS|date=August 2010}} {{cite journal |author=Schechter DS, Gross A, Willheim E, ''et al.'' |title=Is maternal PTSD associated with greater exposure of very young children to violent media? |journal=J Trauma Stress |volume=22 |issue=6 |pages=658–62 |year=2009 |month=December |pmid=19924819 |pmc=2798921 |doi=10.1002/jts.20472}}</ref> Clinical findings indicate that a failure to provide adequate treatment to children after they suffer a traumatic experience, depending on their vulnerability and the severity of the trauma, will ultimately lead to PTSD symptoms in adulthood.<ref>Clarke, C. et. al. 2007. Childhood and Adulthood Psychological Ill Health as Predictors of Midlife and Anxiety disorders. Archives of General Psychiatry. 64. pp668-678</ref>

===Neuroendocrinology===
PTSD symptoms may result when a traumatic event causes an overactive 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="secret">[http://www.pbs.org/wnet/brain/outreach/episode4.html PBS Series "The Secret Life of the Brain Episode 4, 2001]</ref>{{Full}}{{Verify credibility|date=April 2010}}

PTSD displays [[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 |author=Yehuda R, Halligan SL, Golier JA, Grossman R, Bierer LM |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 |year=2004 |pmid=14644068 |doi=10.1016/S0306-4530(03)00052-0}}</ref><ref>{{cite journal |author=Yehuda R, Halligan SL, Grossman R, Golier JA, Wong C |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=Biol Psychiatry |volume=52 |issue=5 |pages=393–403 |year=2002 |pmid=12242055 |doi=10.1016/S0006-3223(02)01357-4}}</ref>

In addition, most people with PTSD also 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>{{cite journal |author=Mason JW, Giller EL, Kosten TR, Harkness L |title=Elevation of urinary norepinephrine/cortisol ratio in posttraumatic stress disorder |journal=J Nerv Ment Dis |volume=176 |issue=8 |pages=498–502 |year=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>{{MEDRS|date=August 2010}}{{cite journal |doi=10.1016/0022-3999(91)90068-Y |author=Bohnen N, Nicolson N, Sulon J, Jolles J |title=Coping style, trait anxiety and cortisol reactivity during mental stress |journal=J Psychosom Res |volume=35 |issue=2-3 |pages=141–7 |year=1991 |pmid=2046048}}</ref>

Brain [[catecholamine]] levels are low,<ref>{{cite journal |author=Geracioti TD Jr, Baker DG, Ekhator NN, West SA, Hill KK, Bruce AB, Schmidt D, Rounds-Kugler B, Yehuda R, Keck PE Jr, Kasckow JW |title=CSF norepinephrine concentrations in posttraumatic stress disorder |journal=Am J Psychiatry |volume=158 |issue=8 |pages=1227–1230 |year=2001 |pmid=11481155 |doi=10.1176/appi.ajp.158.8.1227}}</ref> and [[corticotropin-releasing factor]] (CRF) concentrations are high.<ref>{{MEDRS|date=August 2010}}{{cite journal |doi=10.1016/S0006-3223(03)00571-7 |author=Sautter FJ, Bissette G, Wiley J, ''et al.'' |title=Corticotropin-releasing factor in posttraumatic stress disorder (PTSD) with secondary psychotic symptoms, nonpsychotic PTSD, and healthy control subjects |journal=Biol. Psychiatry |volume=54 |issue=12 |pages=1382–8 |year=2003 |month=December |pmid=14675802}}</ref><ref>{{MEDRS|date=August 2010}}{{cite journal |author=de Kloet CS, Vermetten E, Geuze E, ''et al.'' |title=Elevated plasma corticotrophin-releasing hormone levels in veterans with posttraumatic stress disorder |journal=Prog. Brain Res. |volume=167 |issue= |pages=287–91 |year=2008 |pmid=18037027 |doi=10.1016/S0079-6123(07)67025-3}}{{MEDRS|date=August 2010}}</ref> Together, these findings suggest abnormality in the [[hypothalamic-pituitary-adrenal axis|hypothalamic-pituitary-adrenal (HPA) axis]].

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 |author=Yehuda R |title=Biology of posttraumatic stress disorder |series=62 |journal=J Clin Psychiatry |volume=Suppl 17 |issue= |pages=41–6 |year=2001 |pmid=11495096}}</ref> Some researchers have associated the response to stress in PTSD with long-term exposure to high levels of [[norepinephrine]] and low levels of cortisol, a pattern associated with improved [[learning]] in animals.{{Citation needed|date=June 2008}}

Translating this reaction to human conditions gives a pathophysiological explanation for PTSD by a maladaptive learning pathway to fear response through a hypersensitive, hyperreactive and hyperresponsive HPA axis.<ref>{{cite journal |author=Yehuda R |title=Clinical relevance of biologic findings in PTSD |journal=Psychiatr Q |volume=73 |issue=2 |pages=123–33 |year=2002 |pmid=12025720| doi = 10.1023/A:1015055711424}}</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 |author=Aardal-Eriksson E, Eriksson TE, Thorell LH |title=Salivary cortisol, posttraumatic stress symptoms, and general health in the acute phase and during 9-month follow-up |journal=Biol. Psychiatry |volume=50 |issue=12 |pages=986–93 |year=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.

However, there is considerable controversy within the medical community regarding the neurobiology of PTSD. A review of existing studies on this subject showed no clear relationship between cortisol levels and PTSD. Only a slight majority have found a decrease in cortisol levels while others have found no effect or even an increase.<ref>{{cite journal | author =Lindley SE, Carlson EB, Benoit M |title=Basal and dexamethasone suppressed salivary cortisol concentrations in a community sample of patients with posttraumatic stress disorder |journal=Biol. Psychiatry |volume=55 |issue=9 |pages=940–5 |year=2004 |pmid=15110738 |doi=10.1016/j.biopsych.2003.12.021}}</ref>

===Neuroanatomy===
[[File:PTSD stress brain.gif|thumb|220px|Regions of the brain associated with stress and posttraumatic 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 }}</ref>]]
Three areas of the brain whose function may be altered in PTSD have been identified: the [[prefrontal cortex]], [[amygdala]] and [[hippocampus]]. Much of this research has utilised PTSD victims from the Vietnam War. For example, a prospective study using the Vietnam Head Injury Study showed that damage to the prefrontal cortex may actually be protective against later development of PTSD.<ref>{{MEDRS|date=August 2010}}
{{Cite web
  | last = Newton
  | first = Philip
  | authorlink = http://www.psychologytoday.com/blog/bloggers/phil-newton
  | title = From Mouse to Man; the Anatomy of Posttraumatic Stress Disorder
  | url = http://www.psychologytoday.com/blog/mouse-man/200901/the-anatomy-post-traumatic-stress-disorder
  | accessdate = 20 December 2009}}
</ref> In a study by Gurvits et al., combat veterans of the [[Vietnam War]] with PTSD showed a 20% reduction in the volume of their [[hippocampus]] compared with veterans who suffered no such symptoms.<ref>Carlson, Neil R. (2007). Physiology of Behavior  (9 ed.). Pearson Education, Inc.</ref> This finding could not be replicated in chronic PTSD patients traumatized at an air show plane crash in 1988 (Ramstein, Germany).<ref name="Jatzko">{{cite journal | doi = 10.1016/j.jad.2006.03.010 | author = Jatzko A, Rothenhöfer S, Schmitt A, Gaser C, Demiracka T, Weber-Fahr W, Wessa M, Magnotta V, Braus DF. ''et al.'' | year = 2006 | title = Hippocampal volume in chronic posttraumatic stress disorder (PTSD): MRI study using two different evaluation methods | url = | journal = Journal of Affective Disorders | volume = 94 | issue = 1-3| pages = 121–126 | pmid = 16701903 }}</ref><ref>http://dbm.neuro.uni-jena.de/pdf-files/Jatzko-JAD06.pdf</ref>

In human studies, the amygdala has been shown to be strongly involved in the formation of emotional memories, especially fear-related memories. [[Neuroimaging]] studies in humans have revealed both morphological and functional aspects of PTSD.{{Citation needed|date=May 2010}}

The amygdalocentric model of PTSD proposes that it is associated with hyperarousal of the amygdala and insufficient top-down control by the medial [[prefrontal cortex]] and the [[hippocampus]] particularly during extinction.<ref name="Milad">{{cite journal | author = Milad MR, Pitman RK, Ellis CB, Gold AL, Shin LM, Lasko NB, Zeidan MA, Handwerger K, Orr SP ''et al.'' | year = 2009 | title = Neurobiological basis of failure to recall extinction memory in posttraumatic stress disorder | url = | journal = Biol Psychiatry | volume = 66 | issue = 12| pages = 1075–82 | 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 (psychology)|extinction]] ability.<ref name="Milad"/><ref name="Stein">{{cite journal | author = Stein MB, Paulus MP | year = 2009 | title = Imbalance of approach and avoidance: the yin and yang of anxiety disorders | url = | journal = Biol Psychiatry | volume = 66 | issue = 12| pages = 1072–4 | doi = 10.1016/j.biopsych.2009.09.023 | pmc = 2825567 | pmid = 19944792 }}</ref> Further animal and clinical research into the amygdala and [[fear conditioning]] may suggest additional treatments for the condition.

===Genetics===
There is evidence that susceptibility to PTSD is hereditary. 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 having PTSD compared to twins that were dizygotic (non-identical twins).<ref>{{cite journal |author=True WR, Rice J, Eisen SA, ''et al.'' |title=A twin study of genetic and environmental contributions to liability for posttraumatic stress symptoms |journal=Arch. Gen. Psychiatry |volume=50 |issue=4 |pages=257–64 |year=1993 |pmid=8466386 |doi=}}</ref>

Recently, it has been found that several [[single-nucleotide polymorphism]]s (SNPs) in [[FKBP5|FK506 binding protein 5]] (FKBP5) interact with childhood trauma to predict severity of adult PTSD.<ref>http://www.psychologytoday.com/blog/mouse-man/200811/gene-anxiety-depression-and-posttraumatic-stress-disorder-fkbp5</ref><ref>{{cite journal |author=Binder EB, Bradley RG, Liu W, ''et al.'' |title=Association of FKBP5 polymorphisms and childhood abuse with risk of posttraumatic stress disorder symptoms in adults |journal=JAMA |volume=299 |issue=11 |pages=1291–305 |year=2008 |pmid=18349090 |doi=10.1001/jama.299.11.1291 |pmc=2441757}}</ref> These findings suggest that individuals with these SNPs who are abused as children are more susceptible to PTSD as adults.

This is particularly interesting given that FKBP5 SNPs have previously been associated with peritraumatic dissociation (that is, [[dissociation (psychology)|dissociation]] at the time of the trauma),<ref>{{cite journal |author=Koenen KC, Saxe G, Purcell S, ''et al.'' |title=Polymorphisms in FKBP5 are associated with peritraumatic dissociation in medically injured children |journal=Mol Psychiatry |volume=10 |issue=12 |pages=1058–9 |year=2005 |pmid=16088328 |doi=10.1038/sj.mp.4001727}}</ref> which has itself been shown to be predictive of PTSD.<ref>{{cite journal |author=Birmes P, Brunet A, Carreras D, ''et al.'' |title=The predictive power of peritraumatic dissociation and acute stress symptoms for posttraumatic stress symptoms: a three-month prospective study |journal=Am J Psychiatry |volume=160 |issue=7 |pages=1337–9 |year=2003 |pmid=12832251 |doi=10.1176/appi.ajp.160.7.1337}}</ref><ref name="jtraumastress">{{cite journal |author=Schnurr PP, Lunney CA, Sengupta A |title=Risk factors for the development versus maintenance of posttraumatic stress disorder |journal=J Trauma Stress |volume=17 |issue=2 |pages=85–95 |year=2004 |pmid=15141781 |doi=10.1023/B:JOTS.0000022614.21794.f4}}</ref> Furthermore, FKBP5 may be less [[gene expression|expressed]] in those with current PTSD.<ref>{{cite journal |author=Yehuda R, Cai G, Golier JA, Sarapas C, Galea S, Ising M, Rein T, Schmeidler J, Müller-Myhsok B, Holsboer F, Buxbaum JD |title=Gene expression patterns associated with posttraumatic stress disorder following exposure to the World Trade Center attacks. |journal=Biol Psychiatry |volume= 66|issue= 7|pages=708–11|date=24 April 2009 [Epub ahead of print] |pmid=19393990 |doi=10.1016/j.biopsych.2009.02.034}}</ref> Another recent study found a single SNP in a putative [[estrogen response element]] on [[ADCYAP1R1]] (encodes pituitary adenylate cyclase-activating polypeptide type I receptor or PAC1) to predict PTSD diagnosis and symptoms in females. <ref>{{cite journal|title =Post-traumatic stress disdorder is associated with PACAP and the PAC1 receptor|author=Ressler KJ, Merer KB, Bradley B, ''et al.''|date=February 24, 2011|journal=Nature|pmid =21350482|volume=470|issue =7335|pmc =3046811|pages=492–497|doi=10.1038/nature09856|laysummary=http://www.sciguru.com/newsitem/6364/Fear-Factor-Researchers-on-Trail-of-Marker-to-Predict-Risk-of-PTSD/|laysource=SciGuru|laydate=March 02, 2011}}</ref> Incidentally, this SNP is also associated with fear discrimination. The study suggests that perturbations in the [[PACAP]]-PAC1 pathway are involved in abnormal stress responses underlying PTSD.

===Risk and protective factors for PTSD development===
{{See also|Psychological resilience}}

Although most people (50-90%) encounter trauma over a lifetime,<ref name=Kessler95>{{cite journal |author=Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB |title=Posttraumatic stress disorder in the National Comorbidity Survey |journal=Arch Gen Psychiatry |volume=52 |issue=12 |pages=1048–60 |year=1995 |month=December |pmid=7492257 }}</ref><ref>{{cite journal |author=Breslau N, Kessler RC, Chilcoat HD, Schultz LR, Davis GC, Andreski P |title=Trauma and posttraumatic stress disorder in the community: the 1996 Detroit Area Survey of Trauma |journal=Arch Gen Psychiatry |volume=55 |issue=7 |pages=626–32 |year=1998 |month=July |pmid=9672053 |url=http://archpsyc.ama-assn.org/cgi/pmidlookup?view=long&pmid=9672053 |doi=10.1001/archpsyc.55.7.626}}</ref> only about 8% develop full PTSD.<ref name=Kessler95/> Vulnerability to PTSD presumably stems from an interaction of biological diathesis, early childhood developmental experiences, and trauma severity.{{Citation needed|date=November 2009}}

Predictor models have consistently found that childhood trauma, chronic adversity, and familial stressors increase risk for PTSD as well as risk for biological markers of risk for PTSD after a traumatic event in adulthood.<ref>{{cite journal |author=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=Psychol Med |volume=37 |issue=2 |pages=181–92 |year=2007 |month=February |pmid=17052377 |pmc=2254221 |doi=10.1017/S0033291706009019 }}</ref><ref>{{cite journal |author=Lapp KG, Bosworth HB, Strauss JL, ''et al.'' |title=Lifetime sexual and physical victimization among male veterans with combat-related post-traumatic stress disorder |journal=Mil Med |volume=170 |issue=9 |pages=787–90 |year=2005 |month=September |pmid=16261985 }}</ref><ref>{{cite journal |author=Otte C, Neylan TC, Pole N, ''et al.'' |title=Association between childhood trauma and catecholamine response to psychological stress in police academy recruits |journal=Biol. Psychiatry |volume=57 |issue=1 |pages=27–32 |year=2005 |month=January |pmid=15607297 |doi=10.1016/j.biopsych.2004.10.009 }}</ref><ref>{{cite journal |author=Resnick HS, Yehuda R, Pitman RK, Foy DW |title=Effect of previous trauma on acute plasma cortisol level following rape |journal=Am J Psychiatry |volume=152 |issue=11 |pages=1675–7 |year=1995 |month=November |pmid=7485635 |url=http://ajp.psychiatryonline.org/cgi/pmidlookup?view=long&pmid=7485635}}</ref> This effect of childhood trauma, which is not well understood, may be a marker for both traumatic experiences and attachment problems.<ref>{{cite journal |author=Laor N, Wolmer L, Mayes LC, ''et al.'' |title=Israeli preschoolers under Scud missile attacks. A developmental perspective on risk-modifying factors |journal=Arch Gen Psychiatry |volume=53 |issue=5 |pages=416–23 |year=1996 |month=May |pmid=8624185 }}</ref><ref>{{cite journal |author=Laor N, Wolmer L, Mayes LC, Gershon A, Weizman R, Cohen DJ |title=Israeli preschool children under Scuds: a 30-month follow-up |journal=J Am Acad Child Adolesc Psychiatry |volume=36 |issue=3 |pages=349–56 |year=1997 |month=March |pmid=9055515 |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0890-8567&volume=36&issue=3&spage=349 |doi=10.1097/00004583-199703000-00013}}</ref> Proximity to, duration of, and severity of the trauma also make an impact; and interpersonal traumas cause more problems than impersonal ones.<ref>Janoff-Bulman R: Shattered Assumptions: Toward a New Psychology of Trauma. New York: Free Press, 1992.</ref>

====Military experience====
Schnurr, Lunney, and Sengupta<ref name="jtraumastress"/> identified risk factors for the development of PTSD in [[Vietnam veteran]]s. Among those are:
* [[Hispanics|Hispanic ethnicity]]<!-- PLEASE DO NOT DELETE THIS, as it  correctly summarizes the research findings! -->, coming from an unstable family, being punished severely during childhood, childhood asocial behavior and depression as pre-military factors
* War-zone exposure, [[dissociation (psychology)|peritraumatic dissociation]], depression as military factors
* Recent stressful life events, post-[[Vietnam War|Vietnam]] trauma and depression as post-military factors
They also identified certain protective factors, such as:
*[[Japanese-American]] ethnicity<!-- PLEASE DO NOT DELETE THIS, as it correctly summarizes the research findings! -->, high school degree or college education, older age at entry to war, higher socioeconomic status and a more positive paternal relationship as pre-military protective factors
*Social support at homecoming and current social support as post-military factors.<ref name="autogenerated2">Jennifer L. Price, Ph.D.: Findings from the National Vietnam Veterans' Readjustment Study - Factsheet. National Center for PTSD. United States Department of Veterans Affairs [http://ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_nvvrs.html?printable-template=factsheet].</ref> Other research also indicates the protective effects of social support in averting  PTSD or facilitating recovery if it develops.<ref name=Brewin>{{cite journal |author=Brewin CR, Andrews B, Valentine JD |title=Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults |journal=J Consult Clin Psychol |volume=68 |issue=5 |pages=748–66 |year=2000 |month=October |pmid=11068961 |url=http://content.apa.org/journals/ccp/68/5/748 |doi=10.1037/0022-006X.68.5.748}}</ref><ref name=Ozer/>

There may also be an attitudinal component; for example, a soldier who believes that they will not sustain injuries may be more likely to develop symptoms of PTSD than one who anticipates the possibility, should either be wounded. Likewise, the later incidence of suicide among those injured in home fires above those injured in fires in the workplace suggests this possibility.{{Citation needed|date=December 2010}}

====Foster care====
In the Casey Family Northwest Alumni Study, conducted in conjunction with researchers from the [[Harvard Medical School]] in  Oregon and Washington state, the rate of PTSD in adults who were in [[foster care]] for one year between the ages of 14-18 was found to be higher than that of combat veterans. Up to 25 percent of those in the study meet the diagnostic criteria for PTSD as compared to 12-13 percent of Iraq war veterans and 15 percent of Vietnam War veterans, and a rate of 4 percent in the general population. The recovery rate for foster home alumni was 28.2% as opposed to 47% in the general population.<ref>{{Cite press release | title = Former Foster Children in Oregon and Washington Suffer Posttraumatic Stress Disorder at Twice the Rate of U.S War Veterans | publisher = Casey Family Programs, Harvard Medical School | date = 2005.04.05 | url = http://www.jimcaseyyouth.org/docs/nwa_release.pdf | accessdate = 2010-03-23}}</ref><ref>{{Cite web | last = Casey Family Programs | title = Assessing the Effects of Foster Care: Mental Health Outcomes from the Casey National Alumni Study | year = 2005 | url = http://www.casey.org/Resources/Publications/pdf/CaseyNationalAlumniStudy_MentalHealth.pdf | postscript = <!--None-->}}</ref>

In one study (Dubner and Motta, 1999),<ref>{{cite journal | doi = 10.1037/0022-006X.67.3.367 | pmid = 10369057 | volume=67 | issue=3 | journal = Journal of consulting and clinical psychology | year=1999 | title = Sexually and physically abused foster care children and posttraumatic stress disorder. | month=June | pages=367–73 | author=Dubner AE, Motta RW}}</ref> 60% of children in foster care who had experienced sexual abuse had PTSD, and 42% of those who had been physically abused fulfilled the PTSD criteria. PTSD was also found in 18% of the children who were not abused. These children may have developed PTSD due to witnessing violence in the home, or as a result of real or perceived parental abandonment.

==Diagnosis==
===Criteria===
The diagnostic criteria for PTSD, stipulated in the ''[[Diagnostic and Statistical Manual of Mental Disorders]] IV (Text Revision)'' (DSM-IV-TR), may be summarized as:<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 |pages= |isbn=0890420610 |oclc= |doi=}}; [http://www.behavenet.com/capsules/disorders/ptsd.htm on-line].</ref><ref>{{cite web |url=http://www.nimh.nih.gov/health/publications/post-traumatic-stress-disorder-ptsd/what-are-the-symptoms-of-ptsd.shtml |title=NIMH · What are the symptoms of PTSD? |work=[[National Institute of Mental Health]] |accessdate=}}</ref>

====A: Exposure to a traumatic event====
This must have involved ''both'' (a) loss of "physical integrity", or risk of serious injury or death, to self or others, and (b) a response to the event that involved intense fear, horror or helplessness (or in children, the response must involve disorganized or agitated behavior). (The [[DSM-IV]]-TR criterion differs substantially from the previous DSM-III-R stressor criterion, which specified the traumatic event should be of a type that would cause "significant symptoms of distress in almost anyone," and that the event was "outside the range of usual human experience."<ref>{{Cite book | last = American Psychiatric Association  | title = Diagnostic and Statistical Manual of Mental Disorders: DSM-III-R  | publisher =  | year = 1987  | isbn = 0890420181}}</ref>)

====B: Persistent re-experiencing====
One or more of these must be present in the victim: [[flashback (psychological phenomenon)|flashback]] memories, recurring distressing dreams, subjective re-experiencing of the traumatic event(s), or intense negative psychological or physiological response to any objective or subjective reminder of the traumatic event(s).

====C: Persistent avoidance and emotional numbing====
This involves a sufficient level of:
* avoidance of stimuli associated with the trauma, such as certain thoughts or feelings, or talking about the event(s);
* avoidance of behaviors, places, or people that might lead to distressing memories;
* inability to recall major parts of the trauma(s), or decreased involvement in significant life activities;
* decreased capacity (down to complete inability) to feel certain feelings;
* an expectation that one's future will be somehow constrained in ways not normal to other people.

====D: Persistent symptoms of increased arousal not present before====
These are all physiological response issues, such as difficulty falling or staying asleep, or problems with anger, concentration, or [[hypervigilance]].

====E: Duration of symptoms for more than 1 month====
If all other criteria are present, but 30 days have not elapsed, the individual is diagnosed with [[Acute stress disorder]].

====F: Significant impairment====
The symptoms reported must lead to "clinically significant distress or impairment" of major domains of life activity, such as social relations, occupational activities, or other "important areas of functioning".<ref>{{Cite book| last =American Psychiatric Association| title =Diagnostic and statistical manual of mental disorders, quick reference| publisher =American Psychiatric Association| year =1994| location =Washington, D.C.| page =211| isbn =0-89042-063-7 }}
</ref>

====Assessment====
Since the introduction of [[DSM-IV]], the number of possible events which might be used to diagnose PTSD has increased; one study suggests that the increase is around 50%.<ref name=Breslau>{{cite journal |author=Breslau N, Kessler RC |title=The stressor criterion in DSM-IV posttraumatic stress disorder: an empirical investigation |journal=Biol. Psychiatry |volume=50 |issue=9 |pages=699–704 |year=2001 |pmid=11704077| doi = 10.1016/S0006-3223(01)01167-2}}</ref> Various scales exist to measure the severity and frequency of PTSD symptoms.<ref>{{cite journal |author=Blake DD, Weathers FW, Nagy LM, ''et al.'' |title=The development of a Clinician-Administered PTSD Scale |journal=J Trauma Stress |volume=8 |issue=1 |pages=75–90 |year=1995 |month=January |pmid=7712061 |doi=10.1002/jts.2490080106 }}</ref><ref>Foa E: The Post Traumatic Diagnostic Scale Manual. Minneapolis, NCS, 1995.</ref>

===Research-based alternative symptom group conceptualizations===
Emerging [[factor analysis|factor analytic]] research<ref name=Pietrzak>{{cite journal |author=Pietrzak RH, Southwick SM |title=The importance of four-factor emotional numbing and dysphoria models in PTSD. |journal=Am J Psychiatry |volume=166 |issue= 6|pages=726–727 |date=June |year=2009 |pmid= 19487403|doi=10.1176/appi.ajp.2009.09010032}}</ref> suggests that PTSD symptoms group empirically into four clusters, not the three currently described in the ''[[Diagnostic and Statistical Manual of Mental Disorders]]''{{Update after|2013|05|30|reason=DSM-5 will be out by then}}. One model supported by this research divides the traditional avoidance symptoms into a cluster of numbing symptoms (such as loss of interest and feeling emotionally numb) and a cluster of behavioral avoidance symptoms (such as avoiding reminders of the trauma).<ref>{{cite journal |author=King DW, Leskin GA, King LA, Weathers FW |title=Confirmatory factor analysis of the clinician-administered PTSD Scale: Evidence for the dimensionality of posttraumatic stress disorder. |journal=Psychol Assess |volume=10 |issue=2 |pages=90–96 |date=June |year=1998 |pmid= |doi=10.1037/1040-3590.10.2.90}}</ref> An alternative model adds a fourth cluster of dysphoric symptoms. These include symptoms of emotional numbing, as well as anger, sleep disturbance, and difficulty concentrating (traditionally grouped under the hyperarousal cluster).<ref>{{cite journal |author=Ask E, Mark S |title=The structure of PTSD symptoms: A test of alternative models using confirmatory factor analysis. |journal=Br J Clin Psychol |volume=46 |issue=3 |pages=299–313 |date=Sep |year=2007 |pmid= 17535523|doi=10.1348/014466506X171540}}</ref><ref>{{cite journal |author=Palmieri PA, Weathers FW, Difede J, King DW |title=Confirmatory factor analysis of the PTSD Checklist and the Clinician-Administered PTSD Scale in disaster workers exposed to the World Trade Center Ground Zero. |journal=J Abnorm Psychol |volume=116 |issue=2 |pages=329–341 |date=May |year=2007 |pmid= 17516765|doi=10.1037/0021-843X.116.2.329}}</ref>

===DSM-5 proposed diagnostic criteria changes===

In preparation for the May 2013<ref>
{{Cite web
  | title = Timeline
  | url = http://www.dsm5.org/about/Pages/Timeline.aspx
  | accessdate =2010-04-22 }}</ref>
release of the [[DSM-5]],<ref>{{cite news
| author = American Psychiatric Association
| title = APA Modifies ''DSM'' Naming Convention to Reflect Publication Changes
| date = 2010-03-09
| url = http://www.dsm5.org/Newsroom/Documents/DSM-Name-Change.pdf
| accessdate = 2010-06-11 }}</ref> the fifth version of the [[American Psychiatric Association]]'s diagnostic manual, draft diagnostic criteria was released for public comment, followed by a two-year period of field testing.<ref>{{Cite  web | last = Gever | first = J| title = DSM-V Draft Promises Big Changes in Some Psychiatric Diagnoses |  date = 10 February  2010 |  url = http://www.medpagetoday.com/Psychiatry/GeneralPsychiatry/18399  | accessdate = 10 February 2010}}</ref> Proposed changes to the criteria include:<ref>{{cite web | url = http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=165 | title = 309.81 Posttraumatic Stress Disorder: Proposed Revision | accessdate = 2010-03-20 | year = 2010 | publisher = [[American Psychiatric Association]] }}</ref>{{Update after|2013|05|30|reason=changes will then be adopted, not "proposed"}}
* Criterion A (prior exposure to traumatic events) is more specifically stated, and evaluation of an individual's emotional response at the time (current criterion A2) is dropped.
* Several items in Criterion B (intrusion symptoms) are rewritten to add or augment certain distinctions now considered important.
* Special consideration is given to developmentally appropriate criteria for use with children and adolescents. This is especially evident in the restated Criterion B - intrusion symptoms. Development of age-specific criteria for diagnosis of PTSD is ongoing at this time.
* Criterion C (avoidance and numbing) has been split into "C" and "D":
** Criterion C (new version) now focuses solely on avoidance of behaviors or physical or temporal reminders of the traumatic experience(s). What were formerly two symptoms are now three, due to slight changes in descriptions.
** New Criterion D focuses on negative alterations in cognition and mood  associated with the traumatic event(s), and contains two new symptoms, one expanded symptom, and four largely unchanged symptoms specified in the previous criteria.
* Criterion E (formerly "D"), which focuses on increased arousal and reactivity, contains one modestly revised, one entirely new, and four unchanged symptoms.
* Criterion F (formerly "E") still requires duration of symptoms to have been at least one month.
* Criterion G (formerly "F") stipulates symptom impact ("disturbance") in the same way as before.
* The "acute" vs "delayed" distinction is dropped; the "delayed" specifier is considered appropriate if clinical symptom onset is no sooner than 6 months after the traumatic event(s).

"Developmental trauma disorder", a proposed new diagnosis, was still under discussion at the time of the draft publication.<ref>{{Cite web | title = Conditions Proposed by Outside Sources | work =  | url = http://www.dsm5.org/ProposedRevisions/Pages/ConditionsProposedbyOutsideSources.aspx | accessdate = 11 February 2010}}</ref>{{update after |2013 |05 |30 |reason=diagnosis will have been adopted or dropped by then|date=November 2010}}

==Prevention==
[[File:Vietnam War Memorial Washington DC Maya Lin-editA.jpg|thumb|200px|[[Vietnam Veterans Memorial]], [[Washington, D.C.]]]]

In recent history, catastrophes (by human means or not) such as the [[2004 Indian Ocean earthquake|2004 Indian Ocean tsunami]] may have caused PTSD in many survivors and rescue workers. Today relief workers from organizations such as the [[International Red Cross and Red Crescent Movement|Red Cross]] and the [[Salvation Army]] provide counseling after major disasters as part of their standard procedures to curb severe cases of posttraumatic stress disorder.{{Citation needed|date=November 2009}}

===United States===
In part through the efforts of anti Vietnam War activists and the anti war group [[Vietnam Veterans Against the War]] and [[Chaim F. Shatan]], who worked with them and coined the term ''post-Vietnam Syndrome'', the condition was added to the DSM-III as posttraumatic stress disorder.<ref name=IHHRT>{{cite book |author=Shalev, Arieh Y.; Yehuda, Rachel; Alexander C. McFarlane |title=International handbook of human response to trauma |publisher=Kluwer Academic/Plenum Press |location=New York |year=2000 |pages= |isbn=0-306-46095-5 |oclc= |doi=}}; [http://www.istss.org/what/history2.cfm on-line].</ref>

A review of the provision of compensation to veterans for PTSD by the [[United States Department of Veterans Affairs]] began in 2005 after the VA had noted a 30% increase in PTSD claims in recent years.  This led to a backlash from veterans'-rights groups, and to some highly publicized suicides by veterans who feared losing their benefits,{{Citation needed|date=July 2009}} which in some cases constituted their only income. In response, on November 10, 2005, the Secretary of Veterans Affairs announced that "the Department of Veterans Affairs (VA) will not review the files of 72,000 veterans currently receiving disability compensation for posttraumatic stress disorder..."<ref>{{cite news |author=Secretary Nicholson |title=No Across-the-Board Review of PTSD Cases |publisher=The Department of Veterans Affairs |date= 2005-11-10 |accessdate=2010-01-31}}; [http://www1.va.gov/opa/pressrel/pressrelease.cfm?id=1042 United States Department of Veteran Affairs].</ref>

The diagnosis of PTSD has been a subject of some controversy due to uncertainties in objectively diagnosing PTSD in those who may have been exposed to [[psychological trauma|trauma]], and due to this diagnosis' association with some [[incidence (epidemiology)|incidence]] of compensation-seeking behavior.<ref>{{cite news | url = http://www.washingtonpost.com/wp-dyn/content/article/2005/12/26/AR2005122600792.html | publisher = Washington Post | last = Vedantam | first = Shankar | title = A Political Debate On Stress Disorder: As Claims Rise, VA Takes Stock | date = 2005-12-27 | accessdate = 2008-03-12}}</ref>

Many veterans of the wars in [[Iraq War|Iraq]] and [[War in Afghanistan (2001–present)|Afghanistan]] returning home 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 | accessdate = 2008-04-03 | work=Fox News}}</ref> [[Walter Reed Army Institute of Research]] (WRAIR) developed the [[Battlemind]] program to assist service members avoid or ameliorate PTSD and related problems.

===Other countries===
In the UK, there has been some controversy that National Health Service is dumping veterans on service charities like [[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 |publisher=Times Online |date=February 28, 2009  |accessdate=2009-08-29 | location=London | first=Laura | last=Dixon}}</ref><ref>{{cite web|url=http://www.dailymail.co.uk/news/article-1158350/Troops-face-mental-trauma-scale-Vietnam.html |title=British troops in Afghanistan face mental health timebomb 'on the scale of Vietnam' &#124; Mail Online |publisher=Dailymail.co.uk |date= |accessdate=2009-08-29}}</ref><ref>{{cite news|url=http://news.bbc.co.uk/1/hi/uk/7916852.stm |title=UK &#124; Full interview: L/Cpl Johnson Beharry |publisher=BBC News |date=2009-02-28 |accessdate=2009-08-29}}</ref>

[[Veterans Affairs Canada]] offers a new program that includes rehabilitation, financial benefits, job placement, health benefits program, disability awards and family support.<ref>{{cite web|url=http://www.vac-acc.gc.ca/clients/sub.cfm?source=Forces/nvc&CFID=9295860&CFTOKEN=39698927 |title=The New Veterans Charter for CF Veterans and their Families |publisher=Vac-Acc.Gc.Ca |date=2006-07-12 |accessdate=2009-08-29}}</ref>

==Management==
===Prevention and early intervention strategies===

Modest benefits have been from early access to cognitive behavioral therapy, as well as from some medications such as [[propranolol]].<ref>{{cite journal |author=Feldner MT, Monson CM, Friedman MJ |title=A critical analysis of approaches to targeted PTSD prevention: current status and theoretically derived future directions |journal=Behav Modif |volume=31 |issue=1 |pages=80–116 |year=2007 |pmid=17179532 |doi=10.1177/0145445506295057}}</ref>  [[Critical incident stress management]] has also been suggested as a means of preventing PTSD but subsequent studies suggested [[iatrogenesis|iatrogenic]] effects<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 | last = Carlier | first = IVE | coauthors = Lamberts RD; van Uchelen AJ; Gersons BPR | year = 1998 | url = http://doi.apa.org/?uid=1998-10258-001 | doi = 10.1002/(SICI)1099-1700(199807)14:3<143::AID-SMI770>3.0.CO;2-S }}</ref><ref>{{cite journal |author=Mayou RA, Ehlers A, Hobbs M |title=Psychological debriefing for road traffic accident victims. Three-year follow-up of a randomised controlled trial |journal=Br J Psychiatry |volume=176 |issue= 6|pages=589–93 |year=2000 |pmid=10974967| doi = 10.1192/bjp.176.6.589}}</ref> and later studies both confirmed harm and failed to demonstrate any benefits.{{Citation needed|date=June 2009}}

===Psychotherapeutic interventions===

Many forms of psychotherapy have been advocated for trauma-related problems such as PTSD. Basic counseling practices common to many treatment responses for PTSD include education about the condition and provision of safety and support.<ref>Foa 1997.</ref>{{Full}}

The psychotherapy programs with the strongest demonstrated efficacy include cognitive behavioral programs, variants of [[exposure therapy]], stress inoculation training (SIT), variants of cognitive therapy (CT), [[eye Movement Desensitization and Reprocessing|eye movement desensitization and reprocessing]] (EMDR),{{Failed verification|date=August 2010}}{{Request quotation|date=August 2010}} and many combinations of these procedures.<ref>Cahill, S. P., & Foa, E. B. (2004). A glass half empty or half full? Where we are and directions for future research in the treatment of PTSD. In S. Taylor (ed.), Advances in the Treatment of Posttraumatic Stress Disorder: Cognitive-behavioral perspectives (pp. 267-313) New York: Springer.</ref><ref>{{cite journal |author=Brom D, Kleber RJ, Defares PB |title=Brief psychotherapy for posttraumatic stress disorders |journal=J Consult Clin Psychol |volume=57 |issue=5 |pages=607–12 |year=1989 |month=October |pmid=2571625 |url=http://content.apa.org/journals/ccp/57/5/607 |doi=10.1037/0022-006X.57.5.607}}</ref> A 2010 review disagrees that these treatments have proven efficacy, and points out methodological flaws in the studies and previous meta-analyses.<ref name="pmid20051310">{{cite journal |author=Ehlers A, Bisson J, Clark DM, ''et al.'' |title=Do all psychological treatments really work the same in posttraumatic stress disorder? |journal=Clin Psychol Rev |volume=30 |issue=2 |pages=269–76 |year=2010 |month=March |pmid=20051310 |pmc=2852651 |doi=10.1016/j.cpr.2009.12.001 |url=}}</ref>

EMDR or trauma-focused [[cognitive behavioral therapy]] (TFCBT) was recommended as first-line treatments for trauma victims in a 2007 review; however, "the evidence base [for EMDR] was not as strong as that for TFCBT ... Furthermore, there was limited evidence that TFCBT and EMDR were superior to supportive/non-directive treatments, hence it is highly unlikely that their effectiveness is due to non-specific factors such as attention."<ref name="pmid17267924">{{cite journal |author=Bisson JI, Ehlers A, Matthews R, Pilling S, Richards D, Turner S |title=Psychological treatments for chronic post-traumatic stress disorder. Systematic review and meta-analysis |journal=The [[British Journal of Psychiatry]] : the journal of mental science |volume=190 |issue= 2|pages=97–104 |year=2007 |pmid=17267924 |doi=10.1192/bjp.bp.106.021402|url=http://bjp.rcpsych.org/cgi/content/full/190/2/97}}</ref> A [[meta-analysis|meta-analytic]] comparison of EMDR and [[cognitive behavioral therapy]] 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 |author=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=Psychol Med |volume=36 |issue=11 |pages=1515–22 |year=2006 |pmid=16740177 |doi=10.1017/S0033291706007963}}</ref>

====Behavioral and Cognitive Behavioral therapy====
[[Cognitive Behavioral Therapy]] (CBT) seeks to change the way a trauma victim feels and acts by changing the patterns of thinking and/or behavior responsible for negative emotions. CBT have 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>Hassija, C.M. &  Gray, M.J. (2007). Behavioral Interventions for Trauma and Posttraumatic Stress Disorder. ''International Journal of Behavioral Consultation and Therapy, 3(2),''166-175. [http://www.baojournal.com BAO]</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 cause PTSD-related stress.

Recent research on contextually based third-generation [[behavior therapy|behavior therapies]] suggests that they may produce results comparable to some of the better validated therapies.<ref>Mulick, P.S., Landes, S. & Kanter, J.W. (2005) Contextual Behavior Therapies in the Treatment of PTSD: A Review. ''International Journal of Behavioral Consultation and Therapy, 1(3),'' 223-228 [http://www.uwm.edu/~jkanter/pdf/publication/IJBCT-1-3.pdf]</ref> Many of these therapy methods have a significant element of exposure,<ref>Hassija, C.M. & Gray, M.J. (2007). Behavioral Interventions for Trauma and Posttraumatic Stress Disorder. ''International Journal of Behavioral Consultation and Therapy, 3(2),'' 166-175. [http://eric.ed.gov/ERICWebPortal/contentdelivery/servlet/ERICServlet?accno=EJ801196]</ref> and have demonstrated success in treating the primary problems of PTSD and co-occurring depressive symptoms.<ref>Mulick, P.S., and Naugle, A.E. (2009). Behavioral Activation in the Treatment of Comorbid Posttraumatic Stress Disorder and Major Depressive Disorder. ''International Journal of Behavioral Consultation and Therapy, 5(2),'' 330-339. [http://www.thefreelibrary.com/Behavioral+activation+in+the+treatment+of+comorbid+posttraumatic...-a0221920130]</ref>

Exposure therapy is a type of [[cognitive behavioral therapy]]<ref>{{Cite web | last =Grohol  | first =JM  | title =What is Exposure Therapy?| url =http://psychcentral.com/lib/2009/what-is-exposure-therapy/ | accessdate = 2010-07-14}}</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. Indeed, 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  | last =Joseph  | first =JS  | coauthors =Gray, M.J.  | 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 BAO  | accessdate =2010-05-10 }}</ref> Some organizations have endorsed the need for exposure.<ref>{{cite journal |author=Ursano RJ, Bell C, Eth S, ''et al.'' |title=Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder |journal=Am J Psychiatry |volume=161 |issue=11 Suppl |pages=3–31 |year=2004 |month=November |pmid=15617511 |doi= }}</ref><ref>Committee on Treatment of Posttraumatic Stress Disorder, Institute of Medicine: Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence. Washington, D.C.: National Academies Press, 2008 ISBN 0-309-10926-4.</ref> The US 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
  | accessdate = 2010-07-14}}</ref> and [[Cognitive Processing Therapy]]<ref>{{cite journal | doi = 10.1002/jts.20588 | author = Karlin B. E., Ruzek J. I. Chard, Eftekhari A., Monson C. M., Hembree E.  A., Resick P. A., Foa E. B. | year = 2010 | title = Dissemination of evidence-based psychological treatments for posttraumatic stress disorder in the Veterans Health Administration | url = | journal = Journal of Traumatic Stress | volume = 23 | issue = 6| pages = 663–673 | pmid = 21171126 }}</ref> in an effort to better treat US Veterans with PTSD.

====Eye movement desensitization and reprocessing====
[[Eye movement desensitization and reprocessing]] (EMDR) is specifically targeted as a treatment for PTSD.<ref name="emdr1">{{cite journal |author=Devilly GJ & Spence SH |title=The relative efficacy and treatment distress of EMDR and a cognitive-behavior trauma treatment protocol in the amelioration of posttraumatic stress disorder |journal=J Anxiety Disord |volume=13 |issue=1-2 |pages=131–57 |year=1999 |pmid=10225505| doi = 10.1016/S0887-6185(98)00044-9}}</ref> Based on the evidence of controlled research, the [[American Psychiatric Association]]{{Failed verification|date=August 2010}}<ref>{{cite web | url = http://www.guideline.gov/summary/summary.aspx?doc_id=5954 | year = 2004 | title = Practice Guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder | location = Arlington, VA | publisher = [[American Psychiatric Association]] }}</ref> and the United States Department of Veterans Affairs and Department of Defense{{Failed verification|date=August 2010}}<ref>{{cite book | publisher = [[United States Department of Veterans Affairs|Department of Veteran Affairs]] & [[United States Department of Defense]] | year = 2004 | title = VA/DoD clinical practice guideline for the management of post-traumatic stress | place = Washington, DC | archiveurl = http://web.archive.org/web/20080629095323/http://www.oqp.med.va.gov/cpg/PTSD/PTSD_cpg/frameset.htm | archivedate = 2008-06-29 | url = http://www.oqp.med.va.gov/cpg/PTSD/PTSD_cpg/frameset.htm |date=June 2008}}</ref> have placed EMDR in the highest category of effectiveness and research support in the treatment of trauma. Several international bodies have made similar recommendations.<ref>''See''
* {{cite book | publisher = ACPTMH | year = 2007 | title = Australian guidelines for the treatment of adults with acute stress disorder and post traumatic stress disorder | place = Melbourne, Victoria | url = http://www.acpmh.unimelb.edu.au/resources/resources-guidelines.html#1 | isbn = 9780975224663}}
* {{cite web | publisher = [[National Institute for Health and Clinical Excellence]] | title = Post traumatic stress disorder (PTSD): The management of adults and children in primary and secondary care| location = London | year = 2005 | url = http://www.nice.org.uk/guidance/index.jsp?action=byID&r=true&o=10966}}
* {{ cite book | author = Dutch National Steering Committee Guidelines Mental Health and Care | title = Guidelines for the diagnosis treatment and management of adult clients with an anxiety disorder | location = Utrecht, Netherlands | publisher = The Dutch Institute for Healthcare Improvement (CBO)}}
* {{ cite book | last = Foa | first = EB  | last2 = Keane | first2 = TM | last3 = Friedman | first3 = MJ | title = Effective treatments for PTSD: Practice guidelines of the International Society for Traumatic Stress Studies | location = New York | publisher = [[Guilford Press]] | year = 2000 | url = http://books.google.com/?id=MFyEg007YEIC&printsec=frontcover#v=onepage&q= | isbn = 1606230018}}
* {{cite book | last = Bleich | first = A | last2 = Kolter | first2 = M | last3 = Kutz | first3 = E | last4 = Shaley | first4 = A | title = Guidelines for the assessment and professional intervention with terror victims in the hospital and the community | location = Jerusalem, Israel | year = 2002 |publisher = Israeli National Council for Mental Health }}
* {{cite book | author = United Kingdom Department of Health | title = Treatment choice in psychological therapies and counseling evidence based on clinical practice guideline | place = London | year = 2001  | url = http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4007323}}</ref>  However, some reviewers no longer believe that the eye movements assist in recovery, proposing instead  that the review of and engagement with memories, processing of cognitions, and rehearsal of coping skills are the psychotherapeutically effective components of the procedure.<ref name="pmid20051310"/><ref name = Aust>{{cite book | publisher = Australian Centre for Posttraumatic Mental Health | year = 2007 | title = Australian guidelines for the treatment of adults with acute stress disorder and post traumatic stress disorder | location = Melbourne, Victoria | url = http://www.acpmh.unimelb.edu.au/resources/resources-guidelines.html#1 | isbn = 9780975224663}}</ref>{{POV-statement|date=April 2010}}

====Interpersonal psychotherapy====
Other approaches, particularly involving social supports,<ref name=Brewin/><ref name=Ozer>{{cite journal |author=Ozer EJ, Best SR, Lipsey TL, Weiss DS |title=Predictors of posttraumatic stress disorder and symptoms in adults: a meta-analysis |journal=Psychol Bull |volume=129 |issue=1 |pages=52–73 |year=2003 |month=January |pmid=12555794 |url=http://content.apa.org/journals/bul/129/1/52 |doi=10.1037/0033-2909.129.1.52}}</ref> may also be important. An open trial of interpersonal psychotherapy<ref>Weissman MM, Markowitz JC, Klerman GL: Clinician’s Quick Guide to Interpersonal Psychotherapy. New York: Oxford University Press, 2007.</ref> reported high rates of remission from PTSD symptoms without using exposure.<ref>{{cite journal |author=Bleiberg KL, Markowitz JC |title=A pilot study of interpersonal psychotherapy for posttraumatic stress disorder |journal=Am J Psychiatry |volume=162 |issue=1 |pages=181–3 |year=2005 |month=January |pmid=15625219 |doi=10.1176/appi.ajp.162.1.181 }}</ref> A current, NIMH-funded trial in New York City is now comparing interpersonal psychotherapy, [[prolonged exposure therapy]], and relaxation therapy.<ref>http://www.columbiatrauma.org/</ref>{{Full}}{{Update after |2010 |04|reason=research may be finished}}

===Medication===
A variety of medications has shown adjunctive benefit in reducing PTSD symptoms,<ref name="Maxmen-1995-280">{{cite book | last = Maxmen | first = J. S. | last2 = Ward | first2 = N. G. | title = Essential psychopathology and its treatment, 2nd ed., revised for DSM-IV | place =New York | publisher = W. W. Norton | year = 1995 | edition = second | isbn = 0-393-70173-5 | page = 280}}</ref> but "there is no clear drug treatment for PTSD".<ref name="Maxmen2002-346">{{cite book | last = Maxmen | first = J. S. | last2 = Ward | first2 = N. G. | title = Psychotropic drugs: fast facts | place =New York | publisher = W. W. Norton | year = 2002 | edition = third | isbn = 0-393-70301-0 | page = 346 }}</ref> Positive symptoms (re-experiencing, hypervigilance, increased arousal) generally respond better to medication than negative symptoms (avoidance, withdrawal), and it is recommended that any drug trial last for at least 6–8 weeks.<ref name="Maxmen2002-346"/>

====Symptom management: potentially useful medication classes====
'''SSRIs ([[selective serotonin reuptake inhibitor]]s).''' SSRIs are considered to be a first-line drug treatment.<ref name="Berger-2009">{{Cite journal | last1 = Berger | first1 = W. | last2 = Mendlowicz | first2 = MV. | last3 = Marques-Portella | first3 = C. | last4 = Kinrys | first4 = G. | last5 = Fontenelle | first5 = LF. | last6 = Marmar | first6 = CR. | last7 = Figueira | first7 = I. | title = Pharmacologic alternatives to antidepressants in posttraumatic stress disorder: a systematic review. | journal = Prog Neuropsychopharmacol Biol Psychiatry | volume = 33 | issue = 2 | pages = 169–80 | month = Mar | year = 2009 | doi = 10.1016/j.pnpbp.2008.12.004 | pmid = 19141307 | pmc = 2720612 }}</ref><ref>{{Cite journal | last1 = Cooper | first1 = J. | last2 = Carty | first2 = J. | last3 = Creamer | first3 = M. | title = Pharmacotherapy for posttraumatic stress disorder: empirical review and clinical recommendations. | journal = Aust N Z J Psychiatry | volume = 39 | issue = 8 | pages = 674–82 | month = Aug | year = 2005 | doi = 10.1111/j.1440-1614.2005.01651.x | pmid = 16050921 }}</ref> SSRIs for which there are data to support use include: [[citalopram]], [[escitalopram]],<ref>{{cite journal |author=Yehuda R |title=Biology of posttraumatic stress disorder |journal=J Clin Psychiatry |volume=61 |issue=Suppl 7 |pages=14–21 |year=2000 |pmid=10795605 }}</ref> [[fluoxetine]],<ref name="Maxmen2002-347" /> [[fluvoxamine]],<ref>{{cite journal |author=Marshall RD, Beebe KL, Oldham M, Zaninelli R |title=Efficacy and safety of paroxetine treatment for chronic PTSD: a fixed-dose, placebo-controlled study |journal=Am J Psychiatry |volume=158 |issue=12 |pages=1982–8 |year=2001 |month=December |pmid=11729013 |url=http://ajp.psychiatryonline.org/cgi/pmidlookup?view=long&pmid=11729013 |doi=10.1176/appi.ajp.158.12.1982}}</ref> [[paroxetine]],<ref>{{cite journal |author=Brady K, Pearlstein T, Asnis GM, ''et al.'' |title=Efficacy and safety of sertraline treatment of posttraumatic stress disorder: a randomized controlled trial |journal=JAMA |volume=283 |issue=14 |pages=1837–44 |year=2000 |month=April |pmid=10770145 |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=10770145 |doi=10.1001/jama.283.14.1837}}</ref> and [[sertraline]].<ref name="Maxmen2002-347" /><ref>{{cite journal |author=Davidson JR, Rothbaum BO, van der Kolk BA, Sikes CR, Farfel GM |title=Multicenter, double-blind comparison of sertraline and placebo in the treatment of posttraumatic stress disorder |journal=Arch Gen Psychiatry |volume=58 |issue=5 |pages=485–92 |year=2001 |month=May |pmid=11343529 |url=http://archpsyc.ama-assn.org/cgi/pmidlookup?view=long&pmid=11343529 |doi=10.1001/archpsyc.58.5.485}}</ref>

Among the anti-depressants described in this section, bupropion and [[venlafaxine]] have the lowest patient drop-out rates. Sertraline, [[fluoxetine]], and [[nefazodone]] have a modestly higher drop-out rate (~15%), and the heterocyclics and paroxetine have the highest rates (~20%+).<ref>{{cite book | last = Maxmen | first = J. S. | last2 = Ward | first2 = N. G. | title = Essential psychopathology and its treatment, 2nd ed., revised for DSM-IV | place =New York | publisher = W. W. Norton | year = 1995 | edition = second | isbn = 0-393-70173-5 | page = 104}}</ref> Where drop-out is caused or feared because of medication side-effects, it should be remembered that most patients do not experience such side-effects.<ref>{{cite book | last = Maxmen | first = J. S. | last2 = Ward | first2 = N. G. | title = Essential psychopathology and its treatment, 2nd ed., revised for DSM-IV | place =New York | publisher = W. W. Norton | year = 1995 | edition = second | isbn = 0-393-70173-5 | page = 175}}</ref>

'''[[Alpha-adrenergic antagonist]]s.''' [[Prazosin]] ("Minipress"), in a small study of combat veterans, has shown substantial benefit in relieving or reducing nightmares.<ref name="Maxmen2002-348">{{cite book | last = Maxmen | first = J. S. | last2 = Ward | first2 = N. G. | title = Psychotropic drugs: fast facts | place =New York | publisher = W. W. Norton | year = 2002 |
edition = third | isbn = 0-393-70301-0 | page = 348 }}</ref> Clonidine ("Catapres") can be helpful with startle, hyperarousal, and general autonomic hyperexcitability.<ref name = Maxmen2002-349 />

'''[[Anti-convulsant]]s, [[mood stabilizer]]s, anti-aggression agents.''' [[Carbamazepine]] ("Tegretol") has likely benefit in reducing arousal symptoms involving noxious affect,<ref name="Maxmen2002-347">{{cite book | last = Maxmen | first = J. S. | last2 = Ward | first2 = N. G. | title = Psychotropic drugs: fast facts | place =New York | publisher = W. W. Norton | year = 2002 | edition = third | isbn = 0-393-70301-0 | page = 347 }}</ref> as well as mood or aggression.<ref name="Lacey2008">{{cite book |author=Lacy CF, Armstrong LL et al. |title=Drug Information Handbook |year=2008 |publisher=Lexi-Comp |pages =260, 934}}</ref> [[Topiramate]] ("Topamax")<ref name="Maxmen2002-348" /> has been effective in achieving major reductions in flashbacks and nightmares, and no reduction of effect was seen over time.<ref name="Maxmen2002-348" /> [[Zolpidem]] ("Ambien") has also proven useful in treating sleep disturbances.<ref name="Maxmen2002-349" />

[[Lamotrigine]] ("Lamictal") ''may'' be useful in reducing reexperiencing symptoms, as well as avoidance and emotional numbing.<ref name = Maxmen2002-348 /><ref>{{cite web|url=http://www.psycom.net/depression.central.lamotrigine.html|title=Lamotrigine FAQ|accessdate=2007-05-01}}</ref><ref>[http://www.biopsychiatry.com/ptsd-drugs.html SSRIs versus Non-SSRIs in Post-traumatic Stress Disorder], Department of Psychiatry and Behavioral Sciences, Montefiore Medical Center, Albert Einstein College of Medicine.</ref><ref>{{cite journal |author=Hertzberg MA, Butterfield MI, Feldman ME, ''et al.'' |title=A preliminary study of lamotrigine for the treatment of posttraumatic stress disorder |journal=Biol. Psychiatry |volume=45 |issue=9 |pages=1226–9 |year=1999 |month=May |pmid=10331117 |url=http://linkinghub.elsevier.com/retrieve/pii/S0006-3223(99)00011-6 |doi=10.1016/S0006-3223(99)00011-6}}</ref> [[Valproic acid]] ("Depakene") and has shown reduction of symptoms of irritability, aggression, and impulsiveness, and in reducing flashbacks.<ref name = Maxmen2002-349 /> Similarly, [[lithium|lithium carbonate]] has worked to control mood and aggressions (but not anxiety) symptoms.<ref name="Lacey2008" /> [[Buspirone]] ("BuSpar") has an effect similar to that of lithium, with the additional benefit of working to reduce hyperarousal symptoms.<ref name = Maxmen2002-349 />

'''[[Antipsychotic]]s.''' [[Risperidone]] can be used to help with [[dissociation]], mood issues, and aggression.<ref name="Kapfhammer-2008"/>

'''Atypical [[antidepressant]]s.'''<ref name="Maxmen-1995-95">{{cite book | last =  Maxmen | first = J. S. | last2 = Ward | first2 = N. G. | title =  Essential psychopathology and its treatment, 2nd ed., revised for DSM-IV | place =New  York | publisher = W. W. Norton | year = 1995  |  edition = second | isbn = 0-393-70173-5 | page = 95}}</ref> Nefazodone ("Serzone") can be effective with sleep disturbance symptoms, and with secondary [[Mood disorder|depression]], [[anxiety]], and [[sexual dysfunction]] symptoms.<ref name="Maxmen2002-347" /> [[Trazodone]] ("Desyrel") can also reduce or eliminate problems with disturbed sleep, and with anger and anxiety.<ref name="Maxmen2002-347" />

'''[[Beta blockers]].''' [[Propranolol]] ("Inderal") has demonstrated possibilities in reducing hyperarousal symptoms, including sleep disturbances.<ref name="Maxmen2002-349">{{cite book | last = Maxmen | first = J. S. | last2 = Ward | first2 = N. G. | title = Psychotropic drugs: fast facts | place =New York | publisher = W. W. Norton | year = 2002 |
edition = third | isbn = 0-393-70301-0 | page = 349 }}</ref><ref name="pmid11822998" />

'''[[Benzodiazepines]].''' These can be used with caution for short-term anxiety relief,<ref name="Kapfhammer-2008">{{Cite journal | last1 = Kapfhammer | first1 = HP. | title = [Therapeutic possibilities after traumatic experiences] | journal = Psychiatr Danub | volume = 20 | issue = 4 | pages = 532–45 | month = Dec | year = 2008 | doi = | pmid = 19011595 }}</ref><ref name="autogenerated1">Reist, C (2005). Post-traumatic Stress Disorder. Compendia, Build ID: F000005, published by Epocrates.com</ref> hyperarousal, and sleep disturbance.<ref name="Maxmen2002-349" /> While benzodiazepines can alleviate acute anxiety, there is no consistent evidence that they can stop the development of PTSD, or are at all effective in the ''treatment'' of posttraumatic stress disorder. Additionally benzodiazepines may reduce the effectiveness of psychotherapeutic interventions and there is some evidence that benzodiazepines may contribute to the development and chronification of PTSD. Other drawbacks include the risk of developing a [[benzodiazepine dependence]] and [[benzodiazepine withdrawal syndrome|withdrawal syndrome]]; additionally individuals with PTSD are at an increased risk of [[benzodiazepine misuse|abusing benzodiazepines]].<ref name="Berger-2009"/><ref name="Martényi-2005">{{Cite journal | last1 = Martényi | first1 = F. | title = [Three paradigms in the treatment of posttraumatic stress disorder] | journal = Neuropsychopharmacol Hung | volume = 7 | issue = 1 | pages = 11–21 | month = Mar | year = 2005 | pmid = 16167463 }}</ref>

'''[[glucocorticoids|Glucocorticoids.]]''' Additionally, post-stress high dose [[corticosterone]] administration was recently found to reduce 'PTSD-like' behaviors in a rat model of PTSD. In this study, corticosterone impaired memory performance, suggesting that it may reduce risk for PTSD by interfering with consolidation of traumatic memories.<ref>{{cite journal |author=Cohen H, Matar MA, Buskila D, Kaplan Z, Zohar J. |title=Early post-stressor intervention with high-dose corticosterone attenuates posttraumatic stress response in an animal model of posttraumatic stress disorder. |journal=Biol Psychiatry |volume=64 |issue=8 |pages=708–717 |year=2008 |pmid=18635156 |doi=10.1016/j.biopsych.2008.05.025}}</ref> The neurodegenerative effects of the glucocorticoids, however, may prove this treatment counterproductive.<ref>{{cite journal |author=Sapolsky RM, Romero LM, Munck AU. |title=How do glucocorticoids influence stress responses? Integrating permissive, suppressive, stimulatory, and preparative actions. |journal=Endocr Review |volume=21 |issue=1 |pages=55–89 |year=2000 |pmid=10696570 |doi=10.1210/er.21.1.55 }}</ref>

'''[[heterocyclic antidepressant|Heterocyclic]] / [[tricyclic|Tricyclic anti-depressants]] anti-depressants.''' [[Amitriptyline]] ("Elavil") has shown benefit for positive distress symptoms, and for avoidance, and [[Imipramine]] ("Tofranil") has shown benefit for intrusive symptoms.<ref name="Maxmen2002-347" />

'''[[Monoamine oxidase inhibitor|Monoamine-oxidase inhibitors (MAOs)]].''' [[Phenelzine]] ("Nardil") has for some time been observed to be effective with hyperarousal and depression, and is especially effective with nightmares.<ref name="Maxmen2002-347" />

'''Miscellaneous other medications.''' [[Clinical trial]]s evaluating [[methylenedioxymethamphetamine]] (MDMA, "Ecstasy") in conjunction with psychotherapy are being conducted in Switzerland<ref>{{cite web |url=http://clinicaltrials.gov/ct2/show/NCT00353938 |title=Study of 3,4-Methylenedioxymethamphetamine-Assisted Psychotherapy in People With Posttraumatic Stress Disorder |month=February | year=2009 |publisher=U.S. [[National Institutes of Health]] |work=ClinicalTrials.gov}} Retrieved on June 17, 2009.</ref> and Israel.<ref>{{cite web |url=http://clinicaltrials.gov/ct2/show/NCT00402298 |title=Randomized Placebo-Controlled Study of MDMA-Assisted Psychotherapy in People With PTSD - Israel |month=February | year=2009 |publisher=U.S. [[National Institutes of Health]] |work=ClinicalTrials.gov}} Retrieved on June 17, 2009.</ref>

====Symptom prevention: potentially useful medication classes====
Some medications have shown benefit in preventing PTSD or reducing its incidence, when given in close proximity to a traumatic event. These medications include:

'''[[Alpha-adrenergic agonist]]s.''' Anecdotal report of success in using [[clonidine]] ("Catapres") to reduce traumatic stress symptoms<ref>{{{Cite journal | last = Khoshnu | first = E | title = Clonidine for Treatment of PTSD | journal = Clinical Psychiatry News | volume = 34 | issue = 10 | page = 22 |date = October 2006| url = http://www.clinicalpsychiatrynews.com/article/S0270-6644%2806%2971796-9/fulltext | accessdate = 9 February 2010 }}</ref> suggests that it may have benefit in preventing PTSD.

'''[[Beta blockers]].''' [[Propranolol]] ("Inderal"), similarly to clonidine, may be useful if there are significant symptoms of "over-arousal". These may inhibit the formation of traumatic memories by blocking adrenaline's effects on the [[amygdala]].<ref name="pmid11822998">{{cite journal |author=Pitman RK, Sanders KM, Zusman RM, ''et al.'' |title=Pilot study of secondary prevention of posttraumatic stress disorder with propranolol |journal=Biol. Psychiatry |volume=51 |issue=2 |pages=189–92 |year=2002 |pmid=11822998| doi = 10.1016/S0006-3223(01)01279-3}}</ref>

'''[[Glucocorticoid]]s.''' There is some evidence suggesting that administering [[glucocorticoid]]s immediately after a traumatic experience may help prevent PTSD. Several studies have shown that individuals who receive high doses of [[hydrocortisone]] for treatment of [[septic shock]], or following surgery, have a lower incidence and fewer symptoms of PTSD.<ref>{{cite journal |author=Schelling G, Roozendaal B, Krauseneck T, Schmoelz M, DE Quervain D, Briegel J. |title=Efficacy of hydrocortisone in preventing posttraumatic stress disorder following critical illness and major surgery. |journal=Ann N Y Acad Sci |volume=1071 |issue=1 |pages=46–53 |year=2006 |pmid=16891561 |doi=10.1196/annals.1364.005}}</ref><ref>{{cite journal |author=Weis F, Kilger E, Roozendaal B, de Quervain DJ, Lamm P, Schmidt M, Schmölz M, Briegel J, Schelling G. |title=Stress doses of hydrocortisone reduce chronic stress symptoms and improve health-related quality of life in high-risk patients after cardiac surgery: a randomized study. |journal=J Thorac Cardiovasc Surg |volume=131 |issue=2 |pages=277–282 |year=2006 |pmid=16434254 |doi=10.1016/j.jtcvs.2005.07.063}}</ref><ref>{{cite journal |author=Schelling G, Kilger E, Roozendaal B, de Quervain DJ, Briegel J, Dagge A, Rothenhäusler HB, Krauseneck T, Nollert G, Kapfhammer HP. |title=Stress doses of hydrocortisone, traumatic memories, and symptoms of posttraumatic stress disorder in patients after cardiac surgery: a randomized study. |journal=Biol Psychiatry |volume=55 |issue=6 |pages=627–633 |year=2004 |pmid=15013832 |doi=10.1016/j.biopsych.2003.09.014}}</ref>

'''[[Opiates]].''' In a retrospective analysis of combat injury field data for US troops in Iraq, it was found that those who received morphine in the early stages of their treatment had a significantly lower rate of subsequent PTSD, when compared with those who did not receive morphine at that time.<ref>{{Cite journal | last = Holbrook | first =T.L., et al. | title =Morphine use after combat injury in Iraq and post-traumatic stress disorder. | journal =N Engl J Med | volume =362 | issue =110 | date =2010-01-14 | url =http://content.nejm.org/cgi/content/full/362/2/110 | accessdate = 2009-02-05 | pmid = 20071700 | doi = 10.1056/NEJMoa0903326 | last2 = Galarneau | first2 = MR | last3 = Dye | first3 = JL | last4 = Quinn | first4 = K | last5 = Dougherty | first5 = AL | pages = 110–7}}</ref>

====Medications by symptom group affected====
Medications can affect one or more of the symptoms, in one or more of the three major symptom classes<ref name=DSM4/> involved in diagnosing PTSD, which can be summarized in the following table:<ref name="Kapfhammer-2008"/><ref name="autogenerated1"/><ref name="autogeneratedMaxmen2002-347-349">{{cite book | last = Maxmen | first = J. S. | last2 = Ward | first2 = N. G. | title = Psychotropic drugs: fast facts | place =New York | publisher = W. W. Norton | year = 2002 | edition = third | isbn = 0-393-70301-0 | pages = 347–349 }}</ref>

{| class="wikitable" style="margin: 1em auto 1em auto"
|-
! Symptom class !! Symptom !! Medication
|-
| colspan="3" | ''Reexperiencing''
|-
| rowspan="5" | &nbsp; || intrusive recall || amitriptyline; fluoxetine; imipramine; lamotrigine; sertraline
|-
| intrusive reexperiencing || amitriptyline; fluoxetine; imipramine; nefazodone; sertraline (women only); topiramate;
|-
| sleep disturbance, nightmares || benzodiazepines; carbamazepine; clonidine; nefazodone; phenelzine; prazosin; topiramate; trazodone; zolpidem
|-
| dissociative recall || risperidone
|-
| intense psychological distress (anger, anxiety) when exposed to reminders of traumatic event(s) || benzodiazepines; buspirone; carbamazepine; lithium (not for anxiety); nefazodone; trazodone
|-
| colspan="3" | ''Avoidance''
|-
| rowspan="3" | &nbsp; || avoidance || amitriptyline; fluoxetine; lamotrigine; nefazodone; sertraline
|-
| feelings of detachment or estrangement from others || amitriptyline; risperidone
|-
| restricted range of affect (numbing) || amitriptyline; lamotrigine; sertraline (women only)
|-
| colspan="3" | ''Hyperarousal''
|-
| rowspan="6" | &nbsp; || general hyperarousal || amitriptyline; nefazodone; phenelzine; sertraline (women only)
|-
| sleep disturbance, nightmares || benzodiazepines; carbamazepine; clonidine; nefazodone; phenelzine; trazodone; zolpidem
|-
| irritability, anger (and impulsiveness) || carbamazepine; nefazodone; valproic acid
|-
| anger || buspirone; fluoxetine; lithium; trazodone
|-
| aggression || risperidone
|-
| exaggerated startle response; general autonomic hyperexcitability || benzodiazepines; buspirone; carbamazepine; clonidine; propranolol; valproic acid
|-
|}

Some medications can also help with symptoms which may occur secondary to PTSD.<ref name="autogeneratedMaxmen2002-347-349"/>

{| class="wikitable"
|-
! Secondary symptom !! Medication
|-
| depression || nefazodone; phenelzine
|-
| dream content distortions || nefazodone
|-
| relapse of symptoms || carbamazepine;
|-
| self-mutilation || clonidine; buprenorphine
|-
| sexual function reduction || nefazodone
|-
| sleep hours reduction || nefazodone
|}

====Medication and self-medication issues and risks with PTSD====
[[Alcohol abuse]] and [[drug abuse]] commonly co-occurs with PTSD.<ref name="Maxmen2002-348"/> Recovery from posttraumatic stress disorder or other [[anxiety disorders]] may be hindered, or the condition worsened, by medication or substance overuse, abuse, or dependence; resolving these problems can bring about a marked improvement in an individual's mental health status and anxiety levels.<ref name = "Cohen-1995">{{cite journal |author=Cohen SI |title=Alcohol and benzodiazepines generate anxiety, panic and phobias |journal=J R Soc Med |volume=88 |issue=2 |pages=73–77 |year=1995 |month=February |pmid=7769598 |pmc=1295099 }}</ref><ref>Spates, R. & Souza (2007). Treatment of PTSD and Substance Abuse Comorbidity. ''The Behavior Analyst Today, 9(1),'' 11-26 [http://www.baojournal.com]</ref>

'''Benzodiazepines''' are risky in several ways. They can be especially addictive when PTSD is present, and this is especially true with the fast-acting ones. Dis-inhibition upon initiation of treatment is another risk with this medication class. Finally, termination of the drug can be especially difficult.<ref name="Maxmen2002-348" /> Recovery from benzodiazepine abuse or dependence tends to take a lot longer than recovery from alcohol abuse or dependence, but people ''can'' regain their previous good health. PTSD symptoms may temporarily worsen however, during [[alcohol withdrawal]] or [[benzodiazepine withdrawal]].<ref name = "Cohen-1995" />

'''Yohimbine''' (''not'' considered specifically appropriate for PTSD) increases arousal by increasing release of endogenous norepinephrine, and can ''worsen'' PTSD symptoms.<ref name="Maxmen2002-348"/>

==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=http://www.who.int/entity/healthinfo/global_burden_disease/gbddeathdalycountryestimates2004.xls |title=Mortality and Burden of Disease Estimates for WHO Member States in 2004 |format= |work=World Health Organization |accessdate=}}</ref><div class="references-small" style="-moz-column-count:3; column-count:3;">
{{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}}
</div>]]
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 2007, [[epidemiology|epidemiological]] rates have not changed significantly.<ref name = "Brunet">{{cite journal |author=Brunet A, Akerib V, Birmes P |title=Don't throw out the baby with the bathwater (PTSD is not overdiagnosed) |journal=Can J Psychiatry |volume=52 |issue=8 |pages=501–2; discussion 503 |year=2007 |pmid=17955912 |url = http://publications.cpa-apc.org/media.php?mid=490 | format = PDF | accessdate = 2008-03-12}}</ref>

===International PTSD rates===

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,<ref name=lcbpop>[[List of countries by population]]</ref> 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 USA, and Egypt.<ref name=WHO2004>{{cite web |url=http://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 |accessdate=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=http://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 |accessdate=2009-11-12}}</ref><ref name=WHO2004m>{{cite web |url=http://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 |accessdate=2009-11-12}}</ref>

{| class="wikitable" border="1"
|+ [[Age adjustment|Age-standardized]] [[Disability-adjusted life year]] (DALY) rates for PTSD, per 100,000 inhabitants, in 25 most populous countries,<ref name=lcbpop/> 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 [http://www.hcp.med.harvard.edu/ncs/ National Comorbidity Survey] has estimated that the [[lifetime prevalence]] of PTSD among adult Americans is 7.8%, with women (10.4%) twice as likely as men (5%) to have PTSD at some point in their lives.<ref name=Kessler95/>

The [[United States Department of Veterans Affairs]] estimates that 830,000 Vietnam War veterans suffered symptoms of PTSD.<ref>[http://www.digitalhistory.uh.edu/database/article_display.cfm?HHID=513 The War's Costs ]. Digital History.</ref>  The ''National Vietnam Veterans' Readjustment Study'' (NVVRS) found 15.2% of male and 8.5% of female Vietnam Vets to suffer from current PTSD at the time of the study. Life-Time prevalence of PTSD was 30.9% for males and 26.9% 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 suffered from PTSD symptoms (but not the disorder itself). Four out of five reported recent symptoms when interviewed 20–25 years after Vietnam.<ref name="autogenerated2"/>

===In other species===
There have been reports of captive<ref>{{Cite web  | last =  Bradshaw  | first = G.A.
| coauthors = Lindner, L.
| title = Post-Traumatic Stress and Elephants in Captivity
| date = no date
| url = http://www.elephants.com/ptsd/Bradshaw&Lindner_PTSD-rev.pdf
| accessdate = 2010-01-01}}</ref> and wild<ref>{{Cite journal
| last = Bradshaw
| first = G.A.
| coauthors = Schore, A. N., Brown, J.L., Poole, J.H., & Moss, C.J.
| title = Elephant breakdown
| journal = Nature
| volume = 423
| date = 2005-02-24
| url = http://www.elephants.com/media/Elephant_breakdown_2005.pdf
| accessdate = 2010-01-01}}</ref> [[elephant]]s suffering from posttraumatic stress reactions, the latter from seeing members of their herd shot by hunters. Service dogs used overseas in the military have been said<ref>{{Cite web
| last = Associated Press  | title = PTSD Victims Include Military Dogs, Too
| date = 2010-08-03
| url = http://www.cbsnews.com/stories/2010/08/03/national/main6739176.shtml  | accessdate = }}</ref> to develop posttraumatic stress after witnessing war.

==History==
===Earliest reports===
Reports of battle-associated stress reactions appear as early as the 6th century BC/BCE.<ref name=AllInTheMind>[http://www.abc.net.au/rn/allinthemind/stories/2004/1214098.htm When trauma tips you over: PTSD Part 1] All in the Mind, Australian Broadcasting Commission, 9 October 2004.</ref> One of the first descriptions of PTSD was made by the Greek historian [[Herodotus]]. In 490 BC/BCE he described, during the [[Battle of Marathon]], an Athenian soldier who suffered no injury from war but became permanently blind after witnessing the death of a fellow soldier.<ref>Swartz' Textbook of Physical Diagnosis: History and Examination.</ref>

===Modern recognition in military settings===
[[File:Statue Three Servicemen Vietnam Veterans Memorial-editA.png|thumb|right|250px|Statue, ''Three Servicemen'', Vietnam Veterans Memorial]]
In the early 19th century military medical doctors started diagnosing soldiers with "exhaustion" after the stress of battle. This "exhaustion" was characterized by mental shutdown due to individual or group trauma. Soldiers during the 19th century were not supposed to be scared or show any fear in the midst of battle. The only treatment for this "exhaustion" was to bring the afflicted to the back for a bit then send them back into battle. During the intense and frequently repeated stress, the soldiers became fatigued as a part of their body's natural shock reaction.<ref>{{cite book|chapterurl=http://www.ptsdmanual.com/chap1.htm|title=Military Veterans PTSD Reference Manual|chapter=Ch. 1, Section II. HISTORY|pages=01–03|author=MSG. I. S. Parrish, USA Retired|publisher=Infinity Publishing|location=Bryn Mawr, PA|edition=Revised|month=May|year=2008|accessdate=11 January 2011|isbn=0-7414-0077-4}}</ref>

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>[http://www.ralphmag.org/CG/world-war-one2.html World War One --- A New Kind of War | Part II], From ''14 - 18 Understanding the Great War'', by Stéphane Audoin-Rouzeau, Annette Becker</ref>

Although PTSD-like symptoms have also been recognized in combat veterans of many [[military conflict]]s since, the modern understanding of PTSD dates from the 1970s, largely as a result of the problems that were still being experienced by US military veterans of the [[Vietnam War|war in Vietnam]].<ref name=AllInTheMind/>

Previous diagnoses now considered historical equivalents of PTSD include [[railway spine]], [[stress syndrome]], [[shell shock]], battle fatigue, or traumatic war neurosis.{{Citation needed|date=March 2010}}

===Terminology===
The term ''post-traumatic stress disorder'' or ''PTSD'' was coined in the mid 1970s.<ref name=AllInTheMind/> Early in 1978, the term was used in a working group finding presented to the Committee of Reactive Disorders.<ref name=IHHRT/> The term was formally recognized in 1980.<ref name=AllInTheMind/> (In the authoritative [[DSM-IV]], the spelling "posttraumatic stress disorder" is used. Elsewhere, "posttraumatic" is often rendered as two words &mdash; "post-traumatic stress disorder" or "post traumatic stress disorder" &mdash; especially in less formal writing on the subject.)

==References==
{{Reflist|2}}