Post-Traumatic Stress Disorder

“I can't turn my brain off. Sometimes I stay up all night. The bad part is not staying up, but what’s going through my head. I can't stop it.” — Hurricane Katrina survivor Marvin Turner

What is PTSD?

Post-traumatic stress disorder (PTSD) can occur after you have been through a traumatic event. A traumatic event is something horrible and scary that you see or that happens to you. During this type of event, you think that your life or others' lives are in danger. You may feel afraid or feel that you have no control over what is happening.

Anyone who has gone through a life-threatening event can develop PTSD. These events can include:

• Combat.
• Terrorist attacks.
• Violent crimes, such as rape, child abuse, or a physical attack.
• Serious accidents, such as a car wreck.
• Natural disasters, such as a fire, tornado, flood, or earthquake.

After the event, you may feel scared, confused, and angry. If these feelings don't go away or they get worse, you may have PTSD. These symptoms may disrupt your life, making it hard to continue with your daily activities.

What are the symptoms?

After going through a traumatic event, you may:

• Feel upset by things that remind you of what happened.
• Have nightmares, vivid memories, or flashbacks of the event. You may feel like it's happening all over again.
• Avoid places or things that remind you of what happened.
• Feel numb or lose interest in things you used to care about.
• Feel that you are always in danger.
• Feel anxious, jittery, or grumpy.
• Have trouble sleeping or keeping your mind on one thing.

PTSD symptoms can change your behavior and how you live your life. You may pull away from other people, work all the time, or use drugs or alcohol. You may find it hard to be in relationships, and you may have problems with your spouse and family. You may become depressed. Some people with PTSD also have panic attacks, which are sudden feelings of fear or worry that something bad is about to happen.

Children can have PTSD too. They may have the symptoms above and symptoms that depend on how old they are. As children get older their symptoms are more like those of adults.

• Young children may become upset if their parents are not close by, have trouble sleeping, or suddenly have trouble with toilet training or going to the bathroom.
• Children who are in the first few years of elementary school (ages 6 to 9) may act out the trauma through play, drawings, or stories. They may complain of physical problems or become more irritable or aggressive. They also may develop fears and anxiety that don't seem to be caused by the traumatic event.

I think I have PTSD. What can I do?

If you think you have PTSD, it's important to get treatment. Treatment can work, and early treatment may help reduce long-term symptoms.^{1, 2}

If you think you have PTSD:

• Talk to your family doctor.
• Talk to a mental health professional, such as a therapist.
• If you're a veteran, contact your local VA hospital or Vet Center.
• Talk to a close friend or family member. He or she may be able to support you and find you help.
• Talk to a religious leader.
• Fill out this form (What is a PDF document?) and take it with you to the doctor.

If you have thoughts about hurting yourself or someone else, call 911 or go to a hospital emergency room.

How does PTSD develop?

All people with PTSD have lived through a traumatic event that caused them to fear for their lives, see horrible things, and feel helpless. Strong emotions caused by the event create changes in the brain that may result in PTSD.³

Many people who go through a traumatic event don't get PTSD. It isn't clear why some people develop PTSD and others don't. How likely you are to get PTSD depends on many things. These include:

• How intense the trauma was.
• If you lost a loved one or were hurt.
• How close you were to the event.
• How strong your reaction was.
• How much you felt in control of events.
• How much help and support you got after the event.

PTSD symptoms usually start soon after the traumatic event, but they may not happen until months or years later. They also may come and go over many years. About half (40% to 60%) of people who develop PTSD get better at some time.⁴ But about 1 out of 3 people who develop PTSD always will have some symptoms.⁴

If you have some symptoms, counseling can help you cope. Your symptoms don't have to interfere with your everyday activities, work, and relationships. It is never too late to get professional help or other forms of support that can help you manage the symptoms of PTSD.

Reminders and anniversaries of the event can make symptoms worse. Some older veterans find they have more symptoms after retirement, during a severe illness in themselves or their spouses, or after reminders of their military service, such as reunions and anniversaries.⁵

How is PTSD treated?

The most effective treatments for PTSD are:²

• Counseling, which can help you understand your thoughts and learn ways to cope with your feelings. This can help you feel more in control and get you back to the activities in your life. A type of counseling called cognitive-behavioral therapy has been shown to be the most effective form of counseling for PTSD.^{1, 2}
• Antidepressant medicines, especially selective serotonin reuptake inhibitors (SSRIs). These can help you feel less sad and worried. SSRIs include citalopram (Celexa), fluoxetine (such as Prozac), paroxetine (Paxil), and sertraline (Zoloft).

You may need to try different types of treatment before finding the one that helps you. Your doctor will help you with this. These treatments may include other types of medicines and other forms of counseling, such as group counseling. If you have other problems along with PTSD, such as overuse of alcohol or drugs, you may need treatment for those as well.

Treatment can help you feel more in control of your emotions, have fewer symptoms, and enjoy life again.

Telling others about having post-traumatic stress disorder (PTSD) is hard. But for the following people, it’s part of recovering.

Read what they say about how PTSD felt, how it affected their families, and how treatment is helping them get better.

Marvin Turner and his family survived Hurricane Katrina on a neighbor’s rooftop.

"I have visions of being up on the roof and going through it all over again. I just keep seeing the water coming up and up."Read Marvin's story .

Tim Young is an Iraq war veteran and former medic.

"When I came home, so much had changed for me on a day-to-day basis. I just couldn't communicate the same."Read Tim's story .

Jessica Garfield has been in counseling for PTSD after being raped in 2004.

"It helps to heal when you have an excellent support team."Read Jessica's story .

Ron Shepard is a Vietnam veteran who has had PTSD symptoms for decades.

"Whenever I was under extreme stress, it would come back and slam me."Read Ron's story .

“People don't understand the emotion tied to flashbacks. It’s like it’s happening all over again, and you're having the same physiological reactions.” — Hurricane Katrina survivor Marvin Turner

Symptoms of post-traumatic stress disorder (PTSD) can be terrifying. They may disrupt your life and make it hard to continue with your daily activities. It may be hard just to get through the day.

PTSD symptoms usually start soon after the traumatic event, but they may not happen until months or years later. They also may come and go over many years. If the symptoms last longer than 4 weeks, cause you great distress, or interfere with your work or home life, you probably have PTSD.

Even if you always have some symptoms, counseling can help you cope. Your symptoms don't have to interfere with your everyday activities, work, and relationships.

Most people who go through a traumatic event have some symptoms at the beginning but don't develop PTSD.

There are four types of symptoms:

Reliving the event

Bad memories of the traumatic event can come back at any time. You may feel the same fear and horror you did when the event took place. You may feel like you're going through the event again. This is called a flashback. Sometimes there is a trigger: a sound or sight that causes you to relive the event. Triggers might include:

• Hearing a car backfire, which can bring back memories of gunfire and war for a combat veteran.
• Seeing a car accident, which can remind a crash survivor of his or her own accident.
• Seeing a news report of a sexual assault, which may bring back memories of assault for a woman who was raped.

Avoiding situations that remind you of the event

You may try to avoid situations or people that trigger memories of the traumatic event. You may even avoid talking or thinking about the event.

• A person who was in an earthquake may avoid watching television shows or movies in which there are earthquakes.
• A person who was robbed at gunpoint while ordering at a hamburger drive-in may avoid fast-food restaurants.
• Some people may keep very busy or avoid seeking help. This keeps them from having to think or talk about the event.

Feeling numb

You may find it hard to express your feelings. This is another way to avoid memories.

• You may not have positive or loving feelings toward other people and may stay away from relationships.
• You may not be interested in activities you used to enjoy.
• You may forget about parts of the traumatic event or not be able to talk about them.

Feeling keyed up

You always may be alert and on the lookout for danger. This is known as increased emotional arousal. It can cause you to:

• Suddenly become angry or irritable.
• Have a hard time sleeping.
• Have trouble concentrating.
• Fear for your safety and always feel on guard.
• Be very startled when someone surprises you.

Other symptoms

PTSD symptoms also may include:⁶

• Physical symptoms for no reason you can think of (called somatic complaints).
• Feelings of shame, despair, or hopelessness.
• Difficulty controlling your emotions.
• Problems with family or friends.
• Impulsive or self-destructive behavior.
• Changed beliefs or changed personality traits.

PTSD in children and teens

Children can have PTSD too. They may have the symptoms above and symptoms that depend on how old they are. As children get older their symptoms are more like those of adults.

• Young children may become upset if their parents are not close by, have trouble sleeping, or suddenly have trouble with toilet training or going to the bathroom.
• Children who are in the first few years of elementary school (ages 6 to 9) may act out the trauma through play, drawings, or stories. They may complain of physical problems or become more irritable or aggressive. They also may develop fears and anxiety that don't seem to be caused by the traumatic event.

If you think you or a loved one has symptoms of PTSD, see your doctor right away. Fill out this form (What is a PDF document?) and take it to your doctor. Treatment can work, and early treatment may help reduce long-term symptoms.²

“Being in the Guard now is like a mandatory support group because they've all been there too.” — Iraq war veteran Tim Young

If you are in the military, you may have seen combat. You may have been on missions that exposed you to horrible and life-threatening experiences. You may have been shot at, seen a buddy shot, or seen death. These are types of events that can lead to post-traumatic stress disorder (PTSD).

Experts think PTSD occurs:

• In about 30% of Vietnam veterans, or about 30 out of 100 Vietnam veterans.⁷ A more recent review of data seems to show that about 19%, or 19 out of 100 Vietnam veterans, have had symptoms of PTSD.⁸
• In as many as 10% of Gulf War (Desert Storm) veterans, or in 10 veterans out of 100.⁹
• In about 6% to 11% of veterans of the Afghanistan war (Enduring Freedom), or in 6 to 11 veterans out of 100.¹⁰
• In about 12% to 20% of veterans of the Iraq war (Iraqi Freedom), or in 12 to 20 veterans out of 100.¹⁰

Other factors in a combat situation can add more stress to an already stressful situation and may contribute to PTSD and other mental health problems.^{11, 12} These factors include what you do in the war, the politics around the war, where it's fought, and the type of enemy you face.

• See a chart of different types of combat experiences in Afghanistan and Iraq .
• See information on other factors that may add stress during war.

Another cause of PTSD in the military can be military sexual trauma (MST). This is any sexual harassment or sexual assault that occurs while you are in the military. MST can happen to men and women and can occur during peacetime, training, or war.

Getting treatment

Many veterans don't seek treatment for PTSD. You may feel that treatment won't help, or worry about what people will think. Your military background may add other pressures that keep you from seeking treatment. You may feel that it will hurt your career, or that those in your unit will lose faith in you. You may fear that your unit will see you as weak.

• See a chart of reasons soldiers in Afghanistan and Iraq didn't seek treatment .
• If you need help deciding to see your doctor, see some reasons why people don't get help and how to overcome them.
• The U.S. Department of Veterans Affairs (VA) has many programs for veterans and their families who are worried about PTSD or related problems. If you are a veteran, contact your local VA about these resources. You can find help with treatment, jobs, housing, and sexual assault.

"It's hard to let people in on your private thoughts. A professional is a great listener, and if you can let them in, when you talk about your flashbacks, they understand that they're not some random thoughts." — Hurricane Katrina survivor Marvin Turner

There are many types of treatment for post-traumatic stress disorder (PTSD). You and your doctor will discuss the best treatment for you. You may have to try a number of treatments before you find one that works for you.

A type of counseling called cognitive-behavioral therapy and medicines known as SSRIs appear to be the most effective treatments for PTSD.^{2, 1} Treatment can help you feel more in control of your emotions and result in fewer symptoms, but you may still have some bad memories.

Counseling means talking with a therapist on your own or in a group about the traumatic event and PTSD. You will talk with your therapist about your memories and feelings to help you change how you think about your trauma. You will learn how to deal with painful feelings and memories, so you can feel better.

Counseling

There are different types of counseling for PTSD. Cognitive-behavioral therapy appears to be the most effective.^{2, 1} This type of therapy includes:

• Cognitive therapy, in which you learn to modify thoughts about the trauma that are not true or that cause you stress. For example, survivors of hurricane Katrina may feel guilty for not evacuating their families sooner from their New Orleans homes. Cognitive therapy can help them see that they did the best they could at the time. No one knew that the levees would break.
• Exposure therapy, in which you talk about the traumatic event over and over, in a safe place, until you have less fear.
• Eye movement desensitization and reprocessing (EMDR), in which you focus on distractions like hand movements and sounds while talking about the traumatic event.

Finding a therapist you trust is important. A good therapist will listen to your concerns and help you make changes in your life. Your doctor can help you find one. If you are a veteran, the VA is a good place to start. Churches sometimes offer services that help people get counseling. Or you can call your state Health and Welfare office.

SSRI medicine

SSRIs (selective serotonin reuptake inhibitors) are a type of antidepressant medicine. These can help you feel less sad and worried. They appear to be helpful, and for some people they are very effective. SSRIs include citalopram (Celexa), fluoxetine (such as Prozac), paroxetine (Paxil), and sertraline (Zoloft).

Other types of treatment

Your doctor also may suggest you try other types of medicines and other forms of counseling. People with PTSD have benefited from these other therapies.

• Other types of counseling include group treatment, brief psychodynamic psychotherapy, and family therapy.
• Other types of medicines include:
  • Tricyclic antidepressants such as imipramine (Tofranil) and amitriptyline (Elavil, for example).
  • Atypical antidepressants such as mirtazapine (Remeron) and venlafaxine extended release (Effexor XR). One study has shown that venlafaxine XR reduced PTSD symptoms.¹³
  • Monoamine oxidase inhibitors (MAOIs) such as phenelzine (Nardil) and isocarboxazid (Marplan).
  • Mood stabilizers such as carbamazepine (Tegretol, for example) and lithium (Lithane, Lithobid, or Eskalith, for example). Mood stabilizers are sometimes taken with other medicines used for PTSD.
  • Antipsychotics such as imipramine (Tofranil). These medicines may help with symptoms like nightmares or flashbacks. More research is needed to find out how well these drugs work.
  • Prazosin (Minipress), which is used for nightmares and sleep problems related to PTSD.

If you are using medicine, take it exactly as prescribed. Call your doctor if it's not helping your symptoms or if the side effects are very bad. You and your doctor will decide what to do.

Deciding to get treatment

Unfortunately, many people don't seek treatment for PTSD. You may not seek treatment because you think the symptoms are not bad enough or that you can work things out on your own. But getting treatment is important.

Treatment can make your symptoms less intense and stop them from coming back. It can help you connect with your family, friends, and community. Many people get better with treatment.

If you need help deciding whether to see your doctor, see some reasons why people don't get help and how to overcome them.

When you first see your therapist, he or she will ask questions about the traumatic event causing PTSD and how severe your symptoms are. You may want your spouse, your partner, or a close family member to come with you. This person can help your doctor understand your symptoms and can help your therapist understand what you've been going through. Being with someone you trust helps you relax.

If you have other problems along with PTSD, such as overuse of alcohol or drugs, you also may need treatment for them.

"I'm a much more peaceful person now. I sleep so much better." — Vietnam veteran Ron Shepard

Recovery from post-traumatic stress disorder (PTSD) means finding your path to living a meaningful life. Recovery is not a cure. It helps you believe that you can reach your goals and learn new things to help yourself. It helps you gain self-confidence and respect for yourself.

The 10 principles of recovery make you the most important part of your recovery. Your counselor, doctor, family, and medicines can help you, but you're the one who makes the decisions. In the recovery process, you learn to cope with your symptoms and challenges and develop social support.

Positive coping skills

Coping is about dealing with your symptoms. When you cope with your symptoms in a positive way, you often feel more in control. You accept what the traumatic event did and take steps to improve your life. You can:

• Learn about PTSD to better understand how and why it affects you.
• Relieve stress to relax and feel less anxious.
• Exercise and be active to reduce how tense you feel. People who are fit usually have less anxiety, depression, and stress than people who aren't active.¹⁴
• Get enough sleep to help your mood and make you feel less stressed. Many people with PTSD have trouble sleeping because they feel nervous and anxious or can't stop thinking about the traumatic event.
• Eat a balanced diet to help your body deal with tension and stress. Whole grains, dairy products, fruits, vegetables, and protein are part of a balanced diet.
• Find things to do to ease your memories and reactions. Consider channeling your emotions into activities or sports, painting or writing, or a rewarding job.
• Identify your beliefs to keep you balanced. PTSD can cause a spiritual crisis. You may begin to question your own beliefs and values and ask yourself why war or disasters happen. If this happens to you, talk to a family member, friend, or spiritual advisor. Consider spiritual study, prayer, or meditation.

Negative coping skills

Negative coping skills are certain ways you may try to deal with your symptoms and problems that cause more harm than good. These are quick fixes that don't improve your situation in the long run. They include drinking too much, avoiding others, and lashing out.

Support groups and social support

There are times when you may need a shoulder to cry on or a ride to the doctor. You may want to learn more about PTSD or talk with others who have PTSD. You need people who understand what you are going through and will help you and care about you. This is your support network.

Support takes many forms. You can find it in seminars and groups led by professionals, in groups made up of others with PTSD, and in your relationships with family and friends.

"I didn't know why I needed to drink or wanted to drink. But Vietnam was never very far away when I did." — Vietnam veteran Ron Shepard

Post-traumatic stress disorder (PTSD) doesn't always occur alone. Other medical conditions, such as depression and alcohol abuse, often occur with it.¹⁵

• Alcohol and drug abuse occur with PTSD in both men and women. More than half of men with PTSD have a problem with alcohol. Alcohol also is a problem in women with PTSD.⁴
• Depression occurs more often than any other medical problem in women with PTSD, and it occurs often in men with PTSD.⁴
• Suicide may be a concern in people with PTSD.
• Anger and fear often occur in people with PTSD. Close to half of men with PTSD have problems with their behavior, such as uncontrolled anger.⁴
• Grief may affect post-traumatic stress disorder (PTSD). People who have been through a traumatic event and also have lost a loved one may have symptoms of PTSD for a longer time than those who have not lost a loved one.¹⁶
• Panic attacks and feeling anxious often occur with PTSD.⁴
• Physical health problems also may be linked to PTSD.¹⁷

“Talking about it with my wife is getting easier. The more I talk about it with people, the better.” — Iraq war veteran Tim Young

Post-traumatic stress disorder (PTSD) can harm your relationships with your family and community. Feelings of anger and depression and not wanting to deal with people can make it hard to connect with them. Pay attention to how you act with your family and try not to pull away. Your relationships can make a big difference in your recovery from PTSD.

Here are things you can do to help yourself, your family, and your community better understand and deal with PTSD.

• Know when to get crisis help. Sometimes you need help right away. This may be the case when you have had thoughts about suicide or if anger turns to rage.
• Help your family. Your family plays an important part in your recovery from PTSD. But you also have to help them. This means:
  • Talking to your family about PTSD and what it does to you.
  • Talking to your kids. Be sure they know they aren't to blame.
  • Talking about your triggers. Triggers are places, sounds, and sights that can cause symptoms. They can be locations, social events, or holidays.
• Know that life transitions, even positive ones such as getting married, having a baby, or starting a new job, can cause stress and result in more PTSD symptoms.
• Know that your relationship to your community can be changed by PTSD.
  • Some people may not feel comfortable with you or may look down on you. This is called stigma. You can reduce stigma by telling people about PTSD.
  • It may be hard to find a job, or you may have problems in the workplace.
  • You may have trouble making ends meet and paying bills.

Your family and community are part of your recovery. Do as much as you can to work with them. With knowledge, your family and community can better help you.

What can others do to help?

• If you care about someone with PTSD, here's what you can do to help.
  • Learn what you can about PTSD. The more you know, the better you can understand what your loved one is going through.
  • Help your loved one make friends and form a social network.
  • Learn how to deal with anger. Both you and your loved one may be angry at times.
  • Learn the best way to talk with your loved one. Be positive when you can. Don't give advice unless you are asked.
  • Take care of yourself by taking time for yourself and having your own support system.

Your family and community are part of your recovery. Do as much as you can to work with them. With this knowledge, your family and community can better help you.

Online Resources

Organizations

• Alcohol Abuse and Dependence
• Alcohol and Drug Problems
• Anxiety
• Depression
• Grief and Grieving
• Healthy Eating
• High Blood Pressure (Hypertension)
• Panic Attacks and Panic Disorder
• Stress Management

Citations

1. Rothbaum BO, et al. (2000). Cognitive-behavioral therapy. In EB Foa et al., eds., Effective Treatments for PTSD: Practice Guidelines From the International Society for Traumatic Stress Studies, pp. 60–83. New York: Guilford Press.

2. Bisson J (2006). Post-traumatic stress disorder, search date December 2005. Online version of Clinical Evidence (15): 1–18.

3. Anxiety disorders (2003). In RE Hales, ST Yudofsky, eds., Textbook of Clinical Psychiatry, 4th ed., pp. 595–630. Washington, DC: American Psychiatric Publishing.

4. Kessler RC, et al. (1995). Posttraumatic stress disorders in the National Comorbidity Survey. Archives of General Psychiatry, 52(12): 1048–1060.

5. Schurr PP, et al. (2005). A longitudinal study of retirement in older male veterans. Journal of Consulting and Clinical Psychology, 73(3): 561–566.

6. American Psychiatric Association (2004). Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. American Journal of Psychiatry, 161(11, Suppl): 3–31.

7. Kulka RA, et al. (1990). Evidence of post-traumatic stress disorder. In Trauma and the Vietnam War Generation, pp. 50–71. New York: Brunner/Mazel.

8. Dohrenwend BP, et al. (2006). The psychological risks of Vietnam for U.S. veterans: A revisit with new data and method. Science, 313(5789): 979–982.

9. Kang HK, et al. (2003). Post-traumatic stress disorder and chronic fatigue syndrome-like illness among Gulf War veterans: A population-based survey of 30,000 veterans. American Journal of Epidemiology, 157(2): 141–148.

10. Hoge CW, et al. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351(1): 13–22.

11. Litz BT (2006). The unique circumstances and mental health impact of the wars in Afghanistan and Iraq. A National Center for Post-Traumatic Stress Disorder Fact Sheet. Available online: http://www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_iraqafghanistan_wars.html.

12. Litz BT (2006). A brief primer on the mental health impact of the wars in Afghanistan and Iraq. A National Center for Post-Traumatic Stress Disorder Fact Sheet. Available online: http://www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_iraq_afghanistan_lay_audien.html.

13. Davidson J, et al. (2006). Treatment of posttraumatic stress disorder with venlafaxine extended release. Archives of General Psychiatry, 63(10): 1158–1165.

14. Pratt M (2004). Physical activity. In L Goldman, D Ausiello, eds., Cecil Textbook of Medicine, 22nd ed., vol. 1, pp. 54–57. Philadelphia: Saunders.

15. Davidson RT (2001). Recognition and treatment of posttraumatic stress disorder. JAMA, 286(5): 584–588.

16. Neria Y, Litz BT (2004). Bereavement by traumatic means: The complex synergy of trauma and grief. Journal of Loss and Trauma, 9(1): 73–87.

17. Green BL, Kimerling R (2004). Trauma, posttraumatic stress disorder, and health status. In PP Schnurr, BL Green, eds., Trauma and Health: Physical Health Consequences of Exposure to Extreme Stress, pp. 13–42. Washington, DC: American Psychological Association.