PTSD affects about 5% of the US adult population each year.[261] The National Comorbidity Survey Replication has estimated that the lifetime prevalence of PTSD among adult Americans is 6.8%, with women (9.7%) more than twice as likely as men[126] (3.6%) to have PTSD at some point in their lives.[66] More than 60% of men and more than 60% of women experience at least one traumatic event in their life. The most frequently reported traumatic events by men are rape, combat, and childhood neglect or physical abuse. Women most frequently report instances of rape, sexual molestation, physical attack, being threatened with a weapon and childhood physical abuse.[126] 88% of men and 79% of women with lifetime PTSD have at least one comorbid psychiatric disorder. Major depressive disorder, 48% of men and 49% of women, and lifetime alcohol use disorder or dependence, 51.9% of men and 27.9% of women, are the most common comorbid disorders.[262]
Military combat
The United States Department of Veterans Affairs estimates that 830,000 Vietnam War veterans had symptoms of PTSD.[263] The National Vietnam Veterans' Readjustment Study (NVVRS) found 15% of male and 9% of female Vietnam veterans had PTSD at the time of the study. Life-time prevalence of PTSD was 31% for males and 27% for females. In a reanalysis of the NVVRS data, along with analysis of the data from the Matsunaga Vietnam Veterans Project, Schnurr, Lunney, Sengupta, and Waelde found that, contrary to the initial analysis of the NVVRS data, a large majority of Vietnam veterans had PTSD symptoms (but not the disorder itself). Four out of five reported recent symptoms when interviewed 20–25 years after Vietnam.[264]
A 2011 study from Georgia State University and San Diego State University found that rates of PTSD diagnosis increased significantly when troops were stationed in combat zones, had tours of longer than a year, experienced combat, or were injured. Military personnel serving in combat zones were 12.1 percentage points more likely to receive a PTSD diagnosis than their active-duty counterparts in non-combat zones. Those serving more than 12 months in a combat zone were 14.3 percentage points more likely to be diagnosed with PTSD than those having served less than one year.[265]
Experiencing an enemy firefight was associated with an 18.3 percentage point increase in the probability of PTSD, while being wounded or injured in combat was associated with a 23.9 percentage point increase in the likelihood of a PTSD diagnosis. For the 2.16 million U.S. troops deployed in combat zones between 2001 and 2010, the total estimated two-year costs of treatment for combat-related PTSD are between $1.54 billion and $2.69 billion.[265]
As of 2013, rates of PTSD have been estimated at up to 20% for veterans returning from Iraq and Afghanistan.[266] As of 2013 13% of veterans returning from Iraq were unemployed.[267]
Human-made disasters
The September 11 attacks took the lives of nearly 3,000 people, leaving 6,000 injured.[268] First responders (police, firefighters, and emergency medical technicians), sanitation workers, and volunteers were all involved in the recovery efforts. The prevalence of probable PTSD in these highly exposed populations was estimated across several studies using in-person, telephone, and online interviews and questionnaires.[268][269][270] Overall prevalence of PTSD was highest immediately following the attacks and decreased over time. However, disparities were found among the different types of recovery workers.[268][269] The rate of probable PTSD for first responders was lowest directly after the attacks and increased from ranges of 4.8–7.8% to 7.4–16.5% between the 5–6 year follow-up and a later assessment.[268]
When comparing traditional responders to non-traditional responders (volunteers), the probable PTSD prevalence 2.5 years after the initial visit was greater in volunteers with estimates of 11.7% and 17.2% respectively.[268] Volunteer participation in tasks atypical to the defined occupational role was a significant risk factor for PTSD.[269] Other risk factors included exposure intensity, earlier start date, duration of time spent on site, and constant, negative reminders of the trauma.[268][269]
Additional research has been performed to understand the social consequences of the September 11 attacks. Alcohol consumption was assessed in a cohort of World Trade Center workers using the cut-annoyed-guilty-eye (CAGE) questionnaire for alcohol use disorder. Almost 50% of World Trade Center workers who self-identified as alcohol users reported drinking more during the rescue efforts.[270] Nearly a quarter of these individuals reported drinking more following the recovery.[270] If determined to have probable PTSD status, the risk of developing an alcohol problem was double compared to those without psychological morbidity.[270] Social disability was also studied in this cohort as a social consequence of the September 11 attacks. Defined by the disruption of family, work, and social life, the risk of developing social disability increased 17-fold when categorized as having probable PTSD.[270]
Anthropology
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Cultural and medical anthropologists have questioned the validity of applying the diagnostic criteria of PTSD cross-culturally.[271]
Trauma (and resulting PTSD) is often experienced through the outermost limits of suffering, pain and fear. The images and experiences relived through PTSD often defy easy description through language. Therefore, the translation of these experiences from one language to another is problematic, and the primarily Euro-American research on trauma is necessarily limited.[272] The Sapir-Whorf hypothesis suggests that people perceive the world differently according to the language they speak: language and the world it exists within reflect back on the perceptions of the speaker.[273]
For example, ethnopsychology studies in Nepal have found that cultural idioms and concepts related to trauma often do not translate to western terminologies: piDaa is a term that may align to trauma/suffering, but also people who suffer from piDaa are considered paagal (mad) and are subject to negative social stigma, indicating the need for culturally appropriate and carefully tailored support interventions.[274] More generally, different cultures remember traumatic experiences within different linguistic and cultural paradigms. As such, cultural and medical anthropologists have questioned the validity of applying the diagnostic criteria of PTSD cross-culturally, as defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III),[needs update] and constructed through the Euro-American paradigm of psychology.[271]
There remains a dearth of studies into the conceptual frameworks that surround trauma in non-Western cultures.[271] There is little evidence to suggest therapeutic benefit in synthesizing local idioms of distress into a culturally constructed disorder of the post-Vietnam era, a practice anthropologist believe contributes to category fallacy.[clarification needed][271] For many cultures there is no single linguistic corollary to PTSD, psychological trauma being a multi-faceted concept with corresponding variances of expression.[274]
Designating the effects of trauma as an affliction of the spirit is common in many non-Western cultures where idioms such as "soul loss" and "weak heart" indicate a preference to confer suffering to a spirit-body or heart-body diametric. These idioms reflect the emphasis that collectivist cultures place on healing trauma through familial, cultural and religious activities while avoiding the stigma that accompanies a mind-body approach.[271] Prescribing PTSD diagnostics within these communities is ineffective and often detrimental.[citation needed] For trauma that extends beyond the individual, such as the effects of war, anthropologists believe applying the term "social suffering" or "cultural bereavement" to be more beneficial.[275]
Every facet of society is affected by conflict; the prolonged exposure to mass violence can lead to a 'continuous suffering' among civilians, soldiers, and bordering countries.[276] Entered into the DSM in 1980, clinicians and psychiatrists based the diagnostic criteria for PTSD around American veterans of the Vietnam War.[277] Though the DSM gets reviewed and updated regularly, it is unable to fully encompass the disorder due to its Americanization (or Westernization).[278] That is, what may be considered characteristics of PTSD in western society, may not directly translate across to other cultures around the world. Displaced people of the African country Burundi experienced symptoms of depression and anxiety, though few symptoms specific to PTSD were noted.[279]
In a similar review, Sudanese refugees relocated in Uganda were 'concerned with material [effects]' (lack of food, shelter, and healthcare), rather than psychological distress.[279] In this case, many refugees did not present symptoms at all, with a minor few developing anxiety and depression.[279] War-related stresses and traumas will be ingrained in the individual,[276] however they will be affected differently from culture to culture, and the "clear-cut" rubric for diagnosing PTSD does not allow for culturally contextual reactions to take place.[citation needed]
Veterans
Vietnam Veterans Memorial, Washington, D.C.
United States
See also: Benefits for US Veterans with PTSD
The United States provides a range of benefits for veterans that the VA has determined have PTSD, which developed during, or as a result of, their military service. These benefits may include tax-free cash payments,[280] free or low-cost mental health treatment and other healthcare,[281] vocational rehabilitation services,[282] employment assistance,[283] and independent living support.[284][285]
United Kingdom
In the UK, there are various charities and service organisations dedicated to aiding veterans in readjusting to civilian life. The Royal British Legion and the more recently established Help for Heroes are two of Britain's more high-profile veterans' organisations which have actively advocated for veterans over the years. There has been some controversy that the NHS has not done enough in tackling mental health issues and is instead "dumping" veterans on charities such as Combat Stress.[286][287]
Canada
Veterans Affairs Canada provides assistance to disabled veterans that includes rehabilitation, financial aid, job placement, healthcare, disability compensation, peer support,[288][289] and family support.[290]
History
See also: List of people with post-traumatic stress disorder
Aspects of PTSD in soldiers of ancient Assyria have been identified using written sources from 1300 to 600 BCE. These Assyrian soldiers would undergo a three-year rotation of combat before being allowed to return home, and were reported to have faced immense challenges in reconciling their past actions in war with their civilian lives.[291]
Connections between the actions of Viking berserkers and the hyperarousal of post-traumatic stress disorder have also been drawn.[292]
Psychiatrist Jonathan Shay has proposed that Lady Percy's soliloquy in the William Shakespeare play Henry IV, Part 1 (act 2, scene 3, lines 40–62[293]), written around 1597, represents an unusually accurate description of the symptom constellation of PTSD.[294]
Many historical wartime diagnoses such as railway spine, stress syndrome, nostalgia, soldier's heart, shell shock, battle fatigue, combat stress reaction, and traumatic war neurosis are now associated with PTSD.[295][296]
The correlations between combat and PTSD are undeniable; according to Stéphane Audoin-Rouzeau and Annette Becker, "One-tenth of mobilized American men were hospitalized for mental disturbances between 1942 and 1945, and, after thirty-five days of uninterrupted combat, 98% of them manifested psychiatric disturbances in varying degrees."[297]
The DSM-I (1952) includes a diagnosis of "gross stress reaction", which has similarities to the modern definition and understanding of PTSD.[298] Gross stress reaction is defined as a normal personality using established patterns of reaction to deal with overwhelming fear as a response to conditions of great stress.[299] The diagnosis includes language which relates the condition to combat as well as to "civilian catastrophe".[299]
Statue, Three Servicemen, Vietnam Veterans Memorial
The addition of the term to the DSM-III was greatly influenced by the experiences and conditions of U.S. military veterans of the Vietnam War.[300] In fact, much of the available published research regarding PTSD is based on studies done on veterans of the war in Vietnam.
Because of the initial overt focus on PTSD as a combat related disorder when it was first fleshed out in the years following the war in Vietnam, in 1975 Ann Wolbert Burgess and Lynda Lytle Holmstrom defined rape trauma syndrome (RTS) in order to draw attention to the striking similarities between the experiences of soldiers returning from war and of rape victims.[301] This paved the way for a more comprehensive understanding of causes of PTSD.
Early in 1978, the diagnosis term "post-traumatic stress disorder" was first recommended in a working group finding presented to the Committee of Reactive Disorders.[302]
A USAF study carried out in 1979 focused on individuals (civilian and military) who had worked to recover or identify the remains of those who died in Jonestown. The bodies had been dead for several days, and a third of them had been children. The study used the term "dysphoria" to describe PTSD-like symptoms.[303]
After PTSD became an official American psychiatric diagnosis with the publication of DSM-III (1980), the number of personal injury lawsuits (tort claims) asserting the plaintiff had PTSD increased rapidly. However, triers of fact (judges and juries) often regarded the PTSD diagnostic criteria as imprecise, a view shared by legal scholars, trauma specialists, forensic psychologists, and forensic psychiatrists. The condition was termed "posttraumatic stress disorder" in the DSM-III (1980).[298][302]
Professional discussions and debates in academic journals, at conferences, and between thought leaders, led to a more clearly-defined set of diagnostic criteria in DSM-IV (1994), particularly the definition of a "traumatic event".[304] The DSM-IV classified PTSD under anxiety disorders. In the ICD-10 (first used in 1994), the spelling of the condition was "post-traumatic stress disorder".[305]
In 2012, the researchers from the Grady Trauma Project highlighted the tendency people have to focus on the combat side of PTSD: "less public awareness has focused on civilian PTSD, which results from trauma exposure that is not combat related..." and "much of the research on civilian PTSD has focused on the sequelae of a single, disastrous event, such as the Oklahoma City bombing, September 11th attacks, and Hurricane Katrina".[306] Disparity in the focus of PTSD research affected the already popular perception of the exclusive interconnectedness of combat and PTSD. This is misleading when it comes to understanding the implications and extent of PTSD as a neurological disorder.
The DSM-5 (2013) created a new category called "trauma and stressor-related disorders", in which PTSD is now classified.[1]
America's 2014 National Comorbidity Survey reports that "the traumas most commonly associated with PTSD are combat exposure and witnessing among men and rape and sexual molestation among women."[66]
Terminology
"PTSS" redirects here. Not to be confused with Post Traumatic Slave Syndrome.
The Diagnostic and Statistical Manual of Mental Disorders does not hyphenate "post" and "traumatic", thus, the DSM-5 lists the disorder as posttraumatic stress disorder.[307] However, many scientific journal articles and other scholarly publications do hyphenate the name of the disorder, viz., "post-traumatic stress disorder".[308] Dictionaries also differ with regard to the preferred spelling of the disorder with the Collins English Dictionary – Complete and Unabridged using the hyphenated spelling, and the American Heritage Dictionary of the English Language, Fifth Edition and the Random House Kernerman Webster's College Dictionary giving the non-hyphenated spelling.[309]
Some authors have used the terms "post-traumatic stress syndrome" or "post-traumatic stress symptoms" ("PTSS"),[310] or simply "post-traumatic stress" ("PTS") in the case of the U.S. Department of Defense,[311] to avoid stigma associated with the word "disorder".
The comedian George Carlin criticized the euphemism treadmill which led to progressive change of the way PTSD was referred to over the course of the 20th century, from "shell shock" in the First World War to the "battle fatigue" in the Second World War, to "operational exhaustion" in the Korean War, to the current "post-traumatic stress disorder", coined during the Vietnam War, which "added a hyphen" and which, he commented, "completely burie[s] [the pain] under jargon". He also stated that the name given to the condition has had a direct effect on the way veteran soldiers with PTSD were treated and perceived by civilian populations over time.[312]
Research
Most knowledge regarding PTSD comes from studies in high-income countries.[313]
To recapitulate some of the neurological and neurobehavioral symptoms experienced by the veteran population of recent conflicts in Iraq and Afghanistan, researchers at the Roskamp Institute and the James A Haley Veteran's Hospital (Tampa) have developed an animal model to study the consequences of mild traumatic brain injury (mTBI) and PTSD.[314] In the laboratory, the researchers exposed mice to a repeated session of unpredictable stressor (i.e. predator odor while restrained), and physical trauma in the form of inescapable foot-shock, and this was also combined with a mTBI. In this study, PTSD animals demonstrated recall of traumatic memories, anxiety, and an impaired social behavior, while animals subject to both mTBI and PTSD had a pattern of disinhibitory-like behavior. mTBI abrogated both contextual fear and impairments in social behavior seen in PTSD animals. In comparison with other animal studies,[314][315] examination of neuroendocrine and neuroimmune responses in plasma revealed a trend toward increase in corticosterone in PTSD and combination groups.
Stellate ganglion block is an experimental procedure for the treatment of PTSD.[316]
Researchers are investigating a number of experimental FAAH and MAGL-inhibiting drugs in hopes of finding a better treatment for anxiety and stress-related illnesses.[317] In 2016, the FAAH-inhibitor drug BIA 10-2474 was withdrawn from human trials in France due to adverse effects.[318]
Evidence from clinical trials suggests that MDMA-assisted psychotherapy is an effective treatment for PTSD.[319][320] On August 9, 2024, the FDA issued a letter stating that a further trial was necessary to ascertain that the benefits of MDMA-assisted psychotherapy outweighed the potential harms.[321] Positive findings in clinical trials of MDMA-assisted psychotherapy might be substantially influenced by expectancy effects given the unblinding of participants.[322][323] To prevent this confounding factor, it has been suggested that future trials compare MDMA against an active placebo.[324] There is a lack of trials comparing MDMA-assisted psychotherapy to existent first-line treatments for PTSD, such as trauma-focused psychological treatments, which seems to achieve similar or even better outcomes than MDMA-assisted psychotherapy.[325]
Psychotherapy
Trauma-focused psychotherapies for PTSD (also known as "exposure-based" or "exposure" psychotherapies), such as prolonged exposure therapy (PE), eye movement desensitization and reprocessing (EMDR), and cognitive-reprocessing therapy (CPT) have the most evidence for efficacy and are recommended as first-line treatment for PTSD by almost all clinical practice guidelines.[326][327][328] Exposure-based psychotherapies demonstrate efficacy for PTSD caused by different trauma "types", such as combat, sexual-assault, or natural disasters.[326] At the same time, many trauma-focused psychotherapies evince high drop-out rates.[329]
Most systematic reviews and clinical guidelines indicate that psychotherapies for PTSD, most of which are trauma-focused therapies, are more effective than pharmacotherapy (medication),[330] although there are reviews that suggest exposure-based psychotherapies for PTSD and pharmacotherapy are equally effective.[331] Interpersonal psychotherapy shows preliminary evidence of probable efficacy, but more research is needed to reach definitive conclusions.[332]