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DR. JAN NEWMAN
WHAT IS PTSD?
Despite what many people think, trauma is quite common. Post-traumatic stress disorder – on the other hand – is not.
Most people will experience a traumatic event in their lifetime but will not go onto develop PTSD.
Human resilience is the rule, not the exception.
Immediately following a traumatic event, many people will have symptoms of PTSD. For example, it is quite normal to have upsetting flashbacks, feel tense or nervous, or have trouble sleeping after being injured in a car accident. However, over time, for most people these symptoms naturally decrease. They gradually recover and are never diagnosed with PTSD. Yet there are some people whose symptoms do not decrease, and they are unable to recover naturally.
The word “trauma” comes from the Greek word meaning “to wound.” Therefore, PTSD can be understood as a disorder that occurs when that wound does not heal correctly. In other words, PTSD is a problem of recovery.
HOW COMMON IS TRAUMA?
In a 1997 landmark study, the CDC and Kaiser Permanente examined the relationship between adverse childhood experience (ACE) and health outcomes in a sample of 17,000 adults. The study defined an ACE to include not only events more commonly associated with trauma such as physical and emotional abuse and neglect but also household substance abuse and family mental illness.
The study found that ACEs are quite common. In fact, researchers found that 70% of adults will experience at least one ACE in their lifetime. Many adults will also experience interpersonal trauma—28% of study participants reported physical abuse and 21% reported sexual abuse.
Researchers also found that ACEs had a “dose-response” relationship to negative healthcare outcome. This means that the more ACEs a person experienced the more likely he or she was to experience adverse effects on physical health and well-being. For example, a child with four or more ACEs was 390% more likely to develop COPD, 460% more likely to suffer from depression, and had a 1,220% increased risk of suicide attempts.
A child with four or more ACEs was 390% more likely to develop COPD, 460% more likely to suffer from depression, and had a 1,220% increased risk of suicide attempts.
Researchers believe that ACEs lead to a variety of functional impairments that cause individuals to adopt risky behaviors that led to disease, disability, social problems, and ultimately, early death.
WHAT MAKES SOME PEOPLE MORE LIKELY TO DEVELOP PTSD?
Many factors can influence whether someone develops PTSD or not. If a person develops PTSD, it does not mean that they are weak or flawed. It likely means that something got in the way of their recovery, so the wound could not heal. Likely, the person had more risk than protective factors.
Some of the risk factors for PTSD relate to the traumatic event such as the severity and immediacy of the trauma. Some relate to the person’s prior history such as prior exposure to trauma, neglect, or childhood adversity. One of the biggest risk factors for PTSD is the experience of cumulative trauma. Given that PTSD is a problem of recovery, it makes sense that the more trauma a person experiences, the less likely they are to heal and recover.
Protective factors promote resiliency. One important protective factor for PTSD is social support after a traumatic event.
The National Institute of Mental Health lists some risk and protective factors relating to PTSD:
Living through dangerous events and traumas
Getting hurt
Dealing with extra stress after the event, such as loss of a loved one, pain and injury, or loss of a job or home
Having little or no social support after the event
Seeing another person hurt, or seeing a dead body
Childhood trauma
Feeling horror, helplessness, or extreme fear
Having a history of mental illness or substance abuse
Seeking out support from other people, such as friends and family
Finding a support group after a traumatic event
Learning to feel good about one’s own actions in the face of danger
Having a positive coping strategy, or a way of getting through the bad event and learning from it
Being able to act and respond effectively despite feeling fear
WHAT IS A TRAUMATIC EVENT?
To be diagnosed with PTSD, a person must first have been exposed to a traumatic event.
It is extremely important to distinguish the experience of “trauma” in the general sense from the experience of a “traumatic event” that qualifies under Criterion A of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
If a person experiences a traumatic event that does not qualify under the DSM-5, this does not mean that they do not have symptoms or impairment. It just means that their condition does not satisfy the DSM-5 criteria for PTSD.
Specifically, Criterion A of the DSM-5 requires that a person must be exposed to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, in at least one of the following ways:
Direct exposure
Witnessing the trauma
Learning that a relative or close friend was exposed to a trauma
WHAT ARE THE SYMPTOMS OF PTSD?
Under the DS-5, if the person has experienced a qualifying traumatic event, to meet criteria for PTSD, he or she must have all of the following symptoms for at least one month.
The traumatic event must be re-experienced in one of the following ways:
Intrusive thoughts
Nightmares
Flashbacks (reliving the trauma over and over, including physiological symptoms such as rapid heart rate or sweating)
Emotional distress after exposure to traumatic reminders
Physical reactivity after exposure to traumatic reminders
Difficulty experiencing positive affect
These symptoms can interfere with a person’s day-to-day functioning. Words, images, situations, or places that are reminders of the event may trigger these symptoms. For example, a song or sound (e.g., car backfiring) that the person heard at the time of the event may trigger these symptoms.
A person’s thoughts or feelings may cause them to feel as if they are back at the time of the event. Whatever the cause, these are memories that the person has not tried to and likely does not want to remember. In children, you may see a behavioral reenactment of the traumatic event in play. For example, children who have lived through a tornado, may later act this out in play by running to seek shelter.
The person must avoid trauma-related stimuli in one of the following ways:
Avoidance of internal trauma-related reminders (e.g., thoughts and feelings)
Avoidance of external trauma-related reminders (e.g., situations and places)
Either internal or external reminders of the traumatic event can trigger avoidance symptoms. Experiential avoidance occurs when a person avoids internal reminders about the traumatic event. An assault survivor may try to force himself to think about other things whenever thoughts or feelings about the assault arises. He may try to suppress thoughts or feelings telling himself, “Stop worrying about this” or “Past is past.” When a person avoids places or situations that remind her of the trauma, it is sometimes called behavioral avoidance. For example, a combat veteran may stop watching the news or reading the newspaper because of coverage of the war.
The person must experience negative thoughts or feelings that began or worsened after the trauma, in at least two of the following ways:
Overly negative thoughts and assumptions about oneself or the world
Exaggerated blame of self or others for causing the trauma
Negative affect
Decreased interest in activities
Feeling isolated
Difficulty experiencing positive affect
A person processes a traumatic event within the context of his or her existing beliefs. When a traumatic event occurs, it can directly challenge people’s beliefs about themselves, others, and the world. For example, many people have a “just-world belief” that a person’s actions should bring about morally fair and just consequences. Sadly, this belief can also lead people to blame themselves (i.e., “if this horrible thing happened to me and bad things only happen to bad people, then I must have done something to deserve this.”)
A person may also change his or her belief to incorporate the event. For instance, instead of blaming herself, a rape victim may have distorted beliefs about others such as “all men are violent” or the world “it is not safe to leave the house.” If persistent and rigid, such beliefs could cut her off from meaningful relationships and interactions with people who care about her.
The person must experience trauma-related arousal and reactivity that began or worsened after the trauma, in at least two of the following ways:
Irritability or aggression
Risky or destructive behavior
Hypervigilance
Heightened startle reaction
Difficulty concentrating
Difficulty sleeping
These symptoms are often challenging to differentiate the behavior that arises due to the anger, irritability, hypervigilance, and sleep difficulties of PTSD from non-trauma related behaviors or disorders that mimic these symptoms. For example, in many children and adolescents, this group of PTSD symptoms looks very much like the impulsivity and hyperarousal present in attention-deficit hyperactivity disorder (ADHD). For example, many youth presenting these symptoms are often misdiagnosed with ADHD or other disruptive behavior disorders and never treated for PTSD. Second, this group of symptoms can be difficult to effectively treat because they reflect the effects of overactivation of the sympathetic nervous system (SNS). This overactivation of the SNS can shrink the hippocampus, enlarge the amygdala, and affect other areas of the cortex. In this sense, effective treatment for PTSD involves rewiring or the brain.
PTSD STATISTICS
How common is PTSD? According to the National Center for PTSD and NIMH, here are some statistics based on the U.S. population:
About 7 or 8 out of every 100 people (or 7-8% of the population) will have PTSD at some point in their lives.
About 8 million adults have PTSD during a given year. This is only a small portion of those who have gone through a trauma.
About 10 of every 100 women (or 10%) develop PTSD sometime in their lives compared with about 4 of every 100 men (or 4%). Learn more about women, trauma and PTSD
Among adolescents age 12 – 17, about 6 of every 100 girls (6.3%) or 4 of every 100 boys (3.7%) had PTSD
TREATMENTS
Treatment for PTSD typically involves a combination of psychotherapy, pharmacotherapy, or a combination of the two. There is a great deal of information available online about how to choose the best treatment option for PTSD. It is important that you consult with a mental health professional with experience in treating PTSD to choose the treatment that is right for you.
In their practice guidelines for adults, the American Psychological Association strongly recommends evidence-based treatments (EBTs) for the effective treatment of PTSD. All are some variation of cognitive-behavioral therapy (CBT), which focuses on the relationships between thoughts, feelings, and behaviors.
Cognitive Behavioral Therapy (CBT). CBT for PTSD has the same underlying components as regular CBT but is trauma-focused. It focuses on identifying, understanding, and restructuring thinking and behavior patterns relating to the trauma.
Cognitive Processing Therapy (CPT). CPT is a 12-session treatment that involves the following psychoeducation, cognitive therapy around trauma-related thoughts, a detailed written trauma account, and cognitive restructuring around five core concepts that are often impacted in PTSD (safety, trust, power/control, esteem, and intimacy). The VA has a CPT Coach app that may be helpful for clients completing CPT.
Prolonged Exposure (PE). PE typically lasts 8 – 15 weekly sessions. Like CPT, PE treatment involves psychoeducation regarding the thoughts, feelings, and behaviors relating to the trauma. Unlike CPT, however, PE includes a comprehensive gradual exposure component. The VA also has the PE Coach app that may be helpful for clients completing PE.
Eye Movement Desensitization and Reprocessing Therapy (EMDR). EMDR is another recommended treatment for PTSD. According to the APA Practice Guidelines, EMDR “encourages the patient to briefly focus on the trauma memory while simultaneously experiencing bilateral stimulation (typically eye movements).” This intervention is associated with a reduction in the vividness and emotion associated with the trauma memories.
The National Center for PTSD has also developed a helpful decision aid that discusses the different treatment options for PTSD.
According to the California Evidence Based Clearing House, the EBTs for PTSD in children and adolescents with the strongest evidentiary report include:
EMDR for Children and Adolescents. This version of EMDR treatment is a downward extension of EMDR for children and adolescents.
Prolonged Exposure Therapy for Adolescents (PE-A). PE-A is an adaptation of PE designed to be used with adolescents ages 12 – 18.
Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). TF-CBT is a comprehensive treatment for PTSD in children ages 3 – 18 that typically takes 12-16 sessions. TF-CBT includes child-only, parent-only, and conjoint sessions.
INFORMATION AND RESOURCES
For more information on PTSD and available treatments, you can visit the following websites:
Anxiety and Depression Association of America (offers support groups for many conditions including PTSD)
SERVICES OFFERED BY DR. JAN NEWMAN
Read more about my approach to treating traumatic distress and PTSD, vicarious trauma, and trauma treatment.
I am a certified therapist and supervisor for Trauma-Focused CBT in children and adolescents. I was trained in TF-CBT at the University of Oklahoma Health Sciences Center Center for Child Abuse and Neglect and OU Children’s Hospital and School of Medicine.
With adults, I typically use prolonged exposure therapy (PE) with acceptance and commitment therapy (ACT) and cognitive processing therapy. I received my prior training in these therapies while working at a VA Center of Excellence with veterans and their families.
At my Charlotte, NC therapy office, I offer a variety of mental health services. I also offer online therapy in North Carolina. In my therapy practice, I work with clients in all ages including children, teens, and adults. I provide treatment for anxiety, stress, depression, trauma, vicarious trauma, and life transitions. If you’re interested in group therapy, I offer group therapy for adults and teens. Please contact my office to hear more about the many ways I can help you thrive and be successful at work and at home.
STAY CONNECTED & INFORMED
You can also visit my blog or follow me on Facebook where I offer more information on psychology, human behavior, and neuroscience. You can also visit my resources page for my most frequently recommended resources.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.
Courtois, C. A., & Ford, J. D. (2012). Treatment of complex trauma: A sequenced, relationship-based approach. Guilford Press.
Kilpatrick, D. G., Resnick, H. S., Milanak, M. E., Miller, M. W., Keyes, K. M., & Friedman, M. J. (2013). National estimates of exposure to traumatic events and PTSD prevalence using DSM‐IV and DSM‐5 criteria. Journal of traumatic stress, 26(5), 537-547.
Sar, V. (2011). Developmental trauma, complex PTSD, and the current proposal of DSM-5. European Journal of Psychotraumatology, 2(1), 5622.
Dr. Jan Newman is a Licensed Psychologist and the owner of Momentum Psychology. She received her PhD in Clinical Psychology from Auburn University and her JD from the University of North Carolina School of Law. She is also an executive coach, speaker, podcaster, and author with many peer-reviewed publications. Previously, she served as a professor in a large research university, a director of a treatment program focusing on trauma, and an attorney. As a trauma therapist, she specializes in working with teens and adults who have experienced trauma. She is specially trained in an evidence-based therapy called prolonged exposure therapy (PE) to help clients with traumatic stress and PTSD process and work through traumatic memories. She is also trained in exposure and response prevention (ERP), CBT, ACT, and DBT. Jan believes strongly in the power of therapy through the vehicle of the therapeutic relationship to heal trauma. Her mission is to help support her clients in their journey of healing, self-compassion, and posttraumatic growth to live a rich and fulfilling life.
Momentum’s resources are for informational purposes only and are not intended to assess, diagnose, or treat any medical and/or mental health disease or condition. Our resources do not imply nor establish any type of therapist-client relationship. The information should not be considered a substitute for consultation with a qualified mental health or medical provider who could best evaluate and advise based on a careful evaluation.
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