Post-Traumatic Stress Disorder (PTSD): Current Practice

Post-Traumatic Stress Disorder (PTSD) is a life-altering condition that may occur following exposure to a dramatic life-changing event or series of such events. It is characterized by difficulty accurately interpreting sensory stimuli's threat value following a traumatic event. The prevalence of PTSD globally is “3.9%, with high-income countries having a higher burden of PTSD compared to low-income countries” (Barber & Aaronson, 2022). We refer to experiences of horror, terror, and threatened (real or perceived) injury with the risk of death as "traumatic." This little word fails to convey the scope of the experience, and it is consistently hard for those who have lived through those terrible events to express the profound feelings and changes they have suffered. This inability to articulate one's feelings and thoughts is especially true when talking with people who, due to a lack of personal experience, may not have full insight into feelings that are often beyond the description of words. This course will help the provider to better understand post-traumatic stress disorder, risk factors, and treatment options.

1980 brought PTSD into recognition by its inclusion in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association, which defines the grouping of symptoms within the syndrome. Until then, separating posttraumatic stress from the throws of severe grief or depression had been clouded by disagreeing perceptions and competing definitions among professionals in the mental health fields.

Helplessness, fear, and even horror are normal, strong reactions to profound events. When intense, pervasive feelings linger after the event of origin has concluded, we refer to them as "post-trauma" or use the term "post-traumatic event" to acknowledge the lingering turmoil that accompanies the presence of stresses yet to be resolved. The process of resolving these stresses often requires help. PTSD can lead to chronic health conditions and comorbid psychiatric illnesses and increase the risk of suicide (Mann, Marwaha, & Torrico, 2024).

Brooklyn Foreger is a 10-year-old girl living in a suburban community with her parents and a younger sibling (Malachi, age 7). She is in the 5th grade at her local elementary school. Brooklyn was invited to a community carnival bustling with other children and families, with the sounds of laughter, music, and carnival lights. It was a yearly tradition for her family to attend. A sudden loud noise rang out while Brooklyn and her family were waiting in line for the Rocket Ride. Initially, it was mistaken for a fireworks display or a malfunctioning ride. However, within moments, chaos erupted, and people began screaming, running in all directions. Brooklyn’s parents tried to shield her and her younger brother, pulling them to the ground, covering their heads, and trying to escape the danger.

After a few harrowing moments, it became clear that gunshots had been fired very close to where they were standing. Brooklyn’s father tried to direct his young family to a safer area. Brooklyn and her brother were physically unharmed, but Brooklyn was emotionally shaken.

Authorities confirmed the shooting had been a targeted attack, and several people were injured, one person dead.

In the hours following the shooting, Brooklyn was tearful and repeatedly asked questions about what had happened. She expressed feelings of confusion and fear, not fully understanding the situation, only that she was in imminent danger. She had trouble sleeping during the following weeks, refused to attend school, and missed her best friend’s birthday party. She became irritable and easily startled by loud noises. She often complained of headaches and would become so emotionally upset if her parents tried to force her to leave the house that she would vomit and have uncontrollable diarrhea.

PTSD is called the "I cannot stop remembering!" disease. Overall population studies in the United States and Canada found the lifetime occurrence of PTSD ranged from 6.8 to 12.3 percent of the adult population, with women generally having around four times higher rates of lingering traumatization to horrific events (Lanius, Frewen & Brand, 2024: Sareen, 2024). Be aware that no demographic group is completely spared from the risk of PTSD in response to exposure to extreme events. Lingering fear and horror can affect any person, given the right circumstances.

Risk factors associated with the development of PTSD include:

• The history of trauma exposure before the index traumatic event
• Lower socioeconomic status
• Childhood adversity (including trauma and abuse)
• Gender
• Race
• Personal and family psychiatric history
• Less education
• Poor social support
• Physical injury as part of the event (e.g., traumatic brain injury, broken bones, etc.)
• The initial severity of reaction to the traumatic event(Sareen, 2024).

Another important risk factor for the development of PTSD is the locus of control or the amount of control people feel that they have over their behaviors and outcomes. An internal locus of control is the belief that a person can influence their own fate. In contrast, an external locus of control is the belief that behaviors and outcomes are determined by luck, fate, or external factors. Research shows that individuals who have a high perceived level of external locus of control have a greater risk of developing PTSD (Güzel et al., 2024).

Whether physical changes to the brain occur from heightened levels of stress hormones, as some believe, or those hormones are merely contributing factors, it is clear that the brains of people with PTSD have been changed during the traumatic event. Researchers using both magnetic resonance imaging (MRI) and positron emission tomography (PET) scans have shown a decreased volume of the hippocampus, left amygdala, and anterior cingulate cortex in patients with PTSD (Sareen, 2024). It is as though the environmental shock of the traumatic event physically produces a structural change in how a person stores memories. How this happens, or even why, is not yet known.

During high-stress events, our bodies release adrenaline, a chemical responsible for increasing blood pressure, heart rate, pulse, and the transfer of glucose to muscles. It does this automatically and immediately in the face of fear, without conscious volition. This "hard-wired" response to terror primes our physiology to fight for our lives or to make a run to safety.

Once the immediate danger is over, or at least once the perceived risk has lessened, our body initiates a cascade of chemical reactions designed to "defuse" the reaction fear initiated. This closing down, or damping, of the stress response, is linked to an essential hormone, cortisol.

The hypothalamic-pituitary-adrenal axis (HPA) is the body’s major response system to stress. The release of cortisol activates the sympathetic nervous pathway system, which then generates negative feedback to both the hypothalamus and the anterior pituitary. This feedback system is compromised in people with PTSD (Al Jowf et al., 2023; Sherin & Nemeroff, 2011; Van der Kolk, 2015).

Research has determined that if your body is low or lacking in the hormone cortisol, you cannot effectively or efficiently shut down the stress reaction prompted by the impulse for flight or fight. Without adequate cortisol, you continue to feel the stress effects caused by adrenaline for much longer. Some studies have shown that victims of trauma who possess a higher "normal" level of catecholamines (stimulating hormones of which adrenaline is a member) tend to develop PTSD more easily than those without elevated levels. Whether or not the lingering high levels of stress hormones cause traumatic memories to be "imprinted" or remembered in much greater clarity and detail than would otherwise be the case is unknown. Victims of PTSD are consistent, however, in showing a measurable surge of stress hormones when they are reminded of their trauma (Back, 2024).

An Acute Stress Disorder (ASD) occurs in the initial month after a person has experienced, witnessed, or been confronted with an event that threatens physical or psychological injury, death, or great harm. This harm could have been directed toward the individual, targeted others, or affected material objects of great value to that person. One example of this was the loss of the World Trade Center twin towers on September 11, 2001, an occurrence that traumatized an entire nation. When exposed to such an event, especially when it is beyond that person's ability to influence or control realistically, intense feelings of helplessness, fear, or horror may result. The intent in identifying ASD is to limit the development of PTSD, which is diagnosed only after four weeks of symptoms following exposure (Bryant, 2024). It is unclear why some people only experience ASD, and other people progress to PTSD, but some believe that it relates to neurobiological processes (Benedek & West, 2024). 

The neurobiological response to psychological trauma depends not only on the “stressor characteristics but also on the factors specific to the individual (Sherin & Nemeroff, 2011)”. Genetic, developmental, and experiential factors predispose people to the development of PTSD. In the last decade, “etiological models have been developed to explain the interplay between biology, environment, and mind in manifesting the disease. Examples of those models include the diathesis-stress and the biopsychosocial models” (Al Jowf et al., 2023). Research supports an association between genetic variants and an increased risk for PTSD, including hypothalamic-pituitary-adrenal axis (HPA) dysfunction, neurotransmitter dysregulation, and alterations in brain circuits (Al Jowf et al., 2023; Lanius, Frewen, & Brand, 2024; Van der Kolk, 2015).

According to Kunimatsu et al. (2020), functional magnetic resonance neuroimaging (fMRI) scans of patients who are experiencing PTSD demonstrate focal atrophy of the gray matter, altered fractional anisotropy, and altered focal neural activity and functional connectivity. Several regions of the brain are impacted by the traumatic event, including the medial and dorsolateral prefrontal cortex, orbitofrontal cortex, insula, lentiform nucleus, amygdala, hippocampus and para-hippocampus, anterior and posterior cingulate cortex, precuneus, cuneus, fusiform and lingual gyri, and the white matter tracts connecting these brain regions. Kunimatsu et al. (2020) found that alterations in the brain seen on fMRI scans support the hypothesis that abnormal fear learning and reactions to a perceived threat are highly correlational to the development of PTSD.

In PTSD, the uniting factor is a lingering memory of feelings, thoughts, or images that remain present for some time following an extreme event. These stored sensations may be re-experienced along with a replay of any physiological reactions felt or experienced during the original event (i.e., racing heart, rapid breathing, feelings of falling, or sensations of being trapped, etc.). People experiencing these sensations often attempt to compensate by avoiding triggering experiences or places, dissociating (emotional numbing, extreme detachment from others, decreased responsiveness to external stimuli, memory impairment), or experiencing a disturbance of identity and awareness (depersonalization and derealization) (Lanius, Frewen, & Brand, 2024).

Other clinical manifestations include (American Psychiatric Association, 2013; Lanius, Frewen & Brand, 2024):

• Intrusive thoughts, nightmares, and flashbacks of the traumatic event
• Avoidance of reminders of trauma
• Hypervigilance
• Sleep disturbance
• Physical illness (heart disease, irritable bowel syndrome, headaches, etc.)
• Self-mutilation and suicide attempts
• Mood and Eating disorders
• Panic and agoraphobia disorder
• Substance use disorder

These symptoms typically lead to considerable social, occupational, and interpersonal dysfunction. Various categories of traumatic experiences have been found to result in posttraumatic stress disorder (PTSD). These categories and the percentage of PTSD cases they make up include (Sareen, 2024):

• Sexual relationship violence – 33%  (e.g., rape, childhood sexual abuse, intimate partner violence).
• Interpersonal-network traumatic experiences – 30% (e.g., unexpected death of a loved one, life-threatening illness of a child, other traumatic event of a loved one).
• Interpersonal violence – 12% (e.g., childhood physical abuse or witnessing interpersonal violence, physical assault, or being threatened by violence).
• Exposure to organized violence – 3% (e.g., refugee, kidnapped, civilian in a war zone).
• Participation in organized violence – 11% (e.g., combat exposure, witnessing death/serious injury or discovered dead bodies, accidentally or purposefully caused death or serious injury).
• Other life-threatening traumatic events – 11%(e.g., life-threatening motor vehicle collision, natural disaster, toxic chemical exposure).

Assessment for the diagnosis of PTSD is extremely difficult as people often do not want to acknowledge or discuss the traumatic event, and few clinicians have been trained to assess for traumatization or dissociation. A few self-report assessment tools are available, but they should not replace clinical interviews or judgments. PTSD Checklist (PCL-5) is a 5-item self-report measure that can be used to screen patients for PTSD and monitor the progression of symptoms over time (Stein, 2024).

The five-item Primary Care PTSD measure and the Posttraumatic Stress Disorder Checklist for the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) have demonstrated good reliability and validity.

There is also a Childhood Trauma Questionnaire (CTQ) for assessing childhood trauma exposure. It is a 28-item self-report assessment for childhood maltreatment and can be completed by adolescents (12 and older) as well as adults (Hagborg, Kalin, & Gerdner, 2022). It can usually be completed within five minutes.

To diagnose posttraumatic stress disorder (PTSD) in individuals older than six years, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) outlines a comprehensive set of criteria that must be met. First, the individual must have been exposed to actual or threatened death, serious injury, or sexual violence (APA, 2022). This exposure can occur through direct experience, firsthand witnessing, learning about such events affecting close relations, or repeated exposure to their details in work-related contexts. Importantly, passive exposure through media does not qualify unless it is work-related.

Following this exposure, the individual must experience persistent intrusion symptoms related to the trauma. These include involuntary and recurrent memories, distressing dreams, dissociative reactions like flashbacks, or intense emotional or physiological distress triggered by cues resembling the event. For children, these symptoms may manifest as repetitive trauma-themed play or unrecognizable frightening dreams.

The diagnosis also requires evidence of avoidance behaviors, such as efforts to avoid trauma-related thoughts, feelings, or external reminders. Additionally, there must be negative changes in mood and cognition, including memory gaps, distorted beliefs, persistent negative emotions, diminished interest in activities, detachment from others, or an inability to feel positive emotions.

Alterations in arousal and reactivity are also key diagnostic features. These may include heightened irritability, reckless or self-destructive actions, hypervigilance, exaggerated startle responses, difficulty concentrating, or sleep disturbances.

To confirm PTSD, these symptoms must persist for more than one month, cause significant distress or functional impairment, and cannot be attributed to substance use or another medical condition.

According to McLaughlin (2024), children are not immune to the prolonged effects of trauma. Younger children, in particular, may respond to trauma in ways that differ from adults. For those five and younger, common reactions include fear of separation from a parent or caregiver, crying, whimpering, screaming, motionless or displaying aimless movements, trembling, showing frightened expressions, and excessive clinginess. Caregivers may observe behaviors such as thumb sucking, bedwetting, and other regressions. Children in this age group are often deeply influenced by their caregivers' reactions to traumatic events.

Children between six and eleven years old may display extreme withdrawal, disruptive behaviors, or difficulty focusing. They might also show signs of regressive behaviors, nightmares, sleep disturbances, irrational fears, irritability, refusal to attend school, angry outbursts, and physical fights. Additionally, they may complain of physical symptoms without any medical cause. Academic performance is often affected, and feelings of depression, anxiety, guilt, and emotional numbness are common.

Adolescents aged twelve through seventeen years may have responses similar to adults.

No matter the age, those who experience the effects of PTSD report continually reliving the trauma. This reliving can occur in the form of nightmares or disturbing recollections, sensations, or emotions during the day. Sleep problems, depression, and feelings of numbness or detachment are common. Sufferers may lose interest in things they once enjoyed, including experiencing affection. Irritability, increased aggressiveness, and even violence can be new behaviors they did not exhibit before.

Many with PTSD report experiencing distress when seeing events, objects, or persons that remind them of the traumatic event. It is common to avoid key places, situations, or people who provoke recall of events they would like to forget. Dates, such as the anniversary of the triggering event, can be especially difficult.

Ordinary, commonplace events can serve as memory association triggers for intrusive images or flashbacks. A flashback is a disassociation from reality with a reenactment or intensely real memory of the traumatic event. An individual reliving a flashback can experience sounds, smells, images, and even feelings from the original event and often believes that the event is occurring all over again. Flashbacks may last seconds or hours. Rarely, a flashback may last for days.

Treatment for PTSD combines the best therapeutic approaches with medication-based care. As each person and each traumatic event are different, no one approach is applicable for every person requiring treatment. For most, medication and therapeutic interventions are more successful than either alone.

Brooklyn Foreger’s mother took her to her pediatrician, who referred her to a pediatric psychiatrist. Brooklyn was prescribed Zoloft 25 mg daily as a first-line treatment and assigned a therapist who specialized in trauma therapy. Her parents supported Brooklyn and took the entire family for family therapy sessions. As part of her treatment plan, Brooklyn began drawing pictures and writing in a journal daily. After three months of intense individual therapy, she began to attend group therapy. After six months, she was able to attend school again without having a physical reaction (e.g., diarrhea, nausea, and vomiting).

The U.S. Department of Veterans Affairs (2025a) offers detailed advice on how to best cope with traumatic stress reactions. These include any number of the following:

1. Learn about trauma and its effects: Understanding how PTSD affects them, survivors can recognize they are not alone. Many others have experienced similar traumas and had similar responses. They are not weak or crazy; most especially, they are not alone.
2. Talk to others: Speaking openly with others allows survivors to express their feelings instead of keeping them bottled up. It’s important to exercise caution, though. Some individuals who offer help may not have the proper skills or may even be taking advantage of vulnerable people. Help your client make wise decisions about who to talk to.
3. Schedule regular visits with a health professional: During treatment, questions will arise, such as, “Am I the only one feeling this way?” or “Am I a bad person?” Make it a habit to schedule the next appointment before leaving each session, or establish a fixed schedule like “the second Tuesday of every month at 1 p.m.”
4. Practice relaxation: Remember that relaxation is a skill that must be learned. Techniques such as breathing exercises, stretching, meditation, prayer, listening to calming music, or spending time in nature can help. Initially, relaxation may feel uncomfortable, as it can bring up physical sensations, thoughts, and emotions that are usually avoided. Part of the process is learning to manage these thoughts and feelings and find a calm space free of negative distractions.
5. Increase positive distractions: Activities like art, work, and recreation can help shift focus away from negative thoughts and emotions. Art, in particular, has been a powerful tool for many PTSD survivors, improving mood and promoting faster healing through creative expression.
6. Exercise: Regular physical activity boosts endorphins, which are "feel-good" chemicals that promote a sense of peace and distract from negative emotions. Make sure your client takes advantage of these benefits.
7. Reach out when help is needed: Everyone has both good and bad days, and those with PTSD may find that their usual coping strategies don’t work on some days. It’s important to plan and arrange to have a counselor or support person to contact when nothing else seems to help.
8. Avoid alcohol and drugs: While alcohol and drugs may seem like a way to cope, they can worsen PTSD symptoms by triggering flashbacks, nightmares, or re-living the trauma. They open the door to re-experiencing the pain that lies just below the surface.
9. Join a support group: Joining a group can be challenging, but seeing others share similar experiences can be incredibly healing. Many nationwide and local organizations provide support, and connecting with others can help combat the isolation that often accompanies PTSD. Several online support group organizations can be accessed, including the following:
   1. National Center for PTSD (VA) – PTSD Support Groups. The National Center for PTSD offers resources, including online support options, for veterans and the general public. They provide access to peer support programs and other PTSD-related services.
   2. PTSD Foundation of America – Warrior Support. This foundation offers online support groups for veterans and first responders, along with a variety of resources for those dealing with PTSD.
   3. PTSD Support Forum: A well-established online community for people with PTSD. The forum allows users to share experiences, ask questions, and support others with trauma.
   4. Psychology Today – Online Therapy and PTSD Groups. While primarily known for therapy directory services, Psychology Today also lists online support groups and virtual therapy options for those dealing with PTSD.
10. Volunteer to help others: Helping others can be a powerful way to heal. Encourage your client to volunteer their time and talents in youth programs, medical services, literacy programs, or community activities. This can bring a sense of purpose and fulfillment by positively impacting others' lives.
11. Rebuild relationships with family and friends: Reconnecting with loved ones from before the trauma can help ease feelings of distrust towards strangers and new acquaintances, allowing survivors to feel more supported and connected.
12. Consider relocating: If a person’s living or work environment is tied to traumatic memories, suggest they move away from those triggers. Later, when they feel ready, returning to those places can be part of the healing process, but for now, it’s important to focus on coping and moving forward.

According to the National Center for PTSD (The U.S. Department of Veterans Affairs, 2025a), four signs that a client is receiving good, evidence-based care for PTSD include the following:

1. A provider who communicates the different treatment options and allows the patient to choose which treatment options he/she would like to pursue. Having the patient involved in the decision-making process is important to overall success and continuity of care.
2. Evidence-based treatments are combined. The treatment plan should include multiple modalities (e.g., medications and therapy).
3. Progress is measured and tracked over time using evidence-based tools such as the five-item Primary Care PTSD measure and the Posttraumatic Stress Disorder Checklist for the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).
4. The patient feels he/she is improving. If the patient is not improving, adding or removing different treatment modalities is discussed and, if appropriate, pursued until the patient feels improved.

Josef is a 36-year-old sales manager who travels internationally. While traveling in a foreign country, Josef was involved in a head-on collision in a remote area with a van traveling in the wrong lane. The crash resulted in multiple deaths on the bus and left Josef with fractured ribs and a concussion.

During the aftermath of the accident, Josef was trapped in the car for several hours before emergency services arrived. He could hear the cries of other injured victims on the bus, and being unable to help them intensified his feelings of helplessness and guilt. The traumatic event, compounded by intense physical and emotional distress, eventually led to the onset of PTSD.

In the weeks that followed the accident, Josef began to exhibit intrusive thoughts and memories of the event, especially when traveling by car. Mundane stimuli, such as the sound of screeching tires or the smell of exhaust fumes, often triggered these flashbacks. These intrusive memories caused him great distress and made it difficult to focus on work or engage in conversations with his family. He also experienced avoidance behaviors, refused to travel for work trips, and avoided driving when possible. Josef had difficulty sleeping due to nightmares about the accident, often waking up in a state of panic and sweating. He also reported feeling irritable, tense, and hypervigilant, as though he was constantly in danger.

Socially, Josef stopped engaging with friends and avoided events that he once enjoyed. He stopped attending social gatherings and stopped taking vacations, fearing that traveling would trigger memories of the accident. His physical health also began to decline due to disrupted sleep patterns, lack of exercise, and unhealthy coping mechanisms such as alcohol consumption.

Josef sought medication management from a recommended psychiatrist. He was prescribed an SSRI to help decrease his anxiety symptoms, as well as an alpha-1 blocker to decrease his anxiety and treat his nightmares. He was assigned an EMDR therapist who worked with Josef to help process the traumatic memories of the accident, reduce his emotional charge, and integrate these memories into a more adaptive narrative. Both his psychiatrist and his therapist recommended regular exercise, good sleep hygiene, and a reduction in alcohol consumption as part of his treatment plan.

Over time, Josef reported a marked reduction in the intensity of his intrusive thoughts and feelings of guilt. He could resume his travel obligations for work and rebuild his career while continuing to practice his coping skills and manage his stress.

PTSD is a complex disorder characterized by intrusive thoughts, flashbacks, nightmares, hypervigilance, avoidance of places and events that trigger reminders of trauma, and poor sleep, which leads to significant interpersonal dysfunction impacting social and occupational functioning. “The prevalence of PTSD ranges from 6.1 to 9.2 percent in the general adult population for the United States and Canada with one-year prevalence rates of 3.5 to 4.7 percent” (Sareen, 2024). These symptoms may continue for months, even years, after the event. When a situation, individual, or object triggers a flashback, that individual re-experiences aspects of an event in an involuntary and usually very distressing manner. It is important to know they are not weird or abnormal when this occurs. Their thoughts have simply been prompted or triggered to recall the particularly vivid memories instilled by the event.

Feelings of fear, uncertainty, guilt, or dread following a life-threatening, life-altering traumatic event are completely normal. As the body processes stress chemicals released by terror or horror incidents, the mind also seeks to cope. For most, a balance will eventually be restored, though the process is not easy and may not be quick. For some, perhaps as many as thirty percent, of those exposed to traumatic events, balancing the mind, psyche, and emotion will take much longer.

Treatment that combines medication to help lessen symptoms and psychiatric therapy to help the mind accept and adjust to life after the distress-causing event is very helpful for most people. Using coping skills provides means and methods to get through each day, one day at a time.

There is life, health, and happiness after a profound trauma. It may take work to reach it, yet by increasing our knowledge and ability; we can help survivors of horror achieve health without fear.

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