Psychology Post-Traumatic Stress Disorder (PTSD)
by
Chris R. Brewin
  • LAST REVIEWED: 29 September 2017
  • LAST MODIFIED: 29 June 2015
  • DOI: 10.1093/obo/9780199828340-0094

Introduction

Severe reactions to experiences such as combat and railway accidents have been described since the mid-19th century by numerous physicians, including Sigmund Freud and Pierre Janet. These descriptions include two types of characteristic symptoms: dissociative symptoms, in which there is a general disturbance in normal mental functions, such as memory, consciousness, time estimation, sense of reality, and identity, and reexperiencing symptoms, in which the traumatic event is vividly relived as though it were happening all over again in the present. Despite this early recognition, posttraumatic stress disorder (PTSD) was formally defined only in the third edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders: DSM-III (Washington, DC: American Psychiatric Association, 1980). Prior to this, exposure to stress was assumed to produce only short-term problems in adjustment. In the DSM-III, PTSD required exposure to “a recognizable stressor that would evoke significant symptoms of distress in almost everyone” and was “outside the range of normal human experience.” In addition four symptoms had to be present reflecting reexperiencing of the traumatic event, numbing and detachment, and a more pervasive change in arousal or emotions. The definition was refined in the Diagnostic and Statistical Manual of Mental Disorders: DSM-III-R published in 1987, which introduced more symptoms and required at least one reexperiencing symptom (e.g., intrusive memories or nightmares), three avoidance or numbing symptoms (e.g., avoidance of reminders of the traumatic event or loss of interest in activities), and two hyperarousal symptoms (e.g., exaggerated startle or irritability). Diagnostic and Statistical Manual of Mental Disorders: DSM-IV, introduced in 1994, retained a similar structure. The 2013 Diagnostic and Statistical Manual of Mental Disorders: DSM-5 increased the number of symptoms from seventeen to twenty reorganized them into four symptom clusters, reexperiencing, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity. In 1992 PTSD also appeared in another major international classification system, the tenth edition of the World Health Organization’s International Classification of Diseases (ICD-10) (Geneva, Switzerland: World Health Organization, 1992–1994). This formulation placed more emphasis on “episodes of repeated reliving of the trauma in intrusive memories (‘flashbacks’) or dreams” and also identified avoidance, numbing, and hyperarousal as central features. The introduction of the disorder in the DSM-III was strongly influenced by studies of combat veterans and women in violent relationships, which suggested the existence of more long-lasting psychiatric conditions, variously termed “combat neurosis,” “rape trauma syndrome,” or “battered women syndrome.” The PTSD diagnosis was designed to subsume these syndromes and capture what was considered to be an essentially normal response to any overwhelming trauma. This made it unlike other psychiatric disorders, which all implied some vulnerability on the part of the person who succumbed to it.

Introductory Works

The history of the recognition of posttraumatic reactions starting in the 19th century is described in a number of publications (Weisaeth 2014, Wilson 1994). One of the most influential 20th-century theorists has been the psychiatrist Mardi J. Horowitz (Horowitz 2011), whose work on general reactions to stressors such as bereavement played a major role in the original formulation of PTSD in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders: DSM-III (Washington, DC: American Psychiatric Association, 1980). As of the early 21st century, PTSD and its close relative, acute stress disorder, remain the only psychiatric disorders to specify a causal agent, and PTSD continues to be a controversial diagnosis. The main criticisms are that the disorder was introduced for political rather than scientific reasons, that it inappropriately medicalizes normal human reactions, that it gives too much weight to the stressful event and not enough to the person, that it is not distinct from other recognized disorders, and that its symptom structure is too complex (Brewin 2003; Rosen and Lilienfeld 2008; Spitzer, et al. 2007; Young 1995).

  • Brewin, Chris R. 2003. Posttraumatic stress disorder: Malady or myth? New Haven, CT: Yale Univ. Press.

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    Text written for a general audience that reviews the historical and scientific controversies over PTSD and related issues, such as recovered memories of trauma. Presents an evidence-based update of current knowledge.

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    • Horowitz, Mardi J. 2011. Stress response syndromes: PTSD, grief, adjustment, and dissociative disorders. 5th ed. Northvale, NJ: Aronson.

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      A landmark text putting forward an information-processing model of response to stress involving the interplay of involuntary thoughts and images and the attempts made to avoid them. The first edition, published in 1976, had a major influence on shaping the phenomenology of PTSD in the DSM-III.

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      • Rosen, Gerald M., and Scott O. Lilienfeld. 2008. Posttraumatic stress disorder: An empirical evaluation of core assumptions. Clinical Psychology Review 28.5: 837–868.

        DOI: 10.1016/j.cpr.2007.12.002Save Citation »Export Citation »E-mail Citation »

        The authors dispute the premise that a distinct class of traumatic events is linked to a distinct clinical syndrome, the core assumption that ostensibly distinguishes the PTSD diagnosis from virtually all other psychiatric disorders. They conclude that virtually all core assumptions and hypothesized mechanisms of PTSD lack compelling empirical support. Available online for purchase or by subscription.

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        • Spitzer, Robert L., Michael B. First, and Jerome C. Wakefield. 2007. Saving PTSD from itself in DSM-V. Journal of Anxiety Disorders 21.2: 233–241.

          DOI: 10.1016/j.janxdis.2006.09.006Save Citation »Export Citation »E-mail Citation »

          The authors review evidence that fails to support some of the key assumptions behind the PTSD diagnosis and propose more stringent definitions of a traumatic event and of posttraumatic symptoms. Available online for purchase or by subscription.

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          • Weisaeth, Lars. 2014. The history of psychic trauma. In Handbook of PTSD: Science in practice. 2d ed. Edited by Matthew J. Friedman, Terence M. Keane, and Patricia A. Resick, 38–59. New York: Guilford.

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            Provides an overview of the origins of the clinical and scientific study of traumatic stress from the 19th century to the early 21st century.

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            • Wilson, John P. 1994. The historical evolution of PTSD diagnostic criteria: From Freud to DSM-IV. Journal of Traumatic Stress 7.4: 681–698.

              DOI: 10.1002/jts.2490070413Save Citation »Export Citation »E-mail Citation »

              Reviews Sigmund Freud’s descriptions of reactions to trauma and traces these through the development of the various editions of the American Psychiatric Association’s Diagnostic and Statistical Manual. Available online for purchase or by subscription.

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              • Young, Allan. 1995. The harmony of illusions: Inventing post-traumatic stress disorder. Princeton, NJ: Princeton Univ. Press.

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                Argues that PTSD is not a timeless or universal phenomenon newly discovered; rather, it is a cultural product gradually put together by the practices, technologies, and narratives with which it is diagnosed, studied, and treated by the various interests, institutions, and moral arguments mobilizing these efforts.

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                What Is a Traumatic Event?

                The original idea of an event that is outside normal human experience has gradually been adapted with the recognition that similar symptom patterns can follow less extreme traumatic events to which a majority of the population may be exposed at some time in their lives. Successive editions of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) have tried to modify the definition of what constitutes a traumatic event, but formulations have been criticized both for being too narrow, resulting in some individuals not receiving the diagnosis despite showing the relevant symptoms, or too broad, resulting in a weakening of the diagnosis and opening the door to legal claims for psychological injury following relatively minor events. Others have suggested that there is no need for a formal traumatic event criterion in PTSD (Brewin, et al. 2009). These controversies (collectively referred to as the “criterion A problem”) have been discussed at length (Friedman, et al. 2011; Weathers and Keane 2007). The Diagnostic and Statistical Manual of Mental Disorders: DSM-IV (Washington, DC: American Psychiatric Association, 1994) introduced major changes to the PTSD (A1) stressor criterion, allowing some events with which a person had been “confronted” to qualify, even though the event was not directly experienced or witnessed by the person. The effects of this change are evaluated in Kilpatrick, et al. 2009; the impact of viewing body parts and human remains is reviewed in Ursano, et al. 2003. The ability of PTSD to be produced in people who witnessed terrible events remotely via the mass media is assessed in Bonanno, et al. 2010. DSM-IV also introduced a subjective component, the A2 criterion, which required people to react with extreme fear, helplessness, or horror to the traumatic event; this was subsequently removed in the Diagnostic and Statistical Manual of Mental Disorders: DSM-5 (Washington, DC: American Psychiatric Association, 2013). The DSM-5 tightened the stressor criterion somewhat, for example requiring that learning of the actual or threatened death of a family member must be due to an event that is violent or accidental. In contrast, the International Classification of Diseases (ICD-10) (Geneva, Switzerland: World Health Organization, 1992–1994) has no formal definition of what is a traumatic event.

                • Bonanno, George A., Chris R. Brewin, Krzysztof Kaniasty, and Annette M. La Greca. 2010. Weighing the costs of disaster: Consequences, risk, and resilience in individuals, families, and communities. Psychological Science in the Public Interest 11.1: 1–49.

                  DOI: 10.1177/1529100610387086Save Citation »Export Citation »E-mail Citation »

                  Reviews the effects of remote witnessing of major disasters, such as the 9/11 terrorist attacks in New York City. Concludes that there is no evidence for new cases of PTSD arising in people who did not have an existing psychiatric illness or were not connected to the event.

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                  • Brewin, Chris R., Ruth A. Lanius, Andrei Novac, Ulrich Schnyder, and Sandro Galea. 2009. Reformulating PTSD for DSM-V: Life after criterion A. Journal of Traumatic Stress 22.5: 366–373.

                    DOI: 10.1002/jts.20443Save Citation »Export Citation »E-mail Citation »

                    Reviews evidence suggesting that the absence of a formal stressor criterion would have little effect on the diagnosis of PTSD, which should be made on the symptoms alone.

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                    • Friedman, Matthew J., Patricia A. Resick, Richard A. Bryant, and Chris R. Brewin. 2011. Considering PTSD for DSM-5. Depression and Anxiety 28.9: 750–769.

                      DOI: 10.1002/da.20767Save Citation »Export Citation »E-mail Citation »

                      Reviews the empirical evidence on the stressor criterion and symptom structure of the DSM-IV PTSD diagnosis and makes proposals for how it might be improved in DSM-5. Available online for purchase or by subscription.

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                      • Kilpatrick, Dean G., Heidi S. Resnick, and Ron Acierno. 2009. Should PTSD criterion A be retained? Journal of Traumatic Stress 22.5: 374–383.

                        DOI: 10.1002/jts.20436Save Citation »Export Citation »E-mail Citation »

                        The authors tested the hypothesis that a nonrestrictive definition of a traumatic event would substantially increase PTSD prevalence in large probability samples of US adolescents and Florida adults. Few PTSD cases occurred in the absence of an event meeting DSM-IV criterion A1. Available online for purchase or by subscription.

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                        • Ursano, Robert J., James E. McCarroll, and Carol S. Fullerton. 2003. Traumatic death in terrorism and disasters: The effects on posttraumatic stress and behavior. In Terrorism and disaster: Individual and community mental health interventions. Edited by Robert J. Ursano, Carol S. Fullerton, and Ann E. Norwood, 308–332. Cambridge, UK: Cambridge Univ. Press.

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                          Reviews the effects of witnessing death or human remains on bystanders, rescuers, body handlers, and mortuary workers drawn from civilian and military samples. Discusses factors mediating the impact on PTSD symptoms.

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                          • Weathers, Frank W., and Terence M. Keane. 2007. The criterion A problem revisited: Controversies and challenges in defining and measuring psychological trauma. Journal of Traumatic Stress 20.2: 107–121.

                            DOI: 10.1002/jts.20210Save Citation »Export Citation »E-mail Citation »

                            The authors provide an update on the criterion A problem with particular emphasis on the evolution of the DSM definition of the stressor criterion and the ongoing debate regarding broad versus narrow conceptualizations of traumatic events. Available online for purchase or by subscription.

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                            Symptoms of PTSD

                            Factor analytic studies have shown that the seventeen PTSD symptoms described in the DSM-IV do not fall into the three symptom clusters suggested. The evidence is more consistent with four functionally distinct symptom clusters (Yufik and Simms 2010): either reexperiencing, active avoidance, numbing, and hyperarousal or reexperiencing, active avoidance, dysphoria (made up of the numbing symptoms plus sleep problems, irritability, and lack of concentration), and hyperarousal (specifically, hypervigilance and exaggerated startle). Following this, the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders: DSM-5 (Washington, DC: American Psychiatric Association, 2013) introduced an additional symptom cluster. The issue of whether reexperiencing symptoms are core systems of PTSD has general but not unanimous agreement (Ehlers, et al. 2004). A particularly powerful form of reexperiencing may occur at night in the form of traumatic nightmares or during the day (“flashbacks”). Daytime flashbacks, along with amnesia for details of the trauma, are the only symptom that appears reliably to distinguish PTSD from other disorders (Bryant, et al. 2011). Other symptoms included in the DSM-5 reexperiencing cluster are found in many other disorders. The DSM-5 avoidance cluster includes active avoidance of thoughts or memories of the trauma and of places or situations that trigger reexperiencing. Although the avoidance and numbing symptoms, including loss of interest in activities and inability to feel normal emotions, were suggested to be the most important symptom cluster for differentiating PTSD cases from noncases (North, et al. 2009), numbing symptoms have now in DSM-5 been subsumed within a broader symptom cluster involving negative alterations in cognition and mood. Emotional numbing may nevertheless be important in impaired social functioning (Ruscio, et al. 2002). Marked alterations in arousal and reactivity constitute the fourth DSM-5 symptom cluster, and two of the following symptoms are required to reach the criterion: irritable or angry behavior, self-destructive behavior, excessive awareness of possible danger (hypervigilance), exaggerated startle reaction, lack of concentration, and sleep problems. Several studies have suggested that hyperarousal symptoms are the best predictors of the course of the disorder (Schell, et al. 2004). The fact that so many symptoms of PTSD are found in other disorders suggests that it will often be accompanied by other diagnoses. Rates of comorbidity are indeed particularly high for PTSD, with other anxiety disorders, depression, and substance abuse frequently accompanying it. Changes introduced in DSM-5 are discussed in Friedman, et al. 2011; the need for a developmental perspective to fit the disorder to children and adolescents is discussed in Pynoos, et al. 2009. Instead of increasing the numbers of symptoms, proposed revisions to the PTSD criteria in ICD-11 involve diagnosing it on the basis of only six core symptoms: flashbacks, nightmares, avoidance of trauma-related thoughts and memories, avoidance of situational trauma reminders, hypervigilance, and exaggerated startle (Maercker, et al. 2013).

                            • Bryant, Richard A., Meaghan L. O’Donnell, Mark Creamer, Alexander C. McFarlane, and Derrick Silove. 2011. Posttraumatic intrusive symptoms across psychiatric disorders. Journal of Psychiatric Research 45.6: 842–847.

                              DOI: 10.1016/j.jpsychires.2010.11.012Save Citation »Export Citation »E-mail Citation »

                              A large study of traumatically injured patients and one of the very few to compare the relative frequency of symptoms in different disorders acquired for the first time posttrauma. Available online for purchase or by subscription.

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                              • Ehlers, Anke, Ann Hackmann, and Tanja Michael. 2004. Intrusive re-experiencing in post-traumatic stress disorder: Phenomenology, theory, and therapy. Memory 12.4: 403–415.

                                DOI: 10.1080/09658210444000025Save Citation »Export Citation »E-mail Citation »

                                The authors review evidence that reexperiencing symptoms usually involve the intrusion of sensory impressions and emotional responses from the traumatic event. The characteristics of these intrusions most strongly associated with PTSD are distress, a sense of the events happening in the present, and a lack of context. Available online for purchase or by subscription.

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                                • Friedman, Matthew J., Patricia A. Resick, Richard A. Bryant, and Chris R. Brewin. 2011. Considering PTSD for DSM-5. Depression and Anxiety 28.9: 750–769.

                                  DOI: 10.1002/da.20767Save Citation »Export Citation »E-mail Citation »

                                  Reviews the empirical evidence on the stressor criterion and symptom structure of the DSM-IV PTSD diagnosis and makes proposals for how it may be improved in DSM-5. Available online for purchase or by subscription.

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                                  • Maercker, Andreas, Chris R. Brewin, Richard A. Bryant, et al. 2013. Diagnosis and classification of disorders specifically associated with stress: Proposals for ICD-11. World Psychiatry 12.3: 198–206.

                                    DOI: 10.1002/wps.20057Save Citation »Export Citation »E-mail Citation »

                                    Describes the rationale and criteria for diagnosing PTSD on the basis of only six core symptoms, as proposed for ICD-11.

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                                    • North, Carol S., Alina M. Suris, Miriam Davis, and Rebecca P. Smith. 2009. Toward validation of the diagnosis of posttraumatic stress disorder. American Journal of Psychiatry 166.1: 34–41.

                                      DOI: 10.1176/appi.ajp.2008.08050644Save Citation »Export Citation »E-mail Citation »

                                      The authors review problems with the PTSD diagnosis and propose that avoidance and numbing are most specific of all the symptoms for the identification of PTSD.

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                                      • Pynoos, Robert S., Alan M. Steinberg, Christopher M. Layne, Ernestine C. Briggs, Sarah A. Ostrowski, and John A. Fairbank. 2009. DSM-V PTSD diagnostic criteria for children and adolescents: A developmental perspective and recommendations. Journal of Traumatic Stress 22.5: 391–398.

                                        DOI: 10.1002/jts.20450Save Citation »Export Citation »E-mail Citation »

                                        The authors draw attention to the age-specific manifestations and need for selective modifications of the diagnostic criteria for PTSD among children and adolescents. This includes preliminary evidence for the developmental salience of additional dimensions for PTSD (e.g., recklessness and thrill seeking). Available online for purchase or by subscription.

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                                        • Ruscio, Ayelet M., Frank W. Weathers, Lynda A. King, and Daniel W. King. 2002. Male war-zone veterans’ perceived relationships with their children: The importance of emotional numbing. Journal of Traumatic Stress 15.5: 351–357.

                                          DOI: 10.1023/A:1020125006371Save Citation »Export Citation »E-mail Citation »

                                          Analyses revealed that of all the PTSD symptoms only the emotional numbing cluster was significantly related to perceived quality of all relationship domains. Emotional numbing may be the component of PTSD most closely linked to interpersonal impairment in war-zone veterans. Available online for purchase or by subscription.

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                                          • Schell, Terry L., Grant N. Marshall, and Lisa H. Jaycox. 2004. All symptoms are not created equal: The prominent role of hyperarousal in the natural course of posttraumatic psychological distress. Journal of Abnormal Psychology 113.2: 189–197.

                                            DOI: 10.1037/0021-843X.113.2.189Save Citation »Export Citation »E-mail Citation »

                                            A longitudinal study of young adult survivors of community violence showing that greater hyperarousal symptoms at baseline uniquely influenced levels of other symptoms and predicted poorer recovery. Available online for purchase or by subscription.

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                                            • Yufik, Tom, and Leonard J. Simms. 2010. A meta-analytic investigation of the structure of posttraumatic stress disorder symptoms. Journal of Abnormal Psychology 119.4: 764–776.

                                              DOI: 10.1037/a0020981Save Citation »Export Citation »E-mail Citation »

                                              An investigation of the structure of PTSD symptoms described in the DSM through a meta-analytic synthesis of forty studies and over fourteen thousand individuals. The authors conclude that two four-factor solutions are superior to the three-factor DSM structure. Available online for purchase or by subscription.

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                                              Current Conceptualizations

                                              Since the 1980s the claims made for and against PTSD have been intensively investigated. It has become clear that PTSD does not occur only in the context of overwhelming events outside of the range of normal human experience, but it can also follow more common events, such as muggings, assaults, and motor vehicle accidents (Yehuda and McFarlane 1995). Its similarity to other conditions caused by stress has led to it being included in DSM-5 with other Trauma- and Stressor-Related Disorders instead of, as previously, with Anxiety Disorders. Epidemiological surveys have established that the majority of the population is exposed to a traumatic event at some point in their lives but only a small minority develops PTSD. Along with this has come the realization that PTSD in the context of less extreme events is associated with very similar vulnerability factors as have been noted for other psychiatric conditions. The symptoms of PTSD are still regarded as essentially normal short-term reactions to situations arousing extreme fear, helplessness, or horror. The pathology is now generally perceived as being located in the persistence of these symptoms and their failure to resolve of their own accord, emphasizing the importance of maintenance factors (Peleg and Shalev 2006, Yehuda and Ledoux 2007). In the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders: DSM-III-R (Washington, DC: American Psychiatric Association, 1987) symptoms must persist for at least one month to qualify for a PTSD diagnosis, and it is well established that symptoms persist in some individuals for years, accompanied by sometimes severe impairment (see Course). This contradicts the argument that PTSD is simply a medicalization of normal distress, unless “normal distress” is defined as including any reaction to stress, no matter how prolonged and severe. Arguments have been made on whether PTSD is a unitary condition. A dissociative subtype is now included in DSM-5 that involves reacting to reminders of the trauma with responses such as a decreasing heart rate rather than the usual signs of autonomic arousal, such as an increasing heart rate (Lanius, et al. 2010). This has been linked with different neural responses to trauma reminders. Various types of more “complex” PTSD have also been proposed, recognizing that many individuals experience extreme stress in the form of multiple types of trauma or repeated trauma that may begin in childhood (Cloitre, et al. 2009; van der Kolk, et al. 2005). Complex PTSD as proposed for ICD-11 (Maercker, et al. 2013) requires the symptoms of ordinary PTSD plus evidence of disturbance to a person’s self-concept, ability to regulate emotions, and ability to form social relationships. Finally, it has been observed that vulnerability to PTSD, unlike other anxiety disorders, is associated not only with internalizing problems, such as depression or inhibited behavior, but also with externalizing problems, such as aggression, substance abuse, and conduct disorder (Resick and Miller 2009). This underscores the complexity of the disorder.

                                              Epidemiology

                                              The highest rates of PTSD follow interpersonal assaults and the sudden unexpected death of a loved one, but rates are also substantial following injuries sustained in motor vehicle accidents and close involvement in major incidents such as disasters and terrorist attacks involving loss of life (Bonanno, et al. 2010, cited under Course; Galea, et al. 2005). Rates rarely exceed 30 percent of affected individuals except in cases of sexual assaults or prolonged victimization, for example, by imprisonment and torture. The National Comorbidity Survey in the United States (Kessler, et al. 1995) has suggested that the lifetime risk for PTSD is approximately 7.8 percent with a twelve-month prevalence of 3.5 percent. Adult women are at greater risk than men of developing PTSD following a trauma, with national lifetime rates estimated at 12.3 percent (Resnick, et al. 1993). Children of all ages can likewise suffer from chronic PTSD (Pynoos, et al. 1987; Yule, et al. 2000), with US adolescents reporting a six-month PTSD prevalence of 3.7 percent for boys and 6.3 percent for girls (Kilpatrick, et al. 2003). PTSD is additionally associated with a high degree of functional impairment (Kessler 2000). Somatic complaints without organic cause, such as headaches, breathing difficulties, altered somatic perceptions, and a variety of physical disorders, are common (Schnurr, et al. 2014).

                                              • Galea, Sandro, Arijit Nandi, and David Vlahov. 2005. The epidemiology of post-traumatic stress disorder after disasters. Epidemiologic Reviews 27.1: 78–91.

                                                DOI: 10.1093/epirev/mxi003Save Citation »Export Citation »E-mail Citation »

                                                The authors’ review suggests that in the first year after disasters the prevalence of PTSD among direct victims is 30 to 40 percent, the prevalence among rescue workers is approximately 10 to 20 percent, and the prevalence in the general population is approximately 5 to 10 percent. Available online for purchase or by subscription.

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                                                • Kessler, Ronald C. 2000. Posttraumatic stress disorder: The burden to the individual and to society. Journal of Clinical Psychiatry 61, supp. 5: 4–14.

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                                                  Reviews the high levels of impairment associated with PTSD and their implications for clinical services. Available online for purchase or by subscription.

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                                                  • Kessler, Ronald C., Amanda Sonnega, Evelyn Bromet, Michael Hughes, and Christopher B. Nelson. 1995. Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry 52.12: 1048–1060.

                                                    DOI: 10.1001/archpsyc.1995.03950240066012Save Citation »Export Citation »E-mail Citation »

                                                    In a representative national sample of 5,877 persons aged fifteen to fifty-four years, the estimated lifetime prevalence of PTSD was 7.8 percent, with higher rates among women and the previously married. The traumas most characteristic of PTSD among men were combat exposure and witnessing; among women, rape and sexual molestation. Available online for purchase or by subscription.

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                                                    • Kilpatrick, Dean G., Kenneth J. Ruggiero, Ron Acierno, Benjamin E. Saunders, Heidi S. Resnick, and Connie L. Best. 2003. Violence and risk of PTSD, major depression, substance abuse/dependence, and comorbidity: Results from the national survey of adolescents. Journal of Consulting and Clinical Psychology 71.4: 692–700.

                                                      DOI: 10.1037/0022-006X.71.4.692Save Citation »Export Citation »E-mail Citation »

                                                      This nationally representative survey of 4,023 adolescents aged twelve to seventeen found a six-month PTSD prevalence of 3.7 percent for boys and 6.3 percent for girls. PTSD was more likely to be comorbid than were depression or substance abuse/dependence. Results supported the etiological role of exposure to interpersonal violence found in adult samples.

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                                                      • Pynoos, Robert S., Calvin Frederick, Kathi Nader, et al. 1987. Life threat and posttraumatic stress in school-age children. Archives of General Psychiatry 44.12: 1057–1063.

                                                        DOI: 10.1001/archpsyc.1987.01800240031005Save Citation »Export Citation »E-mail Citation »

                                                        After a fatal sniper attack on their elementary school playground, 159 children were sampled. The results provided strong evidence that acute PTSD symptoms occur in school-age children with a notable correlation between the proximity to the violence and the type and number of PTSD symptoms. Available online for purchase or by subscription.

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                                                        • Resnick, Heidi S., Dean G. Kilpatrick, Bonnie S. Dansky, Benjamin E. Saunders, and Connie L. Best. 1993. Prevalence of civilian trauma and posttraumatic stress disorder in a representative national sample of women. Journal of Consulting and Clinical Psychology 61.6: 984–991.

                                                          DOI: 10.1037/0022-006X.61.6.984Save Citation »Export Citation »E-mail Citation »

                                                          A nationally representative sample of over four thousand women in the United States reported an overall PTSD sample prevalence of 12.3 percent lifetime and 4.6 percent within the past six months. The rate of PTSD was significantly higher among crime versus noncrime victims (25.8 percent versus 9.4 percent). Available online for purchase or by subscription.

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                                                          • Schnurr, Paula P., Jennifer S. Wachen, Bonnie L. Green, and Stacey Kaltman. 2014. Trauma exposure, PTSD, and physical health. 2d ed. In Handbook of PTSD: Science and practice. Edited by Matthew J. Friedman, Terence M. Keane, and Patricia A. Resick, 502–521. New York: Guilford.

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                                                            Reviews the literature on trauma, PTSD, and health and concludes that PTSD is associated with increased risk of numerous physical disorders, including but not limited to circulatory, cardiovascular, gastrointestinal, musculoskeletal, and dermatological disorders, and with increased mortality.

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                                                            • Yule, William, Derek Bolton, Orlee Udwin, Stephanie Boyle, Dominic O’Ryan, and Julie Nurrish. 2000. The long-term psychological effects of a disaster experienced in adolescence, I: The incidence and course of PTSD. Journal of Child Psychology and Psychiatry 41.4: 503–511.

                                                              DOI: 10.1111/1469-7610.00635Save Citation »Export Citation »E-mail Citation »

                                                              This long-term follow-up (five and eight years after the disaster) of teenagers who survived the sinking of the Jupiter found that 51.7 percent of the 217 survivors had developed PTSD at some time during the follow-up period. Available online for purchase or by subscription.

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                                                              Course

                                                              Posttraumatic reactions are commonly thought to begin immediately following a traumatic event and then acquire the PTSD diagnosis if they are still present after one month, based on studies such as Rothbaum, et al. 1992, which found extremely high initial levels of PTSD symptoms in rape victims that declined sharply thereafter. The concept of delayed-onset PTSD, in which onset does not occur until at least six months after the traumatic event, initially attracted considerable skepticism. It is now well established, however, that immediate onset is only one of several possible trajectories and that symptoms in some individuals may be low initially and only gradually build up over time (Bonanno, et al. 2010). Months or years may have passed before individuals have accumulated enough symptoms to meet the diagnosis. A delay of six months or more before meeting the full diagnostic criteria occurs in approximately 15 percent of cases of civilian PTSD and in over 30 percent of cases of military PTSD (Andrews, et al. 2007). Cases in which onset is delayed by six months or more and occurs without any symptoms having previously been present appear to be very rare. Once established, more than one-third of people with an index episode of PTSD fail to recover even after many years (Kessler, et al. 1995).

                                                              Risk Factors

                                                              Comprehensive meta-analyses have established that there are a number of reliable risk factors for PTSD, some occurring pretrauma, some during the trauma (peritrauma), and some posttrauma. Meta-analyses have been reported for adults (Brewin, et al. 2000; Ozer, et al. 2003) and children and adolescents (Trickey, et al. 2012). Some of these risk factors, such as social and educational disadvantage and a positive family psychiatric history, are shared with many other psychiatric disorders. This has led to less emphasis being placed on the etiological importance of the traumatic event itself and more on the importance of individual vulnerability. The risk factors are described in more detail in the following subsections. The different types of risk factor are helpfully described in Vogt, et al. 2014.

                                                              • Brewin, Chris R., Bernice Andrews, and John D. Valentine. 2000. Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology 68.5: 748–766.

                                                                DOI: 10.1037/0022-006X.68.5.748Save Citation »Export Citation »E-mail Citation »

                                                                Seventy-seven articles were included that identified fourteen significant predictors of PTSD. Pretrauma factors included female gender, lower education, childhood abuse history, and other childhood adversity; the peritraumatic factor was trauma severity; and posttrauma factors were subsequent life stress and lack of social support. Available online for purchase or by subscription.

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                                                                • Ozer, Emily J., Suzanne R. Best, Tami L. Lipsey, and Daniel S. Weiss. 2003. Predictors of posttraumatic stress disorder and symptoms in adults: A meta-analysis. Psychological Bulletin 129.1: 52–73.

                                                                  DOI: 10.1037/0033-2909.129.1.52Save Citation »Export Citation »E-mail Citation »

                                                                  Sixty-eight studies met criteria for inclusion in a meta-analysis of seven predictors: prior trauma, prior psychological adjustment, family history of psychopathology, perceived life threat during the trauma, posttrauma social support, peritraumatic emotional responses, and peritraumatic dissociation. Available online for purchase or by subscription.

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                                                                  • Trickey, David, Andy P. Siddaway, Richard Meiser-Stedman, Lucy Serpell, and Andy P. Field. 2012. A meta-analysis of risk factors for post-traumatic stress disorder in children and adolescents. Clinical Psychology Review 32.2: 122–138.

                                                                    DOI: 10.1016/j.cpr.2011.12.001Save Citation »Export Citation »E-mail Citation »

                                                                    Sixty-four studies of children aged six to eighteen were included in a meta-analysis of twenty-five predictors, whereas pretrauma variables and more objective measures of the severity of the event generated small- to medium-effect sizes. Subjective peritrauma factors and postevent factors appeared to play a major role in determining the risk of PTSD. Available online for purchase or by subscription.

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                                                                    • Vogt, Dawne S., Daniel W. King, and Lynda King. 2014. Risk pathways for PTSD: Making sense of the literature. 2d ed. In Handbook of PTSD: Science in practice. Edited by Matthew J. Friedman, Terence M. Keane, and Patricia A. Resick, 146–165. New York: Guilford.

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                                                                      Applies MacArthur approach to classification of risk factors developed by Kraemer and colleagues, requiring temporal precedence and distinguishing between fixed markers, variable risk factors, and causal risk factors. Considers a number of different ways in which risk factors may work together to produce PTSD.

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                                                                      Pretrauma

                                                                      Although the reasons for female gender being a risk factor for PTSD have not been established (Olff, et al. 2007), evidence indicates that women may be more sensitized by previous assaultive violence (Breslau and Anthony 2007) and may receive less social support and be more affected by this lack of social support (Andrews, et al. 2003). Exposure to previous trauma is frequently found to be a risk factor, although some data suggest that the risk could be the result of previous trauma followed by PTSD, that is, the actual risk factor is prior PTSD (Breslau, et al. 2008). Nevertheless, evidence indicates that assaultive violence is a risk factor for later PTSD, whether or not it is accompanied by PTSD at the time (Cougle, et al. 2009).

                                                                      • Andrews, Bernice, Chris R. Brewin, and Susanna Rose. 2003. Gender, social support, and PTSD in victims of violent crime. Journal of Traumatic Stress 16.4: 421–427.

                                                                        DOI: 10.1023/A:1024478305142Save Citation »Export Citation »E-mail Citation »

                                                                        One month after being a victim of crime, women reported significantly more negative responses from family and friends and more PTSD symptoms, with negative responses mediating the relationship between gender and later symptoms. Available online for purchase or by subscription.

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                                                                        • Breslau, Naomi, and James C. Anthony. 2007. Gender differences in the sensitivity to posttraumatic stress disorder: An epidemiological study of urban young adults. Journal of Abnormal Psychology 116.3: 607–611.

                                                                          DOI: 10.1037/0021-843X.116.3.607Save Citation »Export Citation »E-mail Citation »

                                                                          Data from a representative sample of young adults from a large US city indicated that the risk of PTSD following assaultive violence was higher for women than for men. When women experienced assaultive violence followed by a later nonassaultive trauma, their risk of PTSD increased, but this was not observed in men in a similar situation. Available online for purchase or by subscription.

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                                                                          • Breslau, Naomi, Edward L. Peterson, and Lonni R. Schultz. 2008. A second look at prior trauma and the posttraumatic stress disorder effects of subsequent trauma. Archives of General Psychiatry 65.4: 431–437.

                                                                            DOI: 10.1001/archpsyc.65.4.431Save Citation »Export Citation »E-mail Citation »

                                                                            A study of young adults found that the conditional risk of PTSD following a later traumatic event was significantly higher among trauma-exposed persons who had experienced prior PTSD relative to those with no prior trauma. In contrast, the conditional risk of PTSD for persons who had experienced prior traumatic events but not PTSD was not significantly elevated.

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                                                                            • Cougle, Jesse R., Heidi Resnick, and Dean G. Kilpatrick. 2009. Does prior exposure to interpersonal violence increase risk of PTSD following subsequent exposure? Behaviour Research and Therapy 47.12: 1012–1017.

                                                                              DOI: 10.1016/j.brat.2009.07.014Save Citation »Export Citation »E-mail Citation »

                                                                              Examines the effects of history of assault and witnessing serious violence prospectively in a national survey of adolescents. Prior assault without PTSD was found to predict later PTSD following exposure to new assault or witnessed violence. Prior witnessed violence without PTSD did not increase the risk of subsequent PTSD. Available online for purchase or by subscription.

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                                                                              • Olff, Miranda, Willie Langeland, Nel Draijer, and Berthold P. R. Gersons. 2007. Gender differences in posttraumatic stress disorder. Psychological Bulletin 133.2: 183–204.

                                                                                DOI: 10.1037/0033-2909.133.2.183Save Citation »Export Citation »E-mail Citation »

                                                                                Reviews explanations for women’s higher PTSD risk, including the type of trauma they experience, younger age at the time of trauma exposure, stronger perceptions of threat and loss of control, higher levels of peritraumatic dissociation, and insufficient social support resources. Available online for purchase or by subscription.

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                                                                                Peritrauma

                                                                                Retrospective and prospective studies have found consistent evidence that experiencing greater peritraumatic emotions, including fear of death or serious injury, anger, and shame, are all associated with increased risk for later PTSD (Bovin and Marx 2011). Similar findings have been reported for panic (Bryant, et al. 2011), peritraumatic dissociation (Lensvelt-Mulders, et al. 2008), and a sense of mental defeat (Dunmore, et al. 2001). In contrast, comorbid concussion and mild traumatic brain injury were not associated with poorer outcomes at follow-up in a sample of reservists deployed to Iraq (Polusny, et al. 2011).

                                                                                • Bovin, Michelle J., and Brian P. Marx. 2011. The importance of the peritraumatic experience in defining traumatic stress. Psychological Bulletin 137.1: 47–67.

                                                                                  DOI: 10.1037/a0021353Save Citation »Export Citation »E-mail Citation »

                                                                                  Reviews evidence that peritraumatic emotions, particularly fear and anger, lead to a greater risk of PTSD. Available online for purchase or by subscription.

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                                                                                  • Bryant, Richard A., Robert Brooks, Derrick Silove, Mark Creamer, Meaghan O’Donnell, and Alexander C. McFarlane. 2011. Peritraumatic dissociation mediates the relationship between acute panic and chronic posttraumatic stress disorder. Behaviour Research and Therapy 49.5: 346–351.

                                                                                    DOI: 10.1016/j.brat.2011.03.003Save Citation »Export Citation »E-mail Citation »

                                                                                    This longitudinal study of injured trauma victims supported a mediational model whereby initial acute panic responses increased the frequency of dissociative alterations to the perception of self and the world, which in turn predicted chronic PTSD symptoms. Available online for purchase or by subscription.

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                                                                                    • Dunmore, Emma, David M. Clark, and Anke Ehlers. 2001. A prospective investigation of the role of cognitive factors in persistent posttraumatic stress disorder (PTSD) after physical or sexual assault. Behaviour Research and Therapy 39.9: 1063–1084.

                                                                                      DOI: 10.1016/S0005-7967(00)00088-7Save Citation »Export Citation »E-mail Citation »

                                                                                      This prospective study of assault survivors demonstrated that mental defeat predicted the development of PTSD symptoms after controlling for level of symptoms four months posttrauma. Available online for purchase or by subscription.

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                                                                                      • Lensvelt-Mulders, Gerty, Onno van der Hart, Jacobien M. van Ochten, Maarten J. M. van Son, Kathy Steele, and Linda Breeman. 2008. Relations among peritraumatic dissociation and posttraumatic stress: A meta-analysis. Clinical Psychology Review 28.7: 1138–1151.

                                                                                        DOI: 10.1016/j.cpr.2008.03.006Save Citation »Export Citation »E-mail Citation »

                                                                                        Across fifty-nine studies, a substantial positive correlation was found between peritraumatic dissociation and PTSD symptoms. This correlation was significantly stronger in studies of childhood abuse survivors. Available online for purchase or by subscription.

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                                                                                        • Polusny, Melissa A., Shannon M. Kehle, Nathaniel W. Nelson, Christopher R. Erbes, Paul A. Arbisi, and Paul Thuras. 2011. Longitudinal effects of mild traumatic brain injury and posttraumatic stress disorder comorbidity on postdeployment outcomes in National Guard soldiers deployed to Iraq. Archives of General Psychiatry 68.1: 79–89.

                                                                                          DOI: 10.1001/archgenpsychiatry.2010.172Save Citation »Export Citation »E-mail Citation »

                                                                                          Although combat-related PTSD was strongly associated with postconcussive symptoms and psychosocial outcomes one year after soldiers returned from Iraq, little evidence has been found of a long-term negative impact of concussion or mild traumatic brain injury on these outcomes after accounting for PTSD.

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                                                                                          Posttrauma

                                                                                          Among the most important posttrauma factors are subsequent life stress and lack of social support (see Risk Factors), particularly when these result in significant resource loss (Hobfoll, et al. 2006); negative emotions, such as shame and anger (Andrews, et al. 2000); inappropriate coping strategies, such as avoidance and safety behaviors (Dunmore, et al. 2001); and negative interpretations of initial PTSD symptoms (Dunmore, et al. 2001; Ehlers, et al. 1998). Numerous studies also show that an increased heart rate immediately posttrauma (Shalev, et al. 1998) and in response to traumatic stimuli (Blanchard, et al. 1996; Suendermann, et al. 2010) predicts later PTSD. A report indicates that increased heart rate on admission to the emergency room predicts several anxiety disorders and is not specific to PTSD (Bryant, et al. 2011).

                                                                                          • Andrews, Bernice, Chris R. Brewin, Suzanna Rose, and Marilyn Kirk. 2000. Predicting PTSD symptoms in victims of violent crime: The role of shame, anger, and childhood abuse. Journal of Abnormal Psychology 109.1: 69–73.

                                                                                            DOI: 10.1037/0021-843X.109.1.69Save Citation »Export Citation »E-mail Citation »

                                                                                            In this study of victims of violent crime, shame and anger with others predicted the development of PTSD symptoms. The evidence was consistent with shame as a mediator between experiencing abuse in childhood and developing PTSD after an adult trauma. Available online for purchase or by subscription.

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                                                                                            • Blanchard, Edward B., Edward J. Hickling, Todd C. Buckley, Ann E. Taylor, Alisa Vollmer, and Warren R. Loos. 1996. Psychophysiology posttraumatic stress disorder related to motor vehicle accidents: Replication and extension. Journal of Consulting and Clinical Psychology 64.4: 742–751.

                                                                                              DOI: 10.1037/0022-006X.64.4.742Save Citation »Export Citation »E-mail Citation »

                                                                                              Psychophysiological assessments, including heart rate responses to mental arithmetic and idiosyncratic audiotape descriptions of motor vehicle accidents (MVAs), were collected on injured victims of recent MVAs and controls. A victim’s heart rate to the audiotaped description of the MVA distinguishes MVA victims with PTSD from those with subsyndromal PTSD and non-PTSD. Available online for purchase or by subscription.

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                                                                                              • Bryant, Richard A., Mark C. Creamer, Meaghan O’Donnell, Derrick A. Silove, and Alexander C. McFarlane. 2011. Heart rate after trauma and the specificity of fear circuitry disorders. Psychological Medicine 41.12: 2573–2580.

                                                                                                DOI: 10.1017/S0033291711000948Save Citation »Export Citation »E-mail Citation »

                                                                                                A longitudinal study of traumatically injured patients showing that an elevated heart rate assessed within forty-eight hours of hospital admission predicted later development of several anxiety disorders, including PTSD, panic disorder, agoraphobia, and social phobia. Available online for purchase or by subscription.

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                                                                                                • Dunmore, Emma, David M. Clark, and Anke Ehlers. 2001. A prospective investigation of the role of cognitive factors in persistent posttraumatic stress disorder (PTSD) after physical or sexual assault. Behaviour Research and Therapy 39.9: 1063–1084.

                                                                                                  DOI: 10.1016/S0005-7967(00)00088-7Save Citation »Export Citation »E-mail Citation »

                                                                                                  This prospective study of assault survivors demonstrated that negative interpretations of PTSD symptoms, avoidance, safety behaviors, negative appraisal of emotions during assault, and perceived permanent change in the self predicted the development of PTSD symptoms. Available online for purchase or by subscription.

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                                                                                                  • Ehlers, Anke, Richard A. Mayou, and Bridget Bryant. 1998. Psychological predictors of chronic posttraumatic stress disorder after motor vehicle accidents. Journal of Abnormal Psychology 107.3: 508–519.

                                                                                                    DOI: 10.1037/0021-843X.107.3.508Save Citation »Export Citation »E-mail Citation »

                                                                                                    A prospective longitudinal study assessed patients who attended an emergency clinic shortly after a motor vehicle accident, again at three months, and at one year. PTSD at one year was predicted by negative interpretation of intrusions, rumination, thought suppression, and anger cognitions. Available online for purchase or by subscription.

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                                                                                                    • Hobfoll, Stevan E., Melissa Tracy, and Sandro Galea. 2006. The impact of resource loss and traumatic growth on probable PTSD and depression following terrorist attacks. Journal of Traumatic Stress 19.6: 867–878.

                                                                                                      DOI: 10.1002/jts.20166Save Citation »Export Citation »E-mail Citation »

                                                                                                      The authors found that resource loss significantly predicted probable PTSD and probable depression since 9/11 and that resource loss impact was independent of previously identified predictors, such as social support. Available online for purchase or by subscription.

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                                                                                                      • Shalev, Arieh Y., Tali Sahar, Sara Freedman, et al. 1998. A prospective study of heart rate response following trauma and the subsequent development of posttraumatic stress disorder. Archives of General Psychiatry 55.6: 553–559.

                                                                                                        DOI: 10.1001/archpsyc.55.6.553Save Citation »Export Citation »E-mail Citation »

                                                                                                        Trauma survivors’ heart rates and blood pressures were recorded on arrival at the emergency department. Patients who developed PTSD had higher heart rates at the emergency department and one week later but not after one and four months. The groups did not differ in initial blood pressure measurement.

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                                                                                                        • Suendermann, Oliver, Anke Ehlers, Inga Boellinghaus, Matthias Gamer, and Edward Glucksman. 2010. Early heart rate responses to standardized trauma-related pictures predict posttraumatic stress disorder: A prospective study. Psychosomatic Medicine 72.3: 301–308.

                                                                                                          DOI: 10.1097/PSY.0b013e3181d07db8Save Citation »Export Citation »E-mail Citation »

                                                                                                          At one month, trauma survivors with PTSD showed a higher heart rate response to standardized trauma-related pictures than those without PTSD but not to general threat or neutral pictures. Heart rate to trauma-related pictures predicted PTSD severity at one month and six months.

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                                                                                                          Biological Aspects

                                                                                                          Biological aspects of PTSD are divided into Neurotransmitters, Neuroendocrine Factors, Brain Structure and Function, and Genetics. Comprehensive reviews are provided in Shalev, et al. 2011 and Southwick, et al. 2007.

                                                                                                          • Shalev, Arieh Y., Asaf Gilboa, and Ann M. Rasmusson. 2011. Neurobiology of PTSD. In Post-traumatic stress disorder. Edited by Dan J. Stein, Matthew J. Friedman, and Carlos Blanco, 89–148. Chichester, UK: Wiley.

                                                                                                            DOI: 10.1002/9781119998471Save Citation »Export Citation »E-mail Citation »

                                                                                                            Places neuroimaging findings in the context of contemporary models of fear conditioning and extinction, neuroendocrine and genetic contributions to conditioned stress responses, and an evolutionary model of brain development. The review indicates some areas in which the data are inconsistent with a simple conditioning model of PTSD. Includes commentaries. Also available online as an e-book.

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                                                                                                            • Southwick, Steven M., Lori L. Davis, Deane E. Aikins, Ann Rasmusson, Jill Barron, and Charles A. Morgan III. 2007. Neurobiological alterations associated with PTSD. In Handbook of PTSD: Science and practice. Edited by Matthew J. Friedman, Terence M. Keane, and Patricia A. Resick, 166–189. New York: Guilford.

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                                                                                                              Reviews neurobiological factors thought to be critical in the response to stress and in the pathophysiology of PTSD, including glutamate, GABA, norepinephrine, neuropeptide Y, serotonin, corticotropin-releasing factor, and psychophysiological reactivity.

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                                                                                                              Neurotransmitters

                                                                                                              As reviewed in Southwick, et al. 2007 (cited under Biological Aspects), direct evidence for serotonin dysregulation in PTSD comes from a number of studies of traumatized patients at rest or subjected to neuroendocrine challenge paradigms. Serotonin is important in regulating brain regions implicated in PTSD, such as the prefrontal cortex, amygdala, and hippocampus (see Brain Structure and Function). Further evidence for the importance of serotonin comes from the success of selective serotonin reuptake inhibitors (SSRIs) in treating PTSD (see Pharmacological Treatment), which increase the levels of available serotonin and are associated with increases in hippocampal volume (Vermetten, et al. 2003). A study suggested that certain variants of the serotonin transporter gene predicted outcome from cognitive behavior therapy, implicating the serotonergic system in response to exposure-based treatments in PTSD (see Bryant, et al. 2010, cited under Genetics). Southwick, et al. 2007 (cited under Biological Aspects) reviews evidence that PTSD is associated with exaggerated noradrenergic activity in response to a variety of stressors, particularly reminders of personally experienced traumas. This evidence includes increased levels of norepinephrine (noradrenaline) observed during twenty-four-hour blood or urine sampling and fewer alpha-2 adrenergic receptor binding sites per platelet in PTSD samples. The reduction in receptor binding sites is thought to reflect an adaptive response to chronic elevation of circulating catecholamines. Exposure to trauma reminders is associated with elevated plasma epinephrine and norepinephrine and elevated heart rate (Liberzon, et al. 1999), suggesting that the heightened physiological reactivity that predicts the course of PTSD (see Posttrauma) is related to increases in circulating catecholamines. Pharmacological challenge studies using yohimbine as a probe of the noradrenergic system have provoked symptoms such as flashbacks and hypervigilance in PTSD patients (Southwick, et al. 1993).

                                                                                                              • Liberzon, Israel, James L. Abelson, Shelly B. Flagel, Jonathan Raz, and Elizabeth A. Young. 1999. Neuroendocrine and psychophysiologic responses in PTSD: A symptom provocation study. Neuropsychopharmacology 21:40–50.

                                                                                                                DOI: 10.1016/S0893-133X(98)00128-6Save Citation »Export Citation »E-mail Citation »

                                                                                                                Veterans with PTSD exhibited higher skin conductance, heart rate, plasma cortisol, and catecholamines at baseline and exaggerated responses to combat sounds in skin conductance, heart rate, plasma epinephrine, and norepinephrine but not adrenocorticotropic hormone (ACTH).

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                                                                                                                • Southwick, Steven M., John H. Krystal, C. Andrew Morgan, et al. 1993. Abnormal noradrenergic function in posttraumatic stress disorder. Archives of General Psychiatry 50.4: 266–274.

                                                                                                                  DOI: 10.1001/archpsyc.1993.01820160036003Save Citation »Export Citation »E-mail Citation »

                                                                                                                  A classic study finding that administration to PTSD patients of the alpha2 antagonist yohimbine, which results in increased release of noradrenaline in the brain, produced increased flashbacks and other PTSD symptoms, including emotional numbing and hyperarousal. Available online for purchase or by subscription.

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                                                                                                                  • Vermetten, Eric, Meena Vythilingam, Steven M. Southwick, Dennis S. Charney, and J. Douglas Bremner. 2003. Long-term treatment with paroxetine increases verbal declarative memory and hippocampal volume in posttraumatic stress disorder. Biological Psychiatry 54.7: 693–702.

                                                                                                                    DOI: 10.1016/S0006-3223(03)00634-6Save Citation »Export Citation »E-mail Citation »

                                                                                                                    This study showed that nine to twelve months of treatment with an SSRI, paroxetine, produced a significant improvement in PTSD symptoms. Associated improvements also occurred in verbal declarative memory and a 4.6 percent increase in mean hippocampal volume. Available online for purchase or by subscription.

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                                                                                                                    Neuroendocrine Factors

                                                                                                                    Reactions to stress are regulated via neuroendocrine systems, primarily the hypothalamic-pituitary-adrenal (HPA) axis. Cortisol, one of the most important hormones produced in response to extreme stress, is one of the most extensively studied substances. In many studies a pattern of low cortisol output or an increased sensitivity to glucocorticoid negative feedback has been associated with PTSD, but a substantial number of studies have not found these associations or have found opposite effects. Reviews have identified subgroups of PTSD patients likely to have low basal cortisol (Handwerger 2009; Meewisse, et al. 2007). Of note, an influential study reported that low levels of cortisol in a sample of rape victims were associated with exposure to prior trauma (Resnick, et al. 1995). The data have been taken to suggest that trauma results in enhanced negative feedback at points along the HPA axis, resulting in both lower baseline cortisol and heightened dexamethasone sensitivity and responsiveness. Findings on other neuroactive steroids, including allopregnanolone/pregnanolone and dehydroepiandrosterone (DHEA), are also of potential relevance to PTSD (see Shalev, et al. 2011, cited under Biological Aspects).

                                                                                                                    • Handwerger, Kathryn. 2009. Differential patterns of HPA activity and reactivity in adult posttraumatic stress disorder and major depressive disorder. Harvard Review of Psychiatry 17.3: 184–205.

                                                                                                                      DOI: 10.1080/10673220902996775Save Citation »Export Citation »E-mail Citation »

                                                                                                                      This review concludes that basal cortisol levels are generally lower in PTSD than controls following single traumas. However, after multiple traumas, cortisol levels were much more varied. In addition studies using the dexamethasone suppression test (DST) have consistently shown that PTSD is marked by cortisol hypersuppression relative to healthy individuals. Available online for purchase or by subscription.

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                                                                                                                      • Meewisse, Marie-Louise, Johannes B. Reitsma, Giel-Jan De Vries, Berthold P. R. Gersons, and Miranda Olff. 2007. Cortisol and post-traumatic stress disorder in adults: Systematic review and meta-analysis. British Journal of Psychiatry 191:387–392.

                                                                                                                        DOI: 10.1192/bjp.bp.106.024877Save Citation »Export Citation »E-mail Citation »

                                                                                                                        Studies assessing plasma or serum cortisol showed significantly lower levels in individuals with PTSD than in controls not exposed to trauma. Lower levels were also found in individuals with PTSD when females were included, in studies on physical or sexual abuse, and in afternoon samples.

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                                                                                                                        • Resnick, Heidi S., Rachel Yehuda, Roger K. Pitman, and David W. Foy. 1995. Effect of previous trauma on acute plasma cortisol level following rape. American Journal of Psychiatry 152.11: 1675–1677.

                                                                                                                          DOI: 10.1176/ajp.152.11.1675Save Citation »Export Citation »E-mail Citation »

                                                                                                                          Women with a history of previous assault had a lower mean acute cortisol level after the rape but a higher probability of subsequently developing PTSD. Only women who had never been assaulted before had higher cortisol levels following high-severity rapes than low-severity rapes. Available online for purchase or by subscription.

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                                                                                                                          Brain Structure and Function

                                                                                                                          According to a prominent neurocircuitry model of PTSD, hyperresponsivity within the amygdala to threat-related stimuli coexists with inadequate top-down governance over the amygdala by ventromedial prefrontal cortex (vmPFC), the hippocampus, and related structures (see Rauch, et al. 2006 and Elzinga and Bremner 2002, both cited under Theoretical Models). A meta-analytic review reported that hyperactivation in the amygdala and insula were characteristic of several anxiety disorders, including PTSD, whereas only hypoactivation in vmPFC and anterior cingulate cortex was specific to PTSD (Etkin and Wager 2007). Other functional abnormalities that may be associated with PTSD involve the default network, a series of structures that exhibit correlated low-frequency activity at rest (Bluhm, et al. 2009). Structural alterations found in PTSD include reductions in the volume of the hippocampi and the anterior cingulate cortex, with weaker evidence for a reduction in the left amygdala (Karl, et al. 2006), although there is little evidence that these alterations are unique to PTSD. Smaller hippocampal volumes may be a risk factor for rather than a consequence of PTSD (Gilbertson, et al. 2002), as is hyperresponsiveness of the dorsal anterior cingulate cortex (Shin, et al. 2011). Neuroimaging studies need to take into account the existence of different patterns of response associated with hyperarousal and dissociation (Lanius, et al. 2006) and address psychological processes, such as fear conditioning, that are implicated in PTSD (Liberzon and Sripada 2008).

                                                                                                                          • Bluhm, Robyn L., Peter C. Williamson, Elizabeth A. Osuch, et al. 2009. Alterations in default network connectivity in posttraumatic stress disorder related to early-life trauma. Journal of Psychiatry and Neuroscience 34.3: 187–194.

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                                                                                                                            The “default network” consists of a number of brain regions that exhibit correlated low-frequency activity at rest and that have been suggested to be involved in the processing of self-relevant stimuli. Compared to healthy controls, female patients with chronic PTSD related to early life trauma had reduced default network activity.

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                                                                                                                            • Etkin, Amit, and Tor D. Wager. 2007. Functional neuroimaging of anxiety: A meta-analysis of emotional processing in PTSD, social anxiety disorder, and specific phobia. American Journal of Psychiatry 164.10: 1476–1488.

                                                                                                                              DOI: 10.1176/appi.ajp.2007.07030504Save Citation »Export Citation »E-mail Citation »

                                                                                                                              Whereas patients with PTSD, social anxiety disorder, and specific phobia consistently showed greater activity than matched comparison subjects in the amygdala and insula, only patients with PTSD showed hypoactivation in the dorsal and rostral anterior cingulate cortices and the ventromedial prefrontal cortex.

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                                                                                                                              • Gilbertson, Mark W., Martha E. Shenton, Aleksandra Ciszewski, et al. 2002. Smaller hippocampal volume predicts pathologic vulnerability to psychological trauma. Nature Neuroscience 5:1242–1247.

                                                                                                                                DOI: 10.1038/nn958Save Citation »Export Citation »E-mail Citation »

                                                                                                                                In monozygotic twins discordant for trauma exposure, the authors found evidence that smaller hippocampi constituted a risk factor for the development of stress-related psychopathology. Disorder severity in PTSD patients was negatively correlated with the hippocampal volume of both the patients and the patients’ trauma-unexposed identical co-twin. Available online for purchase or by subscription.

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                                                                                                                                • Karl, Anke, Michael Schaefer, Loretta S. Malta, Denise Dörfel, Nicolas Rohleder, and Annett Werner. 2006. A meta-analysis of structural brain abnormalities in PTSD. Neuroscience and Biobehavioral Reviews 30.7: 1004–1031.

                                                                                                                                  DOI: 10.1016/j.neubiorev.2006.03.004Save Citation »Export Citation »E-mail Citation »

                                                                                                                                  Hippocampal volumes were smaller in individuals with PTSD compared to controls with and without trauma exposure. Individuals with PTSD had smaller left amygdala volumes compared to healthy and trauma-exposed controls, and their anterior cingulate volumes were smaller compared to trauma-exposed controls. Available online for purchase or by subscription.

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                                                                                                                                  • Lanius, R. A., R. Bluhm, U. Lanius, and C. Pain. 2006. A review of neuroimaging studies in PTSD: Heterogeneity of response to symptom provocation. Journal of Psychiatric Research 40.8: 709–729.

                                                                                                                                    DOI: 10.1016/j.jpsychires.2005.07.007Save Citation »Export Citation »E-mail Citation »

                                                                                                                                    PTSD neuroimaging findings support two subtypes of trauma response: one characterized predominantly by hyperarousal and the other primarily dissociative, each one representing unique pathways to chronic stress-related psychopathology. Available online for purchase or by subscription.

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                                                                                                                                    • Liberzon, Israel, and Chandra Sekhar Sripada. 2008. The functional neuroanatomy of PTSD: A critical review. Progress in Brain Research 167:151–169.

                                                                                                                                      DOI: 10.1016/S0079-6123(07)67011-3Save Citation »Export Citation »E-mail Citation »

                                                                                                                                      Psychological processes being addressed in neuroimaging research include fear conditioning, habituation, and extinction; cognitive-emotional interactions; and self-related and social emotional processing. Dysregulation of contextualization processes may play a key role in the generation of PTSD symptoms. Available online for purchase or by subscription.

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                                                                                                                                      • Shin, Lisa M., George Bush, Mohammed R. Milad, et al. 2011. Exaggerated activation of dorsal anterior cingulate cortex during cognitive interference: A monozygotic twin study of posttraumatic stress disorder. American Journal of Psychiatry 168.9: 979–985.

                                                                                                                                        DOI: 10.1176/appi.ajp.2011.09121812Save Citation »Export Citation »E-mail Citation »

                                                                                                                                        Combat-exposed veterans with PTSD and their unexposed co-twins had significantly greater activation in the dorsal anterior cingulate compared to combat-exposed veterans without PTSD and their co-twins. Hyperresponsivity in the dorsal anterior cingulate appears to be a familial risk factor for the development of PTSD. Available online for purchase or by subscription.

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                                                                                                                                        Genetics

                                                                                                                                        Early research established that there was a substantial genetic contribution to reported PTSD symptoms (True, et al. 1993). This genetic liability appears to be shared with a liability to depression symptoms (Koenen, et al. 2008) and exposure to certain forms of trauma, particularly assaultive trauma (Stein, et al. 2002). Molecular studies of candidate genes have not produced consistent results as of the early 21st century, which is likely due to difficulties in investigating a disorder that requires a traumatic event (Broekman, et al. 2007). In addition to genomic studies, investigations of gene-environment interaction and correlation and of environmental effects on modifying gene expression hold a great deal of promise (Yehuda, et al. 2011). A study also suggested that certain variants of the serotonin-transporter gene predicted outcome from cognitive behavior therapy, implicating the serotonergic system in response to exposure-based treatments in PTSD (Bryant, et al. 2010). Other recent developments are reviewed in Koenen, et al. 2014.

                                                                                                                                        • Broekman, B. F. P., M. Olff, and F. Boer. 2007. The genetic background to PTSD. Neuroscience and Biobehavioral Reviews 31.3: 348–362.

                                                                                                                                          DOI: 10.1016/j.neubiorev.2006.10.001Save Citation »Export Citation »E-mail Citation »

                                                                                                                                          This article reviews molecular genetic studies relating to PTSD that tested hypotheses involving key candidate genes in the serotonin (5-HTT), dopamine (DRD2, DAT), glucocorticoid (GR), GABA (GABRB), apolipoprotein systems (APOE2), brain-derived neurotrophic factor (BDNF), and neuropeptide Y (NPY). It has been difficult to identify specific genes that substantially contribute to the disorder. Available online for purchase or by subscription.

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                                                                                                                                          • Bryant, Richard A., Kim L. Felmingham, Erin M. Falconer, et al. 2010. Preliminary evidence of the short allele of the serotonin transporter gene predicting poor response to cognitive behavior therapy in posttraumatic stress disorder. Biological Psychiatry 67.2: 1217–1219.

                                                                                                                                            DOI: 10.1016/j.biopsych.2010.03.016Save Citation »Export Citation »E-mail Citation »

                                                                                                                                            Patients underwent an eight-week exposure-based therapy program. After controlling for pretreatment PTSD severity and number of treatment sessions, patients with low-expression alleles of the serotonin transporter gene promoter displayed more severe PTSD six months following treatment relative to other patients. Available online for purchase or by subscription.

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                                                                                                                                            • Koenen, Karestan C., Qiang J. Fu, Karen Ertel, et al. 2008. Common genetic liability to major depression and posttraumatic stress disorder in men. Journal of Affective Disorders 105.1: 109–115.

                                                                                                                                              DOI: 10.1016/j.jad.2007.04.021Save Citation »Export Citation »E-mail Citation »

                                                                                                                                              The degree to which a common genetic liability explains the etiology of the major depression-PTSD association was examined. Results implied that genes implicated in the etiology of depression are strong candidates for PTSD and vice versa, whereas environmental influences on depression and PTSD appear to be largely disorder specific. Available online for purchase or by subscription.

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                                                                                                                                              • Koenen, Karestan C., Guia Guffanti, Lulu Yan, et al. 2014. Genetics of PTSD. In Handbook of PTSD: Science in practice. 2d ed. Edited by Matthew J. Friedman, Terence M. Keane, and Patricia A. Resick, 300–312. New York: Guilford.

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                                                                                                                                                Provides an overview of twin, molecular genetic, epigenetic, and gene expression studies of PTSD.

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                                                                                                                                                • Stein, Murray B., Kerry L. Jang, Steven Taylor, Philip A. Vernon, and W. John Livesley. 2002. Genetic and environmental influences on trauma exposure and posttraumatic stress disorder symptoms: A twin study. American Journal of Psychiatry 159.10: 1675–1681.

                                                                                                                                                  DOI: 10.1176/appi.ajp.159.10.1675Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                  Additive genetic, common environmental, and unique environmental effects best explained the variance in exposure to assaultive trauma, whereas exposure to nonassaultive trauma was best explained by common and unique environmental influences. PTSD symptoms were moderately heritable, and the remaining variance was accounted for by unique environmental experiences.

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                                                                                                                                                  • True, William R., John Rice, Seth A. Eisen, et al. 1993. A twin study of genetic and environmental contributions to liability for posttraumatic stress symptoms. Archives of General Psychiatry 50.4: 257–264.

                                                                                                                                                    DOI: 10.1001/archpsyc.1993.01820160019002Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                    Inheritance had a substantial influence on liability for all PTSD symptoms in twins, even after adjusting for differences in combat exposure, and monozygotic pairs were more highly concordant for combat exposure than dizygotic pairs. No evidence was shown that shared environment contributes to the development of PTSD symptoms.

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                                                                                                                                                    • Yehuda, Rachel, Karestan C. Koenen, Sandro Galea, and Janine D. Flory. 2011. The role of genes in defining a molecular biology of PTSD. Disease Markers 30.2–3: 67–76.

                                                                                                                                                      DOI: 10.1155/2011/185354Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                      The article describes the type of information that can be obtained from candidate gene and genomic studies that incorporate environmental factors in the design (i.e., gene-environment interaction and gene-environment correlation studies) and studies that capitalize on the idea that environment modifies gene expression via epigenetic or other molecular mechanisms. Available online for purchase or by subscription.

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                                                                                                                                                      Psychological Aspects

                                                                                                                                                      This section on psychological aspects discusses Dissociation, Memory, Appraisal and Emotion, and Identity.

                                                                                                                                                      Dissociation

                                                                                                                                                      As well as the important role played by dissociation occurring during the traumatic event (see Peritrauma), chronic PTSD is characterized by numerous forms of dissociation. These include somatic dissociation, a feeling that the world is unreal (derealization), and an altered sense of self (depersonalization) (van der Hart, et al. 2005). Some of these reactions have parallels in animal defensive states, such as freezing (Nijenhuis, et al. 1998). Persistent dissociation posttrauma predicts a greater risk of PTSD in longitudinal studies (Halligan, et al. 2003; Murray, et al. 2002). As discussed in Current Conceptualizations (see Lanius, et al. 2010), a dissociative subtype of PTSD has been introduced into DSM-5.

                                                                                                                                                      • Halligan, Sarah L., Tanja Michael, David M. Clark, and Anke Ehlers. 2003. Posttraumatic stress disorder following assault: The role of cognitive processing, trauma memory, and appraisals. Journal of Consulting and Clinical Psychology 71.3: 419–431.

                                                                                                                                                        DOI: 10.1037/0022-006X.71.3.419Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                        Persistent dissociation posttrauma was related to higher levels of PTSD symptoms in a cross-sectional and longitudinal study of assault survivors. Available online for purchase or by subscription.

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                                                                                                                                                        • Murray, James, Anke Ehlers, and Richard A. Mayou. 2002. Dissociation and post-traumatic stress disorder: Two prospective studies of road traffic accident survivors. British Journal of Psychiatry 180:363–368.

                                                                                                                                                          DOI: 10.1192/bjp.180.4.363Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                          In both studies measures of dissociation, particularly persistent dissociation four weeks after the accident, predicted chronic PTSD severity at six months. Dissociative symptoms predicted subsequent PTSD over and above the other PTSD symptom clusters.

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                                                                                                                                                          • Nijenhuis, Ellert R. S., Johan Vanderlinden, and Philip Spinhoven. 1998. Animal defensive reactions as a model for trauma-induced dissociative reactions. Journal of Traumatic Stress 11.2: 243–260.

                                                                                                                                                            DOI: 10.1023/A:1024447003022Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                            Empirical data and clinical observations are supportive of the idea that similarities exist among freezing, concomitant development of analgesia and anesthesia, and acute pain in threatened animals and severely traumatized human beings. Available online for purchase or by subscription.

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                                                                                                                                                            • van der Hart, Onno, Ellert R. S. Nijenhuis, and Kathy Steele. 2005. Dissociation: An insufficiently recognized major feature of complex posttraumatic stress disorder. Journal of Traumatic Stress 18.5: 413–423.

                                                                                                                                                              DOI: 10.1002/jts.20049Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                              A conceptual article arguing that dissociative phenomena reflect structural alterations to the personality. The authors distinguish between negative and positive dissociative symptoms and psychoform and somatoform symptoms and relate them to the proposed features of complex PTSD. Available online for purchase or by subscription.

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                                                                                                                                                              Memory

                                                                                                                                                              PTSD is associated with numerous changes to memory function that involve memory capacity, the content of memories for trauma, and a variety of memory processes, such as avoidance or suppression of memories and negative interpretations of intrusive memories, several of which appear to be causally implicated in the disorder (Brewin 2011). For example, a lower verbal-memory capacity (Gilbertson, et al. 2006) and impaired ability to retrieve specific autobiographical memories (Bryant, et al. 2007) appear to be premorbid risk factors for PTSD. In PTSD the involuntary intrusion of traumatic images that occur are reexperienced as happening in the present, whereas deliberate attempts to retrieve trauma memories are often disorganized and fragmented. Both of these characteristic aspects of trauma memory predict the course of the disorder (Jones, et al. 2007; Kleim, et al. 2007).

                                                                                                                                                              • Brewin, Chris R. 2011. The nature and significance of memory disturbance in posttraumatic stress disorder. Annual Review of Clinical Psychology 7:203–227.

                                                                                                                                                                DOI: 10.1146/annurev-clinpsy-032210-104544Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                Reviews memory changes in PTSD and concludes that the integration of the trauma with identity, impairment in retrieval of voluntary trauma memories, and increased incidence of sensation-based memories or flashbacks are likely to have causal effects and are also specific to PTSD. Available online for purchase or by subscription.

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                                                                                                                                                                • Bryant, Richard A., Kylie Sutherland, and Rachel M. Guthrie. 2007. Impaired specific autobiographical memory as a risk factor for posttraumatic stress after trauma. Journal of Abnormal Psychology 116.4: 837–841.

                                                                                                                                                                  DOI: 10.1037/0021-843X.116.4.837Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                  Trainee firefighters were assessed during training and again four years later. Impaired retrieval of specific memories in response to positive cues prior to trauma exposure significantly predicted posttraumatic stress severity after trauma exposure. Available online for purchase or by subscription.

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                                                                                                                                                                  • Gilbertson, Mark W., Lynn A. Paulus, Stephanie K. Williston, et al. 2006. Neurocognitive function in monozygotic twins discordant for combat exposure: Relationship to posttraumatic stress disorder. Journal of Abnormal Psychology 115.3: 484–495.

                                                                                                                                                                    DOI: 10.1037/0021-843X.115.3.484Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                    The authors evaluated cognitive performance in monozygotic twin pairs who were discordant for combat exposure. The combat-unexposed co-twins of combat veterans with PTSD largely displayed the same performance as their brothers, which was significantly lower than that of non-PTSD combat veterans and their brothers. Available online for purchase or by subscription.

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                                                                                                                                                                    • Jones, Charlie, Allison G. Harvey, and Chris R. Brewin. 2007. The organisation and content of trauma memories in survivors of road traffic accidents. Behaviour Research and Therapy 45.1: 151–162.

                                                                                                                                                                      DOI: 10.1016/j.brat.2006.02.004Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                      The authors collected trauma narratives from motor vehicle accident survivors at one week, six weeks, and three months posttrauma. Narrative organization at one week predicted PTSD severity at three months after controlling for initial symptoms. Available online for purchase or by subscription.

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                                                                                                                                                                      • Kleim, Birgit, Anke Ehlers, and Edward Glucksman. 2007. Early predictors of chronic post-traumatic stress disorder in assault survivors. Psychological Medicine 37.10: 1457–1467.

                                                                                                                                                                        DOI: 10.1017/S0033291707001006Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                        Assault survivors who had been treated for their injuries were assessed at two weeks (n = 222) and six months (n = 205) after the assault. In univariate and multivariate regressions, “nowness” of trauma memories significantly predicted PTSD status at follow-up.

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                                                                                                                                                                        Appraisal and Emotion

                                                                                                                                                                        Several types of negative appraisal involving the self, the person’s own actions and posttraumatic symptoms, and the role of others are all associated with increased posttraumatic symptoms. Several studies have shown that later PTSD symptoms are predicted by negative interpretations of intrusive symptoms (see Dunmore, et al. 2001 and Ehlers, et al. 1998, both cited under Posttrauma), negative appraisal of emotions during assault (see Dunmore, et al. 2001, cited under Posttrauma), and negative appraisal of the self (Kleim, et al. 2007). Similar results have been found in children and adolescents (Meiser-Stedman, et al. 2009). It is also well established that PTSD is accompanied by emotions other than fear, helplessness, and horror, particularly anger (Orth and Wieland 2006; Orth, et al. 2008), shame (see Andrews, et al. 2000, cited under Posttrauma), and guilt (Hendin and Haas 1991; Wolfe, et al. 1994).

                                                                                                                                                                        • Hendin, Herbert, and Ann P. Haas. 1991. Suicide and guilt as manifestations of PTSD in Vietnam combat veterans. American Journal of Psychiatry 148.5: 586–591.

                                                                                                                                                                          DOI: 10.1176/ajp.148.5.586Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                          In this study of Vietnam veterans with PTSD, five factors were significantly related to suicide attempts: guilt about combat actions, survivor guilt, depression, anxiety, and severe PTSD. Logistic regression analysis showed that combat guilt was the most significant predictor of both suicide attempts and preoccupation with suicide. Available online for purchase or by subscription.

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                                                                                                                                                                          • Kleim, Birgit, Anke Ehlers, and Edward Glucksman. 2007. Early predictors of chronic post-traumatic stress disorder in assault survivors. Psychological Medicine 37.10: 1457–1467.

                                                                                                                                                                            DOI: 10.1017/S0033291707001006Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                            In univariate and multivariate regressions, more negative appraisals of the self significantly predicted the PTSD status of assault survivors at six-month follow-up.

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                                                                                                                                                                            • Meiser-Stedman, Richard, Tim Dalgleish, Ed Glucksman, William Yule, and Patrick Smith. 2009. Maladaptive cognitive appraisals mediate the evolution of posttraumatic stress reactions: A 6-month follow-up of child and adolescent assault and motor vehicle accident survivors. Journal of Abnormal Psychology 118.4: 778–787.

                                                                                                                                                                              DOI: 10.1037/a0016945Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                              In this prospective study of child and adolescent trauma survivors, negative appraisals were found to be associated with later PTSD symptoms after partialing out initial symptoms and as mediating between initial and later symptoms. Maladaptive appraisals are involved in the development and maintenance of PTSD over time. Available online for purchase or by subscription.

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                                                                                                                                                                              • Orth, Ulrich, Shawn P. Cahill, Edna B. Foa, and Andreas Maercker. 2008. Anger and posttraumatic stress disorder symptoms in crime victims: A longitudinal analysis. Journal of Consulting and Clinical Psychology 76.2: 208–218.

                                                                                                                                                                                DOI: 10.1037/0022-006X.76.2.208Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                In two prospective studies of crime victims, analyses indicated that PTSD symptoms predicted a subsequent level of anger but that anger did not predict subsequent PTSD symptoms. Testing alternative models that may account for a spurious association strengthened confidence in the results of the analyses. Available online for purchase or by subscription.

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                                                                                                                                                                                • Orth, Ulrich, and Elias Wieland. 2006. Anger, hostility, and posttraumatic stress disorder in trauma-exposed adults: A meta-analysis. Journal of Consulting and Clinical Psychology 74.4: 698–706.

                                                                                                                                                                                  DOI: 10.1037/0022-006X.74.4.698Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                  This meta-analysis revealed large positive associations between PTSD and anger hostility, anger out, and anger in, and a large negative association with anger control. Effect sizes for anger hostility were substantially larger with increasing time after the event and in samples with military war experience. Available online for purchase or by subscription.

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                                                                                                                                                                                  • Wolfe, David A., Louise Sas, and Christine Wekerle. 1994. Factors associated with the development of posttraumatic stress disorder among child victims of sexual abuse. Child Abuse and Neglect 18.1: 37–50.

                                                                                                                                                                                    DOI: 10.1016/0145-2134(94)90094-9Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                    Analyses in this sample of child victims of sexual abuse indicated that factors related to the nature and severity of the abuse and the child’s self-report of guilt feelings related to the abuse each contributed significantly to explaining the variance in PTSD symptoms when other variables were controlled. Available online for purchase or by subscription.

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                                                                                                                                                                                    Identity

                                                                                                                                                                                    Enduring personality change after a catastrophic experience is recognized as a diagnostic category in the World Health Organization’s International Classification of Diseases (ICD-10: Geneva, Switzerland: World Health Organization, 1992–1994), and formulations of more complex forms of PTSD have recognized the effects on the sense of self (see van der Kolk, et al. 2005 and Maercker, et al. 2013, cited under Current Conceptualizations). Prolonged traumas, such as torture, have been described as involving an assault on the personality amounting to a form of “mental death” (Ebert and Dyck 2004). Two main types of change have been described: high levels of alienation from society and a perceived permanent change in the self or life expectations. Work on the psychological aftermath of traumatic events suggests that people ordinarily operate on the basis of unchallenged, unquestioned assumptions about themselves and the world. Those assumptions are challenged by trauma (Janoff-Bulman 1989), and the PTSD associated with traumatic events comes to dominate a person’s identity (Berntsen and Rubin 2007). Negative changes in perception of the self linked to the trauma predict a greater risk of PTSD developing even after initial symptoms are controlled (Dunmore, et al. 2001, cited under Posttrauma). Consistent evidence for positive changes in conceptual knowledge about the self, such as greater optimism and a greater feeling of connectedness with others, indicates that these are brought about by trauma (Linley and Joseph 2004, Tedeschi and Calhoun 2004).

                                                                                                                                                                                    • Berntsen, Dorthe, and David C. Rubin. 2007. When a trauma becomes a key to identity: Enhanced integration of trauma memories predicts posttraumatic stress disorder symptoms. Applied Cognitive Psychology 21.4: 417–431.

                                                                                                                                                                                      DOI: 10.1002/acp.1290Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                      The authors assessed the extent to which a traumatic memory forms a central component of personal identity, a turning point in the individual’s life story, and a reference point for everyday inferences. In two studies they showed that this was positively correlated with the severity of PTSD symptoms. Available online for purchase or by subscription.

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                                                                                                                                                                                      • Ebert, Angela, and Murray J. Dyck. 2004. The experience of mental death: The core feature of complex posttraumatic stress disorder. Clinical Psychology Review 24.6: 617–635.

                                                                                                                                                                                        DOI: 10.1016/j.cpr.2004.06.002Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                        Mental death is the loss of the victim’s pretrauma identity characterized by a loss of core beliefs and values, distrust and alienation from others, shame and guilt, and a sense of being permanently damaged. Mental death is a primary feature of complex PTSD. Available online for purchase or by subscription.

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                                                                                                                                                                                        • Janoff-Bulman, Ronnie. 1989. Assumptive worlds and the stress of traumatic events: Applications of the schema construct. Social Cognition 7.2: 113–136.

                                                                                                                                                                                          DOI: 10.1521/soco.1989.7.2.113Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                          Results of a study showed that assumptions about the benevolence of the impersonal world, chance, and self-worth differed across those who did or did not experience particular traumatic events in the past and that the impact on basic assumptions may still be apparent years after the negative event. Available online for purchase or by subscription.

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                                                                                                                                                                                          • Linley, P. Alex, and Stephen Joseph. 2004. Positive change following trauma and adversity: A review. Journal of Traumatic Stress 17.1: 11–21.

                                                                                                                                                                                            DOI: 10.1023/B:JOTS.0000014671.27856.7eSave Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                            Reviewed empirical studies that documented positive change following trauma and adversity and found this to be associated with cognitive appraisal variables (threat, harm, and controllability), problem focus, acceptance and positive reinterpretation coping, optimism, religion, cognitive processing, and positive affect. Available online for purchase or by subscription.

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                                                                                                                                                                                            • Tedeschi, Richard G., and Lawrence G. Calhoun. 2004. Posttraumatic growth: Conceptual foundations and empirical evidence. Psychological Inquiry 15.1: 1–18.

                                                                                                                                                                                              DOI: 10.1207/s15327965pli1501_01Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                              Describes the concept of posttraumatic growth and supporting empirical evidence. This is manifested in a variety of ways, including increased appreciation for life in general, more meaningful interpersonal relationships, an increased sense of personal strength, changed priorities, and a richer existential and spiritual life. Available online for purchase or by subscription.

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                                                                                                                                                                                              Theoretical Models

                                                                                                                                                                                              The basic idea that Pavlovian fear conditioning underlies some of the symptoms of PTSD has been elaborated in a number of ways. Leading psychological models of PTSD have sought to include this kind of associative learning within a broader cognitive framework that also recognizes different forms of memory (see Memory) and the key role of conscious cognitions, such as perception of life threat and appraisal of symptoms and consequences (see Peritrauma and Appraisal and Emotion). These models include the dual-representation theory of Brewin, et al. (1996), the cognitive model of Ehlers and Clark 2000, and the emotional-processing theory of Foa and Rothbaum 1998, which are compared and evaluated in Brewin and Holmes 2003. The dual representation theory has been updated in Brewin, et al. 2010 and evidence for it summarized in Brewin 2014. An alternative cognitive perspective is provided in Rubin, et al. Biological theories have sought to elucidate the brain mechanisms supporting the different types of learning and memory that are typical of PTSD (e.g., Elzinga and Bremner 2002; Rauch, et al. 2006). These models have also identified a second, nonassociative learning mechanism—sensitization—that is thought to underlie hyperarousal symptoms; these two mechanisms have been contrasted within a mouse model (Siegmund and Wotjak 2007). In contrast, a leading sociological model—the conservation of resources model of Hobfoll 1989—emphasizes the importance of the social consequences of trauma, especially losses, in determining subsequent disorder.

                                                                                                                                                                                              • Brewin, Chris R. 2014. Episodic memory, perceptual memory, and their interaction: Foundations for a theory of posttraumatic stress disorder. Psychological Bulletin 140.1: 69–97.

                                                                                                                                                                                                DOI: 10.1037/a0033722Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                Summarizes evidence from cognitive psychology, clinical psychology, and neuroscience that PTSD is produced by an imbalance in the encoding of the traumatic event into ordinary episodic memory and a lower-level, perceptual memory system.

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                                                                                                                                                                                                • Brewin, Chris R., James D. Gregory, Michelle Lipton, and Neil Burgess. 2010. Intrusive images in psychological disorders: Characteristics, neural mechanisms, and treatment implications. Psychological Review 117.1: 210–232.

                                                                                                                                                                                                  DOI: 10.1037/a0018113Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                  The dual representation model of PTSD of Chris R. Brewin, Tim Dalgleish, and Stephen Joseph, “A Dual Representation Theory of Post-traumatic Stress Disorder,” Psychological Review 103 (1996): 670–686, is revised on the basis of evidence from neuroscience. Two types of memory are related to the properties of the ventral and dorsal visual streams, placing the explanation of PTSD within a neural systems model of healthy memory and imagery.

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                                                                                                                                                                                                  • Brewin, Chris R., and Emily A. Holmes. 2003. Psychological theories of posttraumatic stress disorder. Clinical Psychology Review 23.3: 339–376.

                                                                                                                                                                                                    DOI: 10.1016/S0272-7358(03)00033-3Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                    The authors describe a number of early theoretical approaches and then provide a comparative analysis and evaluation of emotional processing theory by Edna B. Foa and Barbara O. Rothbaum (Foa and Rothbaum 1998); the dual representation theory by Chris R. Brewin, Tim Dalgleish, and Stephen Joseph, “A Dual Representation Theory of Post-traumatic Stress Disorder,” Psychological Review 103 (1996): 670–686; and the cognitive theory by Anke Ehlers and David M. Clark (Ehlers and Clark 2000). Available online for purchase or by subscription.

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                                                                                                                                                                                                    • Ehlers, Anke, and David M. Clark. 2000. A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy 38.4: 319–345.

                                                                                                                                                                                                      DOI: 10.1016/S0005-7967(99)00123-0Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                      The authors propose that pathological responses to trauma arise when individuals process the traumatic information in a way that produces a sense of current threat. The two major mechanisms involve negative appraisals of the trauma or its sequelae (see Appraisal and Emotion) and the nature of the trauma memory itself (see Memory). Available online for purchase or by subscription.

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                                                                                                                                                                                                      • Elzinga, B. M., and J. D. Bremner. 2002. Are the neural substrates of memory the final common pathway in posttraumatic stress disorder (PTSD)? Journal of Affective Disorders 70.1: 1–17.

                                                                                                                                                                                                        DOI: 10.1016/S0165-0327(01)00351-2Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                        The amygdala, hippocampus, and prefrontal cortex are identified as key structures in several pathways whereby exposure to severe stress may simultaneously result in strong emotional reactions and in difficulties in recalling the emotional event. Available online for purchase or by subscription.

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                                                                                                                                                                                                        • Foa, Edna B., and Barbara O. Rothbaum. 1998. Treating the trauma of rape: Cognitive behavioral therapy for PTSD. New York: Guilford.

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                                                                                                                                                                                                          An earlier theory by the authors was elaborated by describing how appraisals and preexisting beliefs (see Appraisal and Emotion) could interact to reinforce expectations concerning personal incompetence and external threat. High levels of stress lead to disorganization of trauma memories that make them more likely to intrude involuntarily.

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                                                                                                                                                                                                          • Hobfoll, Stevan E. 1989. Conservation of resources: A new attempt at conceptualizing stress. American Psychologist 44.3: 513–524.

                                                                                                                                                                                                            DOI: 10.1037/0003-066X.44.3.513Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                            This resource-oriented model is based on the supposition that people strive to retain, protect, and build resources and that what is threatening to them is the potential or actual loss of these valued resources. The model is extremely relevant for understanding reactions to traumatic events (see Hobfoll, et al. 2006, cited under Posttrauma). Available online for purchase or by subscription.

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                                                                                                                                                                                                            • Rauch, Scott L., Lisa M. Shin, and Elizabeth A. Phelps. 2006. Neurocircuitry models of posttraumatic stress disorder and extinction: Human neuroimaging research—past, present, and future. Biological Psychiatry 60:376–382.

                                                                                                                                                                                                              DOI: 10.1016/j.biopsych.2006.06.004Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                              This neurocircuitry model of PTSD hypothesizes hyperresponsivity within the amygdala to threat-related stimuli with inadequate top-down governance over the amygdala by the ventromedial prefrontal cortex, the hippocampus, and related structures. The pathogenesis of PTSD can be conceptualized as a fear-conditioning process set in motion by the traumatic event that is superimposed over some existing vulnerability.

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                                                                                                                                                                                                              • Rubin, David C., Dorthe Berntsen, and Malene K. Bohni. 2008. Memory-based model of posttraumatic stress disorder: Evaluating basic assumptions underlying the PTSD diagnosis. Psychological Review 115.4: 985–1011.

                                                                                                                                                                                                                DOI: 10.1037/a0013397Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                Present a mnemonic model of PTSD that relates symptoms to current representations of the traumatic event in memory rather than to objective features of the event. According to the model intrusive memories and flashbacks are products of a single episodic memory system rather than of alternative memory systems.

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                                                                                                                                                                                                                • Siegmund, Anja, and Carsten T. Wotjak. 2007. A mouse model of posttraumatic stress disorder that distinguishes between conditioned and sensitised fear. Journal of Psychiatric Research 41.10: 848–860.

                                                                                                                                                                                                                  DOI: 10.1016/j.jpsychires.2006.07.017Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                  According to the model, fear conditioning (a form of associative learning) and stress sensitization (a form of nonassociative learning) both play a crucial role in PTSD. Fear conditioning accounts for reexperiencing and heightened reactivity to trauma-related cues, whereas sensitization accounts for the hyperarousal symptoms. Available online for purchase or by subscription.

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                                                                                                                                                                                                                  Cross-Cultural Observations

                                                                                                                                                                                                                  Considerable debate concerns the cross-cultural applicability of the PTSD diagnosis as specified in the early 21st century. Concerns include the possible status of PTSD as a Western culture-bound disorder and the validity of individual items and criteria thresholds, which are reviewed in Hinton and Lewis-Fernández 2011. These concerns have important implications for intervention in non-Western societies affected by terrorism and disasters. One approach to such intervention is described in de Jong 2011. Jobson 2009 considers how culture may specifically influence how traumatic events affect the sense of self.

                                                                                                                                                                                                                  • de Jong, Joop. 2011. (Disaster) public mental health. In Post-traumatic stress disorder. Edited by Dan J. Stein, Matthew J. Friedman, and Carlos Blanco, 217–280. Chichester, UK: Wiley.

                                                                                                                                                                                                                    DOI: 10.1002/9781119998471Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                    Describes a public mental health model that is aimed particularly at middle- and low-income countries. Draws attention to cultural and political considerations and to issues of cost and sustainability. Includes multimodal interventions designed to improve outcomes for families and communities. Includes commentaries. Also available online as an e-book.

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                                                                                                                                                                                                                    • Hinton, Devon E., and Roberto Lewis-Fernández. 2011. The cross-cultural validity of posttraumatic stress disorder: Implications for DSM-5. Depression and Anxiety 28.9: 783–801.

                                                                                                                                                                                                                      DOI: 10.1002/da.20753Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                      Substantial evidence of the cross-cultural validity of PTSD was found. However, there was also some evidence of cross-cultural variability in certain areas; for example, reduced salience of the avoidance/numbing symptoms in many cultures and an increased prevalence of somatic symptoms. Available online for purchase or by subscription.

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                                                                                                                                                                                                                      • Jobson, Laura. 2009. Drawing current posttraumatic stress disorder models into the cultural sphere: The development of the “threat to the conceptual self” model. Clinical Psychology Review 29.4: 368–381.

                                                                                                                                                                                                                        DOI: 10.1016/j.cpr.2009.03.002Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                        Presents evidence that different conceptualizations of the self in independent and interdependent cultures mean that PTSD can be associated with different, culturally dependent types of self-appraisals.

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                                                                                                                                                                                                                        Treatment

                                                                                                                                                                                                                        This section is divided into Early Intervention, covering both prevention and intervention within the first days and weeks posttrauma; Pharmacological Treatment; and Psychological Treatment, which includes material on treatment of acute stress disorder, a severe posttraumatic reaction occurring in the first month posttrauma.

                                                                                                                                                                                                                        Early Intervention

                                                                                                                                                                                                                        Despite its widespread adoption, a single-session psychological debriefing proved to be ineffective at preventing the development of PTSD symptoms after a traumatic event and is now not recommended (see Bryant 2011, cited under Psychological Treatment, and van Emmerik, et al. 2002). Much progress has been made in identifying alternative methods of intervention after disasters and other major incidents (Watson, et al. 2011), many of them informed by a small number of basic principles for facilitating adaptation to disasters (Hobfoll, et al. 2007). Patients who develop acute stress disorder, the precursor to PTSD that occurs in the first month posttrauma, can also benefit from structured cognitive-behavioral therapy (see Bryant 2011). A great deal of interest has been shown in the possibility of using pharmacological interventions in the immediate aftermath of trauma to prevent the development of PTSD (Pitman and Delahanty 2005), with some promising preliminary results for hydrocortisone (Delahanty, et al. 2013).

                                                                                                                                                                                                                        • Delahanty, Douglas L., Crystal Gabert-Quillen, Sarah A. Ostrowski, et al. 2013. The efficacy of initial hydrocortisone administration at preventing posttraumatic distress in adult trauma patients: A randomized trial. CNS Spectrums 18.2: 103–111.

                                                                                                                                                                                                                          DOI: 10.1017/S1092852913000096Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                          Traumatic injury patients were randomly assigned to receive either a ten-day course of hydrocortisone or placebo initiated within twelve hours of the trauma. Hydrocortisone recipients reported fewer PTSD and depression symptoms, and they had greater improvements in health-related quality of life during the first three months posttrauma than did placebo recipients. Available online for purchase or by subscription.

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                                                                                                                                                                                                                          • Hobfoll, Stevan E., Patricia Watson, Carl C. Bell, et al. 2007. Five essential elements of immediate and mid-term mass trauma intervention: Empirical evidence. Psychiatry 70.4: 283–369.

                                                                                                                                                                                                                            DOI: 10.1521/psyc.2007.70.4.283Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                            A worldwide panel of experts identified five empirically supported principles that should be used to guide and inform intervention and prevention efforts at the early to midterm stages. These are promoting a sense of safety, calming, a sense of self- and community efficacy, connectedness, and hope.

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                                                                                                                                                                                                                            • Pitman, Roger K., and Douglas L. Delahanty. 2005. Conceptually driven pharmacologic approaches to acute trauma. CNS Spectrums 10.2: 99–106.

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                                                                                                                                                                                                                              Review of pharmacological intervention in the aftermath of a trauma to forestall PTSD based on a model emphasizing the overconsolidation of the traumatic memories. Includes studies of propranolol given to trauma victims presenting to emergency rooms, morphine treatment of burned children, and cortisol given to patients in intensive care units.

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                                                                                                                                                                                                                              • van Emmerik, Arnold A. P., Jan H. Kamphuis, Alexander M. Hulsbosch, and Paul M. G. Emmelkamp. 2002. Single session debriefing after psychological trauma: A meta-analysis. Lancet 360:766–771.

                                                                                                                                                                                                                                DOI: 10.1016/S0140-6736(02)09897-5Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                The authors conducted a meta-analysis on the effects of a single-session debriefing after traumatic events. Nondebriefing interventions and no intervention improved symptoms of PTSD, but debriefing did not improve symptoms of PTSD. Debriefing also did not improve natural recovery from other trauma-related disorders. Available online for purchase or by subscription.

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                                                                                                                                                                                                                                • Watson, Patricia J., Melissa J. Brymer, and George A. Bonanno. 2011. Postdisaster psychological intervention since 9/11. American Psychologist 66.6: 482–494.

                                                                                                                                                                                                                                  DOI: 10.1037/a0024806Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                  Reviews advances in needs assessment, screening, surveillance, and program evaluation; clarification of risk and resilience factors; implementation of interventions for children, adults, and families; adaptation of interventions for cultural groups; and strategies to expand access to postdisaster mental health services. Available online for purchase or by subscription.

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                                                                                                                                                                                                                                  Pharmacological Treatment

                                                                                                                                                                                                                                  As of the early 21st century, PTSD has not been the subject of intensive attempts to find specific pharmacotherapies, and international treatment guidelines differ on whether pharmacotherapy, generally antidepressant medication, should be a first-line treatment for PTSD. Reviews of the early-21st-century literature are Ravindran and Stein 2009 and Stein and Ipser 2011, and consistent with US regulatory approval for sertraline and paroxetine, both identify that the strongest evidence is for the efficacy of selective serotonin reuptake inhibitors (SSRIs). Ongoing research on the pathophysiology of PTSD implicates many different neurotransmitter systems and different neuroanatomical circuits, and these are giving rise to a number of novel suggestions for effective pharmacological agents. A novel line of research suggests that giving patients propranolol while they retrieve their traumatic memories may reduce subsequent PTSD symptoms (Brunet, et al. 2011). No convincing evidence has been presented that combining pharmacotherapy with psychological therapy produces superior outcomes to pharmacotherapy alone (Hetrick, et al. 2010).

                                                                                                                                                                                                                                  • Brunet, Alain, Joaquin Poundja, Jacques Tremblay, et al. 2011. Trauma reactivation under the influence of propranolol decreases posttraumatic stress symptoms and disorder: 3 open-label trials. Journal of Clinical Psychopharmacology 31.4: 547–550.

                                                                                                                                                                                                                                    DOI: 10.1097/JCP.0b013e318222f360Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                    In three independent studies, six brief trauma-memory reactivation sessions under the influence of propranolol brought about marked improvements in PTSD symptoms that persisted at a six-month follow-up. The authors commented that the effect sizes reported compared favorably to those produced by exposure-based psychotherapies; however, they were obtained using a different approach that involves fewer and shorter sessions and virtually no side effects.

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                                                                                                                                                                                                                                    • Hetrick, Sarah E., Rosemary Purcell, Belinda Garner, and Ruth Parslow. 2010. Combined pharmacotherapy and psychological therapies for post traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews 7: CD007316.

                                                                                                                                                                                                                                      DOI: 10.1002/14651858.CD007316.pub2Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                      This review assessed whether the combination of psychological therapy and pharmacotherapy provides a more efficacious treatment for PTSD than either of these interventions delivered separately. It concluded that not enough evidence was available to support or refute its effectiveness compared to either of these interventions alone.

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                                                                                                                                                                                                                                      • Ravindran, Lakshmi N., and Murray B. Stein. 2009. Pharmacotherapy of PTSD: Premises, principles, and priorities. Brain Research 1293:24–39.

                                                                                                                                                                                                                                        DOI: 10.1016/j.brainres.2009.03.037Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                        The authors describe a number of underlying pathophysiological dysfunctions in PTSD that could motivate the selection of psychopharmacological agents. They then review evidence for the efficacy of various classes of drugs, including different types of antidepressant, antiadrenergic drugs, anticonvulsant drugs, benzodiazepines, and atypical antipsychotics. Available online for purchase or by subscription.

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                                                                                                                                                                                                                                        • Stein, Dan J., and Jonathan C. Ipser. 2011. Pharmacotherapy of PTSD. In Post-traumatic stress disorder. Edited by Dan J. Stein, Matthew J. Friedman, and Carlos Blanco, 140–170. Chichester, UK: Wiley.

                                                                                                                                                                                                                                          DOI: 10.1002/9781119998471Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                          Discusses the different conclusions reached by regulatory bodies and professional organizations concerning pharmacotherapy and the reasons for this. Covers additional clinical aspects, such as the optimal SSRI for PTSD, the dose and duration of therapy, PTSD subtypes and spectrums, treatment-refractory PTSD, and the use of agents such as propranolol in PTSD prophylaxis. Includes commentaries. Available online as an e-book.

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                                                                                                                                                                                                                                          Psychological Treatment

                                                                                                                                                                                                                                          Meta-analyses have established the superiority of trauma-focused cognitive-behavior therapy and eye-movement desensitization and reprocessing (EMDR) in the treatment of chronic PTSD in adults (Bisson, et al. 2007; Bryant 2011). Both of these therapies involve accessing memories of the worst moments of the traumatic event and involve varying degrees of exposure to them. Innovations include narrative exposure therapy for individuals with multiple traumas (Schauer, et al. 2011), exposure via virtual reality (Gerardi, et al. 2010), Internet-based interventions (Boasso, et al. 2014), telemental health technology (Morland, et al. 2014), an intensive form of trauma-focused cognitive-behavior therapy lasting for one week (Ehlers, et al. 2014), and a phase-based, coping skills–oriented treatment for treating more complex presentations in which immediate exposure may be contraindicated (Cloitre, et al. 2010). Few studies have been done in children, but practice parameters have been published to guide clinicians (Cohen, et al. 2010). A randomized controlled trial found similar efficacy for trauma-focused cognitive-behavior therapy in children as in adults (Smith, et al. 2007). Despite demonstration of the effectiveness of the exposure component of trauma-focused treatment, surveys indicate that many practitioners do not use this in their therapy, suggesting that PTSD often goes ineffectively treated or undertreated (Becker, et al. 2004).

                                                                                                                                                                                                                                          • Becker, Carolyn Black, Claudia Zayfert, and Emily Anderson. 2004. A survey of psychologists’ attitudes towards and utilization of exposure therapy for PTSD. Behaviour Research and Therapy 42.3: 277–292.

                                                                                                                                                                                                                                            DOI: 10.1016/S0005-7967(03)00138-4Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                            Even among psychologists with strong interest and training in behavioral treatment for PTSD, exposure therapy is not completely accepted or widely used. Clinicians also appear to perceive a significant number of barriers to implementing exposure. Available online for purchase or by subscription.

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                                                                                                                                                                                                                                            • Bisson, Jonathan I., Anke Ehlers, Rosa Matthews, Stephen Pilling, David Richards, and Stuart Turner. 2007. Psychological treatments for chronic post-traumatic stress disorder: Systematic review and meta-analysis. British Journal of Psychiatry 190:97–104.

                                                                                                                                                                                                                                              DOI: 10.1192/bjp.bp.106.021402Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                              Trauma-focused cognitive-behavioral therapy (TFCBT), eye-movement desensitization and reprocessing (EMDR), stress management, and group cognitive-behavioral therapy improved PTSD symptoms more than waiting list or usual care. Some evidence showed that TFCBT and EMDR were superior to stress management and other therapies.

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                                                                                                                                                                                                                                              • Boasso, Alyssa, Hanna Kadesch, and Brett T. Litz. 2014. Internet-based interventions for PTSD. In Handbook of PTSD: Science in practice. 2d ed. Edited by Matthew J. Friedman, Terence M. Keane, and Patricia A. Resick, 557–570. New York: Guilford.

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                                                                                                                                                                                                                                                Discusses newly emerging Internet-based preventive and treatment interventions.

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                                                                                                                                                                                                                                                • Bryant, Richard A. 2011. Psychological interventions for trauma exposure and PTSD. In Post-traumatic stress disorder. Edited by Dan J. Stein, Matthew J. Friedman, and Carlos Blanco, 171–215. Chichester, UK: Wiley.

                                                                                                                                                                                                                                                  DOI: 10.1002/9781119998471Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                                  Reviews meta-analyses and treatment guidelines concluding that trauma-focused cognitive-behavior therapy (TFCBT) is the treatment of choice for PTSD. The author discusses the evidence for early prophylactic intervention posttrauma, implementation guidelines, treatment of comorbid conditions, and contraindications. Includes commentaries. Also available online as an e-book.

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                                                                                                                                                                                                                                                  • Cloitre, Marylene, K. Chase Stovall-McClough, Kate Nooner, et al. 2010. Treatment for PTSD related to childhood abuse: A randomized controlled trial. American Journal of Psychiatry 167:915–924.

                                                                                                                                                                                                                                                    DOI: 10.1176/appi.ajp.2010.09081247Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                                    The authors evaluated a treatment for women with PTSD related to childhood abuse combining an initial preparatory phase of skills training in affect and interpersonal regulation followed by exposure. This treatment (STAIR/MPE) was associated with greater benefits and fewer adverse effects than treatments that excluded either skills training or exposure.

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                                                                                                                                                                                                                                                    • Cohen, Judith A., Oscar Bukstein, Heather Walter, et al. 2010. Practice parameter for the assessment and treatment of children and adolescents with posttraumatic stress disorder. Journal of the American Academy of Child and Adolescent Psychiatry 49.4: 414–430.

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                                                                                                                                                                                                                                                      Reviews the evidence and highlights the importance of early identification of PTSD, gathering information from parents and children, and the assessment and treatment of comorbid disorders. It presents evidence to support trauma-focused psychotherapy, medications, and a combination of interventions in a multimodal approach. Available online for purchase or by subscription.

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                                                                                                                                                                                                                                                      • Ehlers, Anke, Ann Hackmann, Nick Grey, et al. 2014. A randomized controlled trial of 7-day intensive and standard weekly cognitive therapy for PTSD and emotion-focused supportive therapy. American Journal of Psychiatry 171.3: 294–304.

                                                                                                                                                                                                                                                        DOI: 10.1176/appi.ajp.2013.13040552Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                                        Authors conducted a randomized controlled trial demonstrating that cognitive therapy for PTSD delivered intensively over little more than a week was as effective as cognitive therapy delivered over three months. Both had specific effects and were superior to supportive therapy. Available online for purchase or by subscription.

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                                                                                                                                                                                                                                                        • Gerardi, Maryrose, Judith Cukor, JoAnn Difede, Albert Rizzo, and Barbara Olasov Rothbaum. 2010. Virtual reality exposure therapy for post-traumatic stress disorder and other anxiety disorders. Current Psychiatry Reports 12.4: 298–305.

                                                                                                                                                                                                                                                          DOI: 10.1007/s11920-010-0128-4Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                                          Virtual reality exposure therapy involves immersion in a computer-generated virtual environment that minimizes avoidance and facilitates emotional processing. The authors review evidence on the application of virtual reality exposure therapy to the treatment of specific phobias and posttraumatic stress disorder and discuss its advantages and cautions. Available online for purchase or by subscription.

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                                                                                                                                                                                                                                                          • Morland, Leslie A., Julia E. Hoffman, Carolyn J. Greene, and Craig S. Rosen. 2014. Handbook of PTSD: Science in practice. 2d ed. Edited by Matthew J. Friedman, Terence M. Keane, and Patricia A. Resick, 571–589. New York: Guilford.

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                                                                                                                                                                                                                                                            Discusses a variety of innovations including clinical videoteleconferencing, telephone-based interventions, web-based interventions, and mobile delivery of mental health treatments.

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                                                                                                                                                                                                                                                            • Schauer, Maggie, Frank Neuner, and Thomas Elbert. 2011. Narrative exposure therapy: A short-term treatment for traumatic stress disorders. 2d ed. Cambridge, MA: Hogrefe.

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                                                                                                                                                                                                                                                              This version of exposure treatment was developed particularly for refugees and trauma survivors in settings where only short-term intervention is practical, and enables a complex trauma history to be addressed.

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                                                                                                                                                                                                                                                              • Smith, Patrick, William Yule, Sean Perrin, Troy Tranah, Tim Dalgleish, and David M. Clark. 2007. Cognitive-behavioral therapy for PTSD in children and adolescents: A preliminary randomized controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry 46.8: 1051–1061.

                                                                                                                                                                                                                                                                DOI: 10.1097/CHI.0b013e318067e288Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                                                Children and young people with PTSD following single traumatic events received individual trauma-focused cognitive-behavioral therapy. Compared to a waiting-list group, those treated showed significantly greater improvement in symptoms of PTSD, depression, and anxiety with significantly better functioning. Gains were maintained at a six-month follow-up. Available online for purchase or by subscription.

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