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112 PTSD Essay Topic Ideas & Examples

🏆 best ptsd topic ideas & essay examples, 👍 good essay topics on ptsd, ⭐ simple & easy ptsd essay titles, ❓ ptsd research questions examples.

• PTSD in Charlie of “The Perks of Being a Wallflower” As an example of the latter, this paper focuses on the analysis of Charlie Kelmeckis, the protagonist of Stephen Chbosky’s novel The Perks of Being a Wallflower, and his PTSD.
• Post Traumatic Stress Disorder: History and Symptoms This essay looks into the history, the symptoms of posttraumatic stress disorder, and the individuals who are likely to suffer from this condition, psychological problems associated with this condition and the treatment of the disorder.
• Post-Traumatic Stress Disorder and Substance Use Disorder The hypothesis of self-medication is one of the mechanisms that can expound the comorbidity between post-traumatic stress disorder and anxiety illness.
• Post Traumatic Stress Disorder (PTSD) as a Health Issue in the Society The treatment is aimed at relieving the symptoms that the patient seems to be experiencing so that the individual can be able to deal with the traumatic experience.
• Aspects of the Posttraumatic Stress Disorder They include direct or indirect exposure to stressors, intrusion symptoms, the persistent avoidance of trauma-related stressors, negative alterations in mood and the development of mental health comorbidities, aggression, and self-destructive behavior, the duration for not […]
• The Importance of PTSD for Master Leaders Course in the Army The multiplicity of this manifestation and presentation of PTSD creates a research question focusing on the need for research into the main types of disorder and the support.
• Self-Reported PTSD (Posttraumatic Stress) Symptoms and Social Support At the same time, multiple authors prove that social support and connectedness with family members, relatives, friends, and other members of the community contribute to PTG and the minimization of the signs of PTSD in […]
• The Traumas from Post Traumatic Stress Disorder Measuring the prevalence and incidence of PTSD requires excellent knowledge of epidemiology and biostatistics. The prevalence and incidence of PTSD have increased since 2000.
• Post-Traumatic Stress Disorder: Preliminary Care Coordination The personal character of trauma and how the patient reacts to it justifies the need to design patient-centered interventions to address this healthcare problem.
• Post-Traumatic Stress Disorder: Causes and Symptoms The article by Smith entitled Posttraumatic Stress Disorder is valuable because it offers important information on the causes and symptoms of PTSD and ways of recognizing and treating the condition.
• Major Depressive Disorder and Post-Traumatic Stress Disorder Her sleep is turbulent, she has rape nightmares, her mood is depressed, and her affect is congruent and constrained. Her mental process is rational and linear, and her mental faculties are largely intact.
• Posttraumatic Stress Disorder: Case Presentation Report Date of initial assessment: N/A PSEUDO Name: Ana Ana is a self-referred and re-occurring client who entered counseling after the case of domestic violence. As a result, Ana expressed feelings of anxiety and fear […]
• The DSM-5 Criteria for Posttraumatic Stress Disorder The inference is backed by the fact that Victor’s traumatic situation is persistently manifesting intrusion symptoms such as nightmares, flashbacks, unwanted upsetting memories, and a lack of willingness to share previous hurtful events. Victor displays […]
• Posttraumatic Stress Disorder Treatment Research Therefore, the advantage of qualitative research, in this case, relates to the ability to investigate patients’ PTSD treatment experiences and uncover their meanings.
• Post-Traumatic Stress Disorder Misapprehension A significant proportion of civilians are affected by post-traumatic stress but ignore the symptoms and fail to seek early interventions influenced by misconceptions about how PTSD develops and its symptoms.
• Post-Traumatic Stress Disorder and Opioid Use in Veterans This study examined the proportion of United States veterans who had PTSD and engaged in the use of illegal opioids to cope with it or had done so in the past.
• Post Traumatic Stress Disorder in A Journal for Jordan Considering the loss of her husband in the war, Dana had not recovered, and the expression of irate reaction is a symptom of PTSD.
• Post-Traumatic Stress Disorder Development Avoidance of objects that remind you of the traumatic incident is another symptom of PTSD. Identifying erroneous and unreasonable beliefs about the incident and replacing them with a more balanced image is also part of […]
• Sexual Aversion and Post-Traumatic Stress Disorder This aspect causes difficulties in prescribing therapy, since the latter requires a thorough study of the psychological nature of the problems. In the treatment of sexual aversion disorder, a doctor needs to investigate a complex […]
• Zaccari et al. (2020). “Yoga for Veterans With PTSD”: Content, Strength, and Weaknesses This discussion reviews the strengths and weaknesses of the method, sampling, and validity of Zaccari et al.research. The assertions reported in the article are supported by cited and referenced scientific studies, which enhances the validity […]
• Secondary Post Traumatic Stress Disorder in Children The relationship between parents’ experiences and interactions with the onset of PTSD in children will be explored. There is vast information on the management of treatment and prevention of PTSD in children.
• Aspects of Secondary PTSD in Children They constantly contact and interact with each other, and the latter inadvertently affects the mental health of the former, which leads to the development of secondary PTSD.
• Post-Traumatic Stress Disorder and Parenting Style On a scale of 1 to 10, with 1 being lowest and 10 being highest, how much do you believe that kids need to learn early who the boss is in the family?
• Psychiatry: PTSD Following Refugee Trauma The psychiatrists finally recognized PTSD in the first version of the Diagnostic and Statistical Manual of Mental Disorders after the mass occurrence of similar symptoms in Vietnam veterans.
• 35-Year-Old Man With PTSD: Case Study In such a case, it is recommended this is precisely a recommendation, not a requirement to do an MRI, which would allow a better study of the patient’s body.
• PTSD Dual Representation Theory Use in Military Personnel However, it is the position of this paper that this is mere gender stereotyping and the real cause of trauma among women veterans has to do with sexual harassment.
• Substance Abuse Disorders and PTSD The concept indicates that people who have PTSD are at higher risk of substance abuse and consequently substance disorders due to the tendency to consume alcohol and use drugs to deal with stress.
• “Mindfulness Interventions in the Treatment of PTSD” by Williston The primary purpose of that article is to conduct a survey of meta-analyses related to the efficiency of cognitive behavioral therapy.
• “Experiences of Military Spouses of Veterans With Combat-Related PTSD” by Yambo Spouses living with PTSD veterans are unprepared and struggling to deal with issues that their husbands experience.
• Post-Traumatic Stress Disorder Pathophysiology Sakellariou and Stefanatou, further link threat responsiveness and fear regulation with the signalling of 5-HT within the amygdala; this is an area within the brain deemed essential in comprehending the reaction to fear and aetiology […]
• The Fiction Character`s PTSD Diagnosis: Rambo According to the American Psychiatric Association, experiencing traumatic events, witnessing the events, learning that a traumatic event occurred to a close person, and is exposed to aversive details of events are the triggers of PTSD.
• IL-6: Predicting the Development of PTSD Therefore, it is important to understand and define the biological underpinnings of immune dysregulation in PTSD as it also plays a crucial role in helping us to understand the nature of the associations between PTSD […]
• Cognitive Processing Therapy and Evidence Based Interventions for Veterans Diagnosed With PTSD According to the evidence attained, comprehensive and extensive evidence is crucial in providing a clear correlation of the benefits accrued from CPT in comparison to other forms of treatment.
• Effective Use of Prazosin for Posttraumatic Stress Disorder All the traditional agents have shown to have several side effects and cannot be fully relied on in treatment of PTSD.
• Post-Traumatic Stress Disorder Diagnostics and Screening Do you observe a headache from the early morning? Do you have a headache when you sleep well?
• PTSD Mental Disorder: Triggers, Clinical Manifestations, and Treatment PTSD is normally characterized as a mental disorder that is a direct result of anxiety-related syndromes that came about as a direct result of a traumatic event.
• Posttraumatic Stress Disorder The study seeks to find out the prevalence of TBI/PTSD and the variations in the prevalence based on the severity of TBI, as well as other related variables.
• Post-Traumatic Stress Disorder (PTSD) Among Vets One of the integral components of this concept is the problem of traumatic stressors, as is customary in international classifications, the issue of post-traumatic stress disorder.
• Post-Traumatic Stress Disorder: Overview The overall process of evaluation and analysis of the film was done correctly and adhered to the standard principles of counseling.
• Post-Traumatic Stress Disorder Treatment in Intellectually Disabled Patients: The Promise of Eye Movement Desensitization and Reprocessing Therapy The use and application of findings that shed light on current research gaps related to the effectiveness of EMDR in PTSD patients with IDs may contribute to improvements in this population’s quality of life and […]
• Client Diagnosis: Posttraumatic Stress Disorder As for the PTSD itself, the client meets criterion A because she reported car accident involving death of the other passenger.
• Disaster Crisis: Post-Traumatic Stress Disorder Symptoms Since the account of the incidence, almost a month, she lost interest in work and concentration on activities relating to work at her place of work.
• Living With Post Traumatic Stress Disorder This can be achieved by making efforts to keep away from the people and also the places that act as a reminder of the events.
• Posttraumatic Stress Disorder After Rape Attempt During the treatment of the patient, the Target Memory is the day the girl was attacked. In her treatment, it is necessary to eliminate the feeling of guilt for the accident.
• Post Traumatic Stress Disorder: Causes and Consequences An interesting finding from the interview is that Abby and her husband had faced the accident together, however, the reactions of the two to the accident were radically different.
• Post Traumatic Stress Disorder: German Researches The other objective of the study was to identify the specific features a traumatic event could influence PTSP in the solders.
• Posttraumatic Stress Disorder in Veteran Community The creation of special programs for the rehabilitation of veterans helped alleviate the problem of PTSD during the wars in Iraq and Afghanistan and facilitated the development of a support system that is currently used.
• “Emotional Freedom Technique and Post-Traumatic Stress Disorder” by Rebecca L. Fahey The author considers a special method of influencing military veterans who experience the effects of PTSD and feel acute bouts of depression.
• Post-Traumatic Stress Disorder and Treatment Effectiveness In the final section, the effectiveness of all the explored interventions will be discussed to summarize the results of the present literature review.
• Post-Traumatic Stress Disorder in Missouri Veterans Unfortunately, the implemented policies have failed to meet the needs of different veterans, such as the Welcome Back Veterans, the Veterans Health Administration, and the Military Health System. Louis has several policies and programs aimed […]
• Posttraumatic Stress Disorder Management in Children The purpose of this paper is to determine whether the application of the perspective of clinical psychology as the platform for treating PTSD in children will have better effects than the adoption of the methods […]
• Racial Disparities in Posttraumatic Stress Disorder Treatment Within the framework of this submission, the author is going to discuss several components that may critically impact the complexity of psychological traumas received by African American soldiers and provide a conceptualized policy that will […]
• Posttraumatic Stress Disorder in Hispanic Teenager Family dynamics and social withdrawal do not seem to have affected the client’s academic history; her grades are good and she has no history of behavioral problems.
• Posttraumatic Stress Disorder Treatment in Soldier Within the framework of the reviewed case, one of the key needs of the soldier is to be able to cope with anger and irritation.
• Cognitive Behavioral Therapy in Treating PTSD The chosen case is the case of Ivan S, who is a war veteran who suffers from a variety of psychological symptoms that affect his relationships with his family and loved ones. Secondly, Ivan shows […]
• Posttraumatic Stress Disorder: Modality Treatment Plan With the problem of nightmares and the related lack of sleep, the unmet need of psychological stability results in the interruption of sleep because of traumatic thoughts and nightmares.
• Post-Traumatic Stress Disorder and Its Theories The study by Bandelow et al.showed that the development of PTSD is associated with the dysregulation of the hypothalamic-pituitary-adrenal axis and the impaired sympathoadrenal medullary system as part of immunity.
• Emotion Regulation and Posttraumatic Stress Disorder This choice can be attributed to the positive role of the family in the emotional and cognitive function of a sufferer. The proposed intervention is to be in the form of a workshop for families […]
• PTSD as the Primary Factor Causing Infant Death The lack of studies on the issue of expecting mothers and their subgroups needs to be mentioned among the primary issues that hamper the process of addressing the problem concerning high infant death rates.
• Kant’s and Mill’s Ideas for Post-Traumatic Stress Disorder From this review, the fourth section of the paper outlines the more compelling view, which is that Kant’s vision of a good life is more superior to Mill’s vision of the same.
• Post-Traumatic Stress Disorder Assets and Facilities It was easy to detect PTSD assets and facilities in the area, as the society and the government are currently establishing a vast amount of amenities for this disorder.
• Post Traumatic Stress Disorder or Combat Fatigue According to Walser, the use of acceptance and commitment therapy is effective in treating a case of post-traumatic stress disorder, which entails the patients to experience positive and negative events without treating them as reality.
• Post Traumatic Stress Disorder: Caucasian Girl’ Case In Mary’s case, the medical practitioner will listen and encourage her to talk about the events when she feels ready. As a result, she will be in a better position to cope with the problem.
• “One Family’s Fight Against PTSD” by Shawn Gourley It was a counselor, who precipitated the harmony in the family explaining both husband and spouse the fact that their life could not be the same as before.
• Post-Traumatic Stress Disorder in Soldiers With the help of the course materials, I was able to understand that Huerta had a panic attack just from its description. It is critical to be honest with oneself and to accept the problem.
• Post-Traumatic Stress Disorder: Gender Variations In this regard, the aim of the current research is to provide evidence that women have the same probability of getting PTSD as men.
• Post Traumatic Stress Disorder: Joseph Wolpe Treatment Theory This is similar to the concept of phobias wherein a person is presented with an animal that he is irrationally afraid of and the result is fear or in the case of an inanimate object […]
• SNOMED-CT and PTSD Terminologies Based on the research questions described in the foregoing discussions, the researchers mapped a total of 153 PTSD-specific concepts and terms to the SNOMED-CT controlled medical terminologies and concept codes.
• Post-Traumatic Stress Disorder – Psychology Post-traumatic stress disorder is thought to be as a result of either corporeal disturbance or emotional disturbance, or more often a mishmash of both.
• Post Traumatic Stress Disorder Principles and Types The affected areas of the body include the nervous system, the brain and hormonal system. A number of issues are to be taken into consideration as for the treatment of the PDST.
• Post-Traumatic Stress Disorder in Veterans Patient education is important in order to eradicate any form of misconception that the patients may have about PTSD, and enhance the levels of understanding of the patients, along with an improvement on their ability […]
• Post-Traumatic Stress Disorder: Causes, Symptoms and Treatments One who is trying to numb and avoid remembrance of the event is likely to avoid thoughts, activities, places and even feelings that may associate with the trauma, have a feeling of detachment from others […]
• Critical Review of a Mental Disorder: The Post Traumatic Stress Disorder in DSM-IV-TR However, the risk to contracting the condition is always determined by the resilience of the personnel to these exposures, past unsettled concerns in their life history, and the quantity as well as intensity of depiction […]
• Post Traumatic Stress Disorder and Its Treatment In this case a person constantly relieves the event through any of the following exposure to a situation that is similar to the event, vivid memories of the event, perceptions, and sometimes through dreams.
• Comparison of the Etiology, Diagnosis, and Treatment of DID and PTSD Individuals who were exposed to acts of violence in the past are likely to try and expose others to similar conditions. The inability to diagnose is attributed to the fact that the effects of these […]
• Post-Traumatic Stress Disorder and Abused Women In most cases, these incidences of women abuse occur within the confine of a family set up or relationship where one partner tends to mistreat, mishandle, abuse and assaults the other partner and in most […]
• Earthquakes as a Cause of the Post Traumatic Stress Disorder Although earthquake is a major cause of the post traumatic stress disorder, there are other factors that determine the development of the same.
• Post Traumatic Stress Disorder Developed in Repeated War Zones Deployment Most of the combatants, usually, tailored a war awareness state to manage the consistent pressure of battle duty. Majority of the combat soldiers that were repeatedly deployed to war zones suffered post traumatic stress disorders.
• Effects of PTSD and Correlation between Diagnosis and Violence It is also worth noting that there is a correlation between PTSD and violence, though this has been cited to be of minimal significance.
• Abnormal Psychology: Posttraumatic Stress Disorder In addition, some of this research indicates that the differences in the degree of the disorder are due to the varying nature of the trauma experienced by that individual.
• Post Traumatic Stress Disorder: Assessment and Treatment Strategies If PTSD is ignored and fails to be treated, it can lead to disturbing consequences which widely affects not only the PTSD victim but also the relationships of the victim with his family and the […]
• The Effects of PTSD on Families of Veterans Drug abuse may result from the inadequacies in the coping abilities of family members as they try to come into terms with the suffering of their fellow family member.
• Post Traumatic Stress Disorder in Veterans and How Family Relationships Are Affected Both qualitative and quantitative data shall be used with numbers being used to provide evidence of the occurrence and magnitude of the effects of the condition on the population.
• Characteristics and Treatments of Post Traumatic Stress Disorder For in-depth understanding of the background of PTSD is, this paper will adopt a specific definition of abnormality that relates to the disorder itself. The category of the syndrome will also determine the type of […]
• Analysis of Posttraumatic Stress Disorder in Military Personnel The experiences that military personnel undergo determine the nature and extent of the posttraumatic stress disorder they develop during and after their deployment. However, Ramirez had resilience factors that helped him to cope and manage […]
• How PTSD Affects Veteran Soldiers’ Families The effects are even worse to the partner who is left behind; whether wife or husband because they are required to care for the children and the thought of being the sole bread winner makes […]
• What Are the Signs of PTSD?
• How Dogs Can Help Veterans Overcome PTSD?
• What Is PTSD Usually Caused By?
• How Do People Deal With PTSD?
• What Are the Symptoms of PTSD?
• What’s the Difference Between PTSD and TBI?
• How the Cherokee Nation Can Overcome Generational PTSD?
• Why Are People With PTSD Angry?
• Does PTSD Change Personality?
• What Happens if PTSD Is Untreated?
• How Does PTSD Effect Veterans?
• What Is the Diagnostic Criteria for Post-traumatic Stress Disorder?
• Is PTSD a Permanent Disorder?
• What Type of Mental Disorder Is PTSD?
• Can PTSD Cause Mental Breakdown?
• What Are PTSD Triggers?
• Are People With PTSD Mentally Ill?
• How Do Doctors Test for PTSD?
• Can PTSD Be Mistaken for Bipolar?
• What Are the Causes and Psychological Consequences of Post-traumatic Stress Disorder?
• What Do PTSD Episodes Look Like?
• What’s It Like Living With Someone With PTSD?
• Can PTSD Cause Jealousy?
• Does PTSD Affect Intimacy?
• Can PTSD Cause Emotional Detachment?
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Posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) may develop when someone lives through or witnesses an event in which they believe that there is a threat to life or physical integrity and safety and experiences fear, terror, or helplessness.

People with PTSD may relive the trauma in painful recollections, flashbacks, or recurrent dreams or nightmares; avoid activities or places that recall the traumatic event; or experience physiological arousal, leading to symptoms such as an exaggerated startle response, disturbed sleep, difficulty in concentrating or remembering, and guilt about surviving the trauma when others did not.

Adapted from the APA Dictionary of Psychology

Resources from APA

Spotlight: Bringing effective posttraumatic stress disorder treatment to those in need

In a recent study in Psychological Services, Sheila Rauch investigated how PE-PC works in Veterans Health Administration practice for veterans with PTSD.

Exploring the 8 phases of EMDR

Eye movement desensitization and reprocessing therapy uses this eight-phase approach over a series of sessions until a patient’s symptoms have been fully resolved.

What is EMDR therapy and why is it used to treat PTSD?

Eye movement desensitization and reprocessing is a structured form of psychotherapy used to help patients with PTSD resolve upsetting memories.

Women who experience trauma are twice as likely as men to develop PTSD. Here’s why

Women are typically exposed to more interpersonal trauma than men, and often at a younger age, which can have a greater negative impact on their lives

More resources about PTSD

What APA is doing

Clinical practice guideline for the treatment of PTSD in adults

Trauma Psychology

APA’s Division 56 provides a forum for scientific research, professional and public education, and the exchange of collegial support for professional activities related to traumatic stress.

Alternative Therapies for PTSD

Mindfulness-Based Interventions for Trauma and Its Consequences

PTSD Casebook

Eye Movement Desensitization and Reprocessing (EMDR) Therapy

Written Exposure Therapy for PTSD

Magination Press children’s books

Why Are You So Scared?

A Terrible Thing Happened

Journal special issues

APA Clinical Practice Guidelines for PTSD

Psychiatric Rehabilitation for Veterans

Trauma Among Youth, Adolescents, and Emerging Adults

A Psychotherapy Integration Perspective on PTSD

Innovations in Treatment of Post-Traumatic Stress Disorder (PTSD)

APA journals

Psychological Trauma: Theory, Research, Practice, and Policy

Traumatology

Psychological Services

Psychotherapy

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Post-traumatic stress disorder articles from across Nature Portfolio

Post-traumatic stress disorder (PTSD) can be an acute, chronic or delayed reaction to a traumatic event. Symptoms can include intrusive, disturbing flashbacks or nightmares of the event, accompanied with anxiety and disturbed sleep.

Latest Research and Reviews

Findings of PTSD-specific deficits in default mode network strength following a mild experimental stressor

• Christopher L. Averill
• Lynnette A. Averill
• Chadi G. Abdallah

Interdisciplinary approach to identify language markers for post-traumatic stress disorder using machine learning and deep learning

• Robin Quillivic
• Frédérique Gayraud
• Salma Mesmoudi

FNDC5 prevents oxidative stress and neuronal apoptosis after traumatic brain injury through SIRT3-dependent regulation of mitochondrial quality control

New insights into the effects of type and timing of childhood maltreatment on brain morphometry

• Yasmin Grauduszus
• Maurizio Sicorello
• Gabriele Ende

The impact of childhood trauma on emotional distress and the moderating role of sense of coherence among college students in China

• Ningdan Fan
• Huanhuan Fan
• Xiaohong Ma

AI and narrative embeddings detect PTSD following childbirth via birth stories

• Alon Bartal
• Kathleen M. Jagodnik
• Sharon Dekel

News and Comment

Active forgetting in post-traumatic stress.

• Linn Petersdotter

The rise of eco-anxiety: scientists wake up to the mental-health toll of climate change

Researchers want to unpick how climate change affects mental health around the world — from lives that are disrupted by catastrophic weather to people who are anxious about the future.

• Helen Pearson

A call for a formal diagnosis for childbirth-related PTSD

Ibogaine therapy in tbi.

• Leonie Welberg

Heal the aftermath of intergenerational trauma and grief

• Yafit Levin
• Menachem Ben-Ezra
• Yaira Hamama-Raz

Why does cancer spread to the spine? Newly discovered stem cells might be the key

A stem cell vital for vertebral growth also drives spine metastases, and the use of MDMA in the treatment of PTSD.

• Benjamin Thompson
• Shamini Bundell

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• Published: 28 September 2018

Posttraumatic stress disorder: from diagnosis to prevention

• Xue-Rong Miao   ORCID: orcid.org/0000-0002-0665-8271 1 ,
• Qian-Bo Chen 1 ,
• Kai Wei 1 ,
• Kun-Ming Tao 1 &
• Zhi-Jie Lu 1  

Military Medical Research volume  5 , Article number:  32 ( 2018 ) Cite this article

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Posttraumatic stress disorder (PTSD) is a chronic impairment disorder that occurs after exposure to traumatic events. This disorder can result in a disturbance to individual and family functioning, causing significant medical, financial, and social problems. This study is a selective review of literature aiming to provide a general outlook of the current understanding of PTSD. There are several diagnostic guidelines for PTSD, with the most recent editions of the DSM-5 and ICD-11 being best accepted. Generally, PTSD is diagnosed according to several clusters of symptoms occurring after exposure to extreme stressors. Its pathogenesis is multifactorial, including the activation of the hypothalamic–pituitary–adrenal (HPA) axis, immune response, or even genetic discrepancy. The morphological alternation of subcortical brain structures may also correlate with PTSD symptoms. Prevention and treatment methods for PTSD vary from psychological interventions to pharmacological medications. Overall, the findings of pertinent studies are difficult to generalize because of heterogeneous patient groups, different traumatic events, diagnostic criteria, and study designs. Future investigations are needed to determine which guideline or inspection method is the best for early diagnosis and which strategies might prevent the development of PTSD.

Posttraumatic stress disorder (PTSD) is a recognized clinical phenomenon that often occurs as a result of exposure to severe stressors, such as combat, natural disaster, or other events [ 1 ]. The diagnosis of PTSD was first introduced in the 3rd edition of the Diagnostic and Statistical Manual (DSM) (American Psychiatric Association) in 1980 [ 2 ].

PTSD is a potentially chronic impairing disorder that is characterized by re-experience and avoidance symptoms as well as negative alternations in cognition and arousal. This disease first raised public concerns during and after the military operations of the United States in Afghanistan and Iraq, and to date, a large number of research studies report progress in this field. However, both the underlying mechanism and specific treatment for the disease remain unclear. Considering the significant medical, social and financial problems, PTSD represents both to nations and to individuals, all persons caring for patients suffering from this disease or under traumatic exposure should know about the risks of PTSD.

The aim of this review article is to present the current understanding of PTSD related to military injury to foster interdisciplinary dialog. This article is a selective review of pertinent literature retrieved by a search in PubMed, using the following keywords: “PTSD[Mesh] AND military personnel”. The search yielded 3000 publications. The ones cited here are those that, in the authors’ view, make a substantial contribution to the interdisciplinary understanding of PTSD.

Definition and differential diagnosis

Posttraumatic stress disorder is a prevalent and typically debilitating psychiatric syndrome with a significant functional disturbance in various domains. Both the manifestation and etiology of it are complex, which has caused difficulty in defining and diagnosing the condition. The 3rd edition of the DSM introduced the diagnosis of PTSD with 17 symptoms divided into three clusters in 1980. After several decades of research, this diagnosis was refined and improved several times. In the most recent version of the DSM-5 [ 3 ], PTSD is classified into 20 symptoms within four clusters: intrusion, active avoidance, negative alterations in cognitions and mood as well as marked alterations in arousal and reactivity. The diagnosis requirement can be summarized as an exposure to a stressor that is accompanied by at least one intrusion symptom, one avoidance symptom, two negative alterations in cognitions and mood symptoms, and two arousal and reactivity turbulence symptoms, persisting for at least one month, with functional impairment. Interestingly, in the DSM-5, PTSD has been moved from the anxiety disorder group to a new category of ‘trauma- and stressor-related disorders’, which reflects the cognizance alternation of PTSD. In contrast to the DSM versions, the World Health Organization’s (WHO) International Classification of Diseases (ICD) has proposed a substantially different approach to diagnosing PTSD in the most recent ICD-11 version [ 4 ], which simplified the symptoms into six under three clusters, including constant re-experiencing of the traumatic event, avoidance of traumatic reminders and a sense of threat. The diagnosis requires at least one symptom from each cluster which persists for several weeks after exposure to extreme stressors. Both diagnostic guidelines emphasize the exposure to traumatic events and time of duration, which differentiate PTSD from some diseases with similar symptoms, including adjustment disorder, anxiety disorder, obsessive-compulsive disorder, and personality disorder. Patients with the major depressive disorder (MDD) may or may not have experienced traumatic events, but generally do not have the invasive symptoms or other typical symptoms that PTSD presents. In terms of traumatic brain injury (TBI), neurocognitive responses such as persistent disorientation and confusion are more specific symptoms. It is worth mentioning that some dissociative reactions in PTSD (e.g., flashback symptoms) should be recognized separately from the delusions, hallucinations, and other perceptual impairments that appear in psychotic disorders since they are based on actual experiences. The ICD-11 also recognizes a sibling disorder, complex PTSD (CPTSD), composed of symptoms including dysregulation, negative self-concept, and difficulties in relationships based on the diagnosis of PTSD. The core CPTSD symptom is PTSD with disturbances in self-organization (DSO).

In consideration of the practical applicability of the PTSD diagnosis, Brewin et al. conducted a study to investigate the requirement differences, prevalence, comorbidity, and validity of the DSM-5 and ICD-11 for PTSD criteria. According to their study, diagnostic standards for symptoms of re-experiencing are higher in the ICD-11 than the DSM, whereas the standards for avoidance are less strict in the ICD-11 than in the DSM-IV [ 5 ]. It seems that in adult subjects, the prevalence of PTSD using the ICD-11 is considerably lower compared to the DSM-5. Notably, evidence suggested that patients identified with the ICD-11 and DSM-5 were quite different with only partially overlapping cases; this means each diagnostic system appears to find cases that would not be diagnosed using the other. In consideration of comorbidity, research comparing these two criteria show diverse outcomes, as well as equal severity and quality of life. In terms of children, only very preliminary evidence exists suggesting no significant difference between the two. Notably, the diagnosis of young children (age ≤ 6 years) depends more on the situation in consideration of their physical and psychological development according to the DSM-5.

Despite numerous investigations and multiple revisions of the diagnostic criteria for PTSD, it remains unclear which type and what extent of stress are capable of inducing PTSD. Fear responses, especially those related to combat injury, are considered to be sufficient enough to trigger symptoms of PTSD. However, a number of other types of stressors were found to correlate with PTSD, including shame and guilt, which represent moral injury resulting from transgressions during a war in military personnel with deeply held moral and ethical beliefs. In addition, military spouses and children may be as vulnerable to moral injury as military service members [ 6 ]. A research study on Canadian Armed Forces personnel showed that exposure to moral injury during deployments is common among military personnel and represents an independent risk factor for past-year PTSD and MDD [ 7 ]. Unfortunately, it seems that pre- and post-deployment mental health education was insufficient to moderate the relationship between exposure to moral injury and adverse mental health outcomes.

In general, a large number of studies are focusing on the definition and diagnostic criteria of PTSD and provide considerable indicators for understanding and verifying the disease. However, some possible limitations or discrepancies continue to exist in current research studies. One is that although the diagnostic criteria for a thorough examination of the symptoms were explicit and accessible, the formal diagnosis of PTSD using structured clinical interviews was relatively rare. In contrast, self-rating scales, such as the Posttraumatic Diagnostic Scale (PDS) [ 8 ] and the Impact of Events Scale (IES) [ 9 ], were used frequently. It is also noteworthy that focusing on PTSD explicitly could be a limitation as well. The complexity of traumatic experiences and the responses to them urge comprehensive investigations covering all aspects of physical and psychological maladaptive changes.

Prevalence and importance

Posttraumatic stress disorder generally results in poor individual-level outcomes, including co-occurring disorders such as depression and substance use, and physical health problems. According to the DSM-5 reporting, more than 80% of PTSD patients share one or more comorbidities; for instance, the morbidity of PTSD with concurrent mild TBI is 48% [ 8 ]. Moreover, cognitive impairment has been identified frequently in PTSD. The reported incidence rate for PTSD ranges from 5.4 to 16.8% in military service members and veterans [ 10 , 11 , 12 , 13 , 14 ], which is almost double those in the general population. The estimated prevalence of PTSD varies depending on the group of patients studied, the traumatic events occurred, and the measurement method used (Table  1 ). However, it still reflects the profound effect of this mental disease, especially with the rise in global terrorism and military conflict in recent years. While PTSD can arise at any life stage in any population, most research in recent decades has focused on returned veterans; this means most knowledge regarding PTSD has come from the military population. Meanwhile, the impact of this disease on children has received scant attention.

The discrepancy of PTSD prevalence in males and females is controversial. In a large study of OEF/OIF veterans, the prevalence of PTSD in males and females was similar, although statistically more prevalent in men versus women (13% vs. 11%) [ 15 ]. Another study on the Navy and Marine Corps showed a slightly higher incidence for PTSD in the women compared to men (6.6% vs. 5.3%) [ 12 ]. However, the importance of combat exposure is unclear. Despite a lower level of combat exposure than male military personnel, females generally have considerably higher rates of military sexual trauma, which is significantly associated with the development of PTSD [ 16 ].

It is reported that 44–72% of veterans suffer high levels of stress after returning to civilian life. Many returned veterans with PTSD show emotion regulation problems, including emotion identification, expression troubles and self-control issues. Nevertheless, a meta-analytic investigation of 34 studies consistently found that the severity of PTSD symptoms was significantly associated with anger, especially in military samples [ 17 ]. Not surprisingly, high levels of PTSD and emotional regulation troubles frequently lead to poor family functioning or even domestic violence in veterans. According to some reports, parenting difficulties in veteran families were associated with three PTSD symptom clusters. Evans et al. [ 18 ] conducted a survey to evaluate the impact of PTSD symptom clusters on family functioning. According to their analysis, avoidance symptoms directly affected family functioning, whereas hyperarousal symptoms had an indirect association with family functioning. Re-experience symptoms were not found to impact family functioning. Notably, recent epidemiologic studies using data from the Veterans Health Administration (VHA) reported that veterans with PTSD were linked to suicide ideations and behaviors [ 19 ] (e.g., non-suicidal self-injury, NSSI), in which depression as well as other mood disruptions, often serve as mediating factors.

Previously, there was a controversial attitude toward the vulnerability of young children to PTSD. However, growing evidence suggests that severe and persistent trauma could result in stress responses worse than expected as well as other mental and physical sequelae in child development. The most prevalent traumatic exposures for young children above the age of 1 year were interpersonal trauma, mostly related to or derived from their caregivers, including witnessing intimate partner violence (IPV) and maltreatment [ 20 ]. Unfortunately, because of the crucial role that caregivers play in early child development, these types of traumatic events are especially harmful and have been associated with developmental maladaptation in early childhood. Maladaptation commonly represents a departure from normal development and has even been linked to more severe effects and psychopathology. In addition, the presence of psychopathology may interfere with the developmental competence of young children. Research studies have also broadened the investigation to sequelae of PTSD on family relationships. It is proposed that the children of parents with symptoms of PTSD are easily deregulated or distressed and appear to face more difficulties in their psychosocial development in later times compared to children of parents without. Meanwhile, PTSD veterans described both emotional (e.g., hurt, confusion, frustration, fear) and behavioral (e.g., withdrawal, mimicking parents’ behavior) disruption in their children [ 21 ]. Despite the increasing emphasis on the effects of PTSD on young children, only a limited number of studies examined the dominant factors that influence responses to early trauma exposures, and only a few prospective research studies have observed the internal relations between early PTSD and developmental competence. Moreover, whether exposure to both trauma types in early life is associated with more severe PTSD symptoms than exposure to one type remains an outstanding question.

Molecular mechanism and predictive factors

The mechanisms leading to posttraumatic stress disorder have not yet been fully elucidated. Recent literature suggests that both the neuroendocrine and immune systems are involved in the formulation and development of PTSD [ 22 , 23 ]. After traumatic exposures, the stress response pathways of the hypothalamic–pituitary–adrenal (HPA) axis and sympathetic nervous system are activated and lead to the abnormal release of glucocorticoids (GC) and catecholamines. GCs have downstream effects on immunosuppression, metabolism enhancement, and negative feedback inhibition of the HPA axis by binding to the GC receptor (GR), thus connecting the neuroendocrine modulation with immune disturbance and inflammatory response. A recent meta-analysis of 20 studies found increased plasma levels of proinflammatory cytokines tumor necrosis factor-alpha (TNF-a), interleukin-1beta (IL-1b), and interleukin-6 (IL-6) in individuals with PTSD compared to healthy controls [ 24 ]. In addition, some other studies speculate that there is a prospective association of C-reactive protein (CRP) and mitogen with the development of PTSD [ 25 ]. These findings suggest that neuroendocrine and inflammatory changes, rather than being a consequence of PTSD, may in fact act as a biological basis and preexisting vulnerability for developing PTSD after trauma. In addition, it is reported that elevated levels of terminally differentiated T cells and an altered Th1/Th2 balance may also predispose an individual to PTSD.

Evidence indicates that the development of PTSD is also affected by genetic factors. Research has found that genetic and epigenetic factors account for up to 70% of the individual differences in PTSD development, with PTSD heritability estimated at 30% [ 26 ]. While aiming to integrate genetic studies for PTSD and build a PTSD gene database, Zhang et al. [ 27 ] summarized the landscape and new perspective of PTSD genetic studies and increased the overall candidate genes for future investigations. Generally, the polymorphisms moderating HPA-axis reactivity and catecholamines have been extensively studied, such as FKBP5 and catechol-O-methyl-transferase (COMT). Other potential candidates for PTSD such as AKT, a critical mediator of growth factor-induced neuronal survival, were also explored. Genetic research has also made progress in other fields. For example, researchers have found that DNA methylation in multiple genes is highly correlated with PTSD development. Additional studies have found that stress exposure may even affect gene expression in offspring by epigenetic mechanisms, thus causing lasting risks. However, some existing problems in the current research of this field should be noted. In PTSD genetic studies, variations in population or gender difference, a wide range of traumatic events and diversity of diagnostic criteria all may attribute to inconsistency, thus leading to a low replication rate among similar studies. Furthermore, PTSD genes may overlap with other mental disorders such as depression, schizophrenia, and bipolar disorder. All of these factors indicate an urgent need for a large-scale genome-wide study of PTSD and its underlying epidemiologic mechanisms.

It is generally acknowledged that some mental diseases, such as major depressive disorder (MDD), bipolar disorder, and schizophrenia, are associated with massive subcortical volume change. Recently, numerous studies have examined the relationship between the morphology changes of subcortical structures and PTSD. One corrected analysis revealed that patients with PTSD show a pattern of lower white matter integrity in their brains [ 28 ]. Prior studies typically found that a reduced volume of the hippocampus, amygdala, rostral ventromedial prefrontal cortex (rvPFC), dorsal anterior cingulate cortex (dACC), and the caudate nucleus may have a relationship with PTSD patients. Logue et al. [ 29 ] conducted a large neuroimaging study of PTSD that compared eight subcortical structure volumes (nucleus accumbens, amygdala, caudate, hippocampus, pallidum, putamen, thalamus, and lateral ventricle) between PTSD patients and controls. They found that smaller hippocampi were particularly associated with PTSD, while smaller amygdalae did not show a significant correlation. Overall, rigorous and longitudinal research using new technologies, such as magnetoencephalography, functional MRI, and susceptibility-weighted imaging, are needed for further investigation and identification of morphological changes in the brain after a traumatic exposure.

Psychological and pharmacological strategies for prevention and treatment

Current approaches to PTSD prevention span a variety of psychological and pharmacological categories, which can be divided into three subgroups: primary prevention (before the traumatic event, including prevention of the event itself), secondary prevention (between the traumatic event and the development of PTSD), and tertiary prevention (after the first symptoms of PTSD become apparent). The secondary and tertiary prevention of PTSD has abundant methods, including different forms of debriefing, treatments for Acute Stress Disorder (ASD) or acute PTSD, and targeted intervention strategies. Meanwhile, the process of primary prevention is still in its infancy and faces several challenges.

Based on current research on the primary prevention of post-trauma pathology, psychological and pharmacological interventions for particular groups or individuals (e.g., military personnel, firefighters, etc.) with a high risk of traumatic event exposure were applicable and acceptable for PTSD sufferers. Of the studies that reported possible psychological prevention effects, training generally included a psychoeducational component and a skills-based component relating to stress responses, anxiety reducing and relaxation techniques, coping strategies and identifying thoughts, emotion and body tension, choosing how to act, attentional control, emotion control and regulation [ 30 , 31 , 32 ]. However, efficiency for these training has not been evaluated yet due to a lack of high-level evidence-based studies. Pharmacological options have targeted the influence of stress on memory formation, including drugs relating to the hypothalamic-pituitary-adrenal (HPA) axis, the autonomic nerve system (especially the sympathetic nerve system), and opiates. Evidence has suggested that pharmacological prevention is most effective when started before and early after the traumatic event, and it seems that sympatholytic drugs (alpha and beta-blockers) have the highest potential for primary prevention of PTSD [ 33 ]. However, one main difficulty limiting the exploration in this field is related to rigorous and complex ethical issues, as the application of pre-medication for special populations and the study of such options in hazardous circumstances possibly touches upon questions of life and death. Significantly, those drugs may have potential side effects.

There are several treatment guidelines for patients with PTSD produced by different organizations, including the American Psychiatric Association (APA), the United Kingdom’s National Institute for Health and Clinical Excellence (NICE), the International Society for Traumatic Stress Studies (ISTSS), the Institute of Medicine (IOM), the Australian National Health and Medical Research Council, and the Department of Veterans Affairs and Department of Defense (VA, DoD) [ 34 , 35 , 36 , 37 , 38 ]. Additionally, a large number of research studies are aiming to evaluate an effective treatment method for PTSD. According to these guidelines and research, treatment approaches can be classified as psychological interventions and pharmacological treatments (Fig.  1 ); most of the studies provide varying degrees of improvement in individual outcomes after standard interventions, including PTSD symptom reduction or remission, loss of diagnosis, release or reduction of comorbid medical or psychiatric conditions, quality of life, disability or functional impairment, return to work or to active duty, and adverse events.

Psychological and pharmacological strategies for treatment of PTSD. CBT. Cognitive behavioral therapy; CPT. Cognitive processing therapy; CT. Cognitive therapy; CR. Cognitive restructuring; EMDR. Eye movement desensitization and reprocessing; SSRIs. Selective serotonin reuptake inhibitors; SNRIs. Serotonin and norepinephrine reuptake inhibitors; MAO. Monoamine oxidase

Most guidelines identify trauma-focused psychological interventions as first-line treatment options [ 39 ], including cognitive behavioral therapy (CBT), cognitive processing therapy (CPT), cognitive therapy (CT), cognitive restructuring (CR), coping skills therapy (including stress inoculation therapy), exposure-based therapies, eye movement desensitization and reprocessing (EMDR), hypnosis and hypnotherapy, and brief eclectic psychotherapy. These treatments are delivered predominantly to individuals, but some can also be conducted in family or group settings. However, the recommendation of current guidelines seems to be projected empirically as research on the comparison of outcomes of different treatments is limited. Jonas et al. [ 40 ] performed a systematic review and network meta-analysis of the evidence for treatment of PTSD. The study suggested that all psychological treatments showed efficacy for improving PTSD symptoms and achieving the loss of PTSD diagnosis in the acute phase, and exposure-based treatments exhibited the strongest evidence of efficacy with high strength of evidence (SOE). Furthermore, Kline et al. [ 41 ] conducted a meta-analysis evaluating the long-term effects of in-person psychotherapy for PTSD in 32 randomized controlled trials (RCTs) including 2935 patients with long-term follow-ups of at least 6 months. The data suggested that all studied treatments led to lasting improvements in individual outcomes, and exposure therapies demonstrated a significant therapeutic effect as well with larger effect sizes compared to other treatments.

Pharmacological treatments for PTSD include antidepressants such as selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), and monoamine oxidase (MAO) inhibitors, sympatholytic drugs such as alpha-blockers, antipsychotics, anticonvulsants, and benzodiazepines. Among these medications, fluoxetine, paroxetine, sertraline, topiramate, risperidone, and venlafaxine have been identified as efficacious in treatment. Moreover, in the Jonas network meta-analysis of 28 trials (4817 subjects), they found paroxetine and topiramate to be more effective for reducing PTSD symptoms than most other medications, whereas evidence was insufficient for some other medications as research was limited [ 40 ]. It is worth mentioning that in these studies, efficacy for the outcomes, unlike the studies of psychological treatments, was mostly reported as a remission in PTSD or depression symptoms; other outcomes, including loss of PTSD diagnosis, were rarely reported in studies.

As for the comparative evidence of psychological with pharmacological treatments or combinations of psychological treatments and pharmacological treatments with other treatments, evidence was insufficient to draw any firm conclusions [ 40 ]. Additionally, reports on adverse events such as mortality, suicidal behaviors, self-harmful behaviors, and withdrawal of treatment were relatively rare.

PTSD is a high-profile clinical phenomenon with a complicated psychological and physical basis. The development of PTSD is associated with various factors, such as traumatic events and their severity, gender, genetic and epigenetic factors. Pertinent studies have shown that PTSD is a chronic impairing disorder harmful to individuals both psychologically and physically. It brings individual suffering, family functioning disorders, and social hazards. The definition and diagnostic criteria for PTSD remain complex and ambiguous to some extent, which may be attributed to the complicated nature of PTSD and insufficient research on it. The underlying mechanisms of PTSD involve changes in different levels of psychological and molecular modulations. Thus, research targeting the basic mechanisms of PTSD using standard clinical guidelines and controlled interference factors is needed. In terms of treatment, psychological and pharmacological interventions could relief PTSD symptoms to different degrees. However, it is necessary to develop systemic treatment as well as symptom-specific therapeutic methods. Future research could focus on predictive factors and physiological indicators to determine effective prevention methods for PTSD, thereby reducing its prevalence and preventing more individuals and families from struggling with this disorder.

Abbreviations

American Psychiatric Association

Acute stress disorder

Cognitive behavioral therapy

Catechol-O-methyl-transferase

Cognitive processing therapy

Complex posttraumatic stress disorder

Cognitive restructuring

C-reactive protein

Cognitive therapy

Dorsal anterior cingulate cortex

Diagnostic and Statistical Manual

Disturbances in self-organization

Eye movement desensitization and reprocessing

Glucocorticoids

Glucocorticoids receptor

Hypothalamic–pituitary–adrenal axis

International classification of diseases

Impact of events scale

Interleukin-1beta

Interleukin-6

Institute of Medicine

Intimate partner violence

International Society for Traumatic Stress Studies

Monoamine oxidase

Major depressive disorder

United Kingdom’s National Institute for Health and Clinical Excellence

Non-suicidal self-injury

Posttraumatic diagnostic scale

Posttraumatic stress disorder

Randomized controlled trials

Rostral ventromedial prefrontal cortex

Serotonin and norepinephrine reuptake inhibitors;

Strength of evidence

Selective serotonin reuptake inhibitors

Tumor necrosis factor-alpha

DoD Department of Veterans Affairs and Department of Defense

Veterans Health Administration

World Health Organization

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Acknowledgments

We thank Jamie Bono for providing professional writing suggestions.

This work was supported by the National Natural Science Foundation of China (31371084 and 31171013 by ZJL), and the National Natural Science Foundation of China (81100276 by XRM).

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Post-Traumatic Stress Disorder

2021 year in review of trauma and ptsd research, seven studies that highlight helpful versus unhelpful trauma research..

Posted December 27, 2021 | Reviewed by Tyler Woods

• What Is PTSD?
• Find a therapist to heal from trauma
• Knowing which psychological research studies to trust is difficult because behavior is complicated and papers are shrouded in jargon.
• Three helpful studies are described that provide meaningful new knowledge and can be immediately useful.
• Four unhelpful studies are described that have impressive jargon or appealing concepts, but are useless or misleading.

At the end of each year, I pick research studies on posttraumatic stress disorder ( PTSD ) that I think represent the most and least helpful examples of research in this field.

I believe the best types of studies are ones that are actually helpful for real patients, and that’s usually around prediction:

• Prediction of who is going to develop problems so that the problems may be prevented.
• Prediction of treatment response in controlled settings.

The unhelpful studies in psychological research tend to be of no use in one of three ways:

• Attempts to confirm ideological biases that the authors appear only dimly aware of.
• Poorly-conceived studies that provide no important new information but are dressed up in fancy jargon to sound momentous.
• Samples of convenience that lack controls and/or quality control.

With that introduction, here is the good and the bad of 2021.

The Helpful

1. A voice of reason against the tide of COVID hysteria

Roel van Overmeire, of Vrije University Brussel in Belgium, makes the list for the second year in a row. He wrote a critical commentary on a study published by other authors that claimed journalists were getting PTSD by covering the COVID-19 pandemic. Van Overmeire pointed out several major flaws in the study, but the main one he astutely noted was that researchers never clearly ascertained whether the journalists covering stories about other people experienced the most basic criterion of PTSD, which is exposure to events where someone was threatened with death, serious injury or sexual violence . Thus, the journalists’ responses on the PTSD measure are invalid. Van Overmeire concluded that diagnosing journalists with PTSD who don’t really have PTSD was “problematizing possibly normal behavior.” I call it false positives and politicized research.

2. Another notch for evidence-based practices (EBP)

Brian Shiner and colleagues wanted to examine how the culture shift at the Veterans Administration to implement EBP has played out. Their study tells at least two interesting stories. First, while it’s positive that the percentage of patients with PTSD who received any EBP increased from 0.7 percent in fiscal year 2004-2005 to 14 percent in 2012-2013, it is unfortunately conceivable that 86 percent of veterans with PTSD are still not receiving treatment based on EBPs. Second, they classified patients into three levels on the quality of delivery of services:

• Lowest quality received psychotherapy of eight or more sessions
• Middle quality received eight sessions or more delivered by the same therapist
• Highest quality received these within a 14-week period. The group that received the highest quality delivery of services improved the most. These data are useful for the VA’s continuing attempts to set the bar for where a quality standard should exist for the delivery of psychotherapy for PTSD.

3. One small step back from mother-blaming

Ellisa Brown plus the two founders of trauma-focused cognitive behavioral therapy (TF-CBT), Judith Cohen and Anthony Mannarino, reviewed the literature in regards to whether involving parents in the work of TF-CBT impacts children’s outcomes. Their conclusion was that “Including non-offending caregivers in TF-CBT can improve youth outcomes.” But that’s not what I found noteworthy. What I think is noteworthy is that, thankfully, they didn’t try to frame the review around blaming parents for causing their children’s PTSD. Crafting a literature review that was not about the worn-out myth of parent-blaming probably took enormous self-restraint. It is so rare it is worth mentioning. I think they still vastly overestimated the impact of parenting behaviors, but it was a baby step away from the traditional mother-bashing in our field.

The Unhelpful

4. The myth of trauma-informed approach makes the best-seller list

Child psychiatrist Bruce Perry and talk show host Oprah Winfrey wrote a book titled What Happened to You? Conversations on Trauma and Resilience and Healing . This book was full-throttle marketing of the myth of toxic stress in a book-length treatment with the high-gloss spin of talk show-style anecdotes but none of the research. Among their many unsupported claims, the key one is that if you received love and affection during the first two months of life, your neural development protects you with resilience. If you didn’t, your brain was permanently altered in many maladaptive ways which affect literally everything in your life because this allegedly shapes the very core of our selves. As I and others have written before, none of this is close to being proven, but this narrative has been leveraged to support ideological-based social agendas.

5. A complex PTSD study by (fill in the blank)

The so-called complex PTSD syndrome is unproven by any measure of diagnostic validation, as I and many other researchers have noted, yet it seems to only increase in popularity. It’s been one of the most counterfactual developments in the history of the trauma field. There are too many studies published on it every year to be able to cite one study as more egregious than the others, so I picked one example authored by three of the biggest stokers of this phenomenon. Joseph Spinazzola, Bessel van der Kolk, and Julian Ford showed that children diagnosed with developmental trauma disorder (DTD), which is essentially the childhood version of complex PTSD, had experienced more emotional abuse and separations from caregivers compared to children diagnosed with regular PTSD. Since DTD includes emotional abuse and separations from caregivers in the criteria, and regular PTSD does not, this was entirely circular reasoning, which the authors, reviewers, and editor seemed blissfully unaware of.

6. Towards the vanishing promise of machine learning

Research using the number-crunching function of machine learning started appearing in psychology journals around 2010, and scholars are already noting the inability to produce useful results. Like so many other promises from new technology that never materialized, machine learning has captured scant meaningful new knowledge about human behavior. In one typical example, Jiang and colleagues applied a machine learning technique to diagnosing PTSD. Their conclusion was that instead of using an interview with all 20 PTSD symptoms, you could achieve good, but not perfect, diagnostic accuracy with 16 items for males and 14 items for females. Obviously, this would not shorten the time spent interviewing very much.

7. Towards the vanishing promise of network analysis

Take everything I wrote about machine learning above, and apply it to network analysis, except that network analysis has been around longer. Network analysis was supposed to be a promising new statistical methodology to optimize tasks too complicated for the human brain. In the social sciences, this was supposed to discern how large sets of variables associate with each other, which would somehow enlighten us on how to help individuals better. As the typical example I’ve chosen shows next, we’re still waiting for that to occur. In a study by Zhu and colleagues, they applied network analysis to resting functional magnetic resonance imaging. Using profiles of functional connectivity, they could accurately distinguish individuals with PTSD from non-PTSD with 89 percent accuracy. When a simple diagnostic interview can achieve near 100 percent accuracy more rapidly and less expensively, one wonders how network analysis is a meaningful advance.

Brown EJ; Cohen JA; Mannarino AP (2020). Trauma-Focused Cognitive-Behavioral Therapy: The role of caregivers. [Review] Journal of Affective Disorders. 277:39-45.

Jiang T; Dutra S; Lee DJ; Rosellini AJ; Gauthier GM; Keane TM; Gradus JL; Marx BP (2021). Toward Reduced Burden in Evidence-Based Assessment of PTSD: A Machine Learning Study. Assessment. 28(8):1971-1982.

Perry P; Winfrey 0 (2021). What Happened to You? Conversations on Trauma and Resilience and Healing. New York: Flatiron Books.

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Spinazzola; van der Kolk B; Ford JD (2021 online ahead of print). Developmental Trauma Disorder: A Legacy of Attachment Trauma in Victimized Children. J Trauma Stress 2021 May 28.

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Zhu H; Yuan M; Qiu C; Ren Z; Li Y; Wang J; Huang X; Lui S; Gong Q; Zhang W; Zhang Y (2020). Multivariate classification of earthquake survivors with post-traumatic stress disorder based on large-scale brain networks. Acta Psychiatrica Scandinavica. 141(3):285-298.

Michael S. Scheeringa, M.D., is Professor and Vice Chair of Research for psychiatry at Tulane University School of Medicine.

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To predict, prevent, and manage post-traumatic stress disorder (ptsd): a review of pathophysiology, treatment, and biomarkers.

1. Introduction

2. epidemiology and models of ptsd development, 2.1. epidemiology of ptsd, 2.2. models of disease development, 2.2.1. diathesis–stress model for ptsd, 2.2.2. biopsychosocial model.

• Biological disturbance alone is insufficient to cause the disease, as disease appearance results from multi-factor interaction.
• Vulnerability is better accounted for by psychological and social factors than by biological changes.
• The effectiveness of biological treatments is influenced by the psychological status of a “placebo effect.”
• Health outcomes are affected by the doctor–patient relationship to a great extent.

2.2.3. Animal Models of PTSD

3. pathophysiology, 3.1. brain circuits, 3.2. neurochemical factors, 3.2.1. dysregulation of the noradrenergic system, 3.2.2. dysregulation of serotonin signalling, 3.2.3. dopamine, 3.2.4. gamma-aminobutyric acid (gaba), 3.2.5. neuropeptide y (npy), 3.2.6. brain-derived neurotropic factor (bdnf), 3.2.7. cannabinoid and opioid receptors, 3.2.8. oxytocin, 3.3. dysfunctional hpa axis, 3.4. conclusive remarks, 4. prevention model of ptsd, the social-ecological model for ptsd prevention, 5. treatment modalities for ptsd and e-mental health, 5.1. trauma-based psychotherapy, 5.2. non-trauma focused psychotherapy, 5.3. pharmacological therapy, 5.4. e-mental health and virtual reality (vr), 5.5. conclusive remarks, 6. ptsd biomarkers, 6.1. susceptibility biomarkers, 6.2. diagnostic biomarkers, 6.3. therapeutic biomarkers, 6.4. conclusive remarks, 7. limitations and future directions, 8. conclusions and perspectives, author contributions, institutional review board statement, informed consent statement, data availability statement, acknowledgments, conflicts of interest.

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Al Jowf, G.I.; Ahmed, Z.T.; Reijnders, R.A.; de Nijs, L.; Eijssen, L.M.T. To Predict, Prevent, and Manage Post-Traumatic Stress Disorder (PTSD): A Review of Pathophysiology, Treatment, and Biomarkers. Int. J. Mol. Sci. 2023 , 24 , 5238. https://doi.org/10.3390/ijms24065238

Al Jowf GI, Ahmed ZT, Reijnders RA, de Nijs L, Eijssen LMT. To Predict, Prevent, and Manage Post-Traumatic Stress Disorder (PTSD): A Review of Pathophysiology, Treatment, and Biomarkers. International Journal of Molecular Sciences . 2023; 24(6):5238. https://doi.org/10.3390/ijms24065238

Al Jowf, Ghazi I., Ziyad T. Ahmed, Rick A. Reijnders, Laurence de Nijs, and Lars M. T. Eijssen. 2023. "To Predict, Prevent, and Manage Post-Traumatic Stress Disorder (PTSD): A Review of Pathophysiology, Treatment, and Biomarkers" International Journal of Molecular Sciences 24, no. 6: 5238. https://doi.org/10.3390/ijms24065238

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Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment (2014)

Chapter: 9 research on ptsd.

9 Research on PTSD

Ahigh-performing system for posttraumatic stress disorder (PTSD) management identifies and effectively applies research findings on prevention, assessment, diagnosis, and treatment to provide optimal care. Other attributes of a high-performing system are fostering new research on innovative approaches for PTSD management; expediting translation of new research findings to people who have PTSD and to their health care settings; striving to anticipate future research directions to address knowledge gaps; and exploring new ways to reduce stigma and promote access to and dissemination of evidence-based treatment. In its phase 1 report, the committee presented an overview of the current knowledge base on PTSD prevention, assessment, diagnosis, and treatment, including comorbidities and rehabilitation. This chapter reviews the research portfolios of the Department of Defense (DoD), the Department of Veterans Affairs (VA), and the National Institutes of Health (NIH) to assess specifically how science is fostered and what research is being conducted. The chapter ends with a discussion of the challenges to translating research into practice and a discussion of leveraging technology to improve access to and delivery of PTSD care.

FOSTERING RESEARCH

Conducting basic science, clinical, and health-management research requires an environment that can provide knowledgeable investigators with sufficient resources, a collaborative organizational structure, and innovative and forward-thinking leadership. Some of the ways in which DoD

and VA (and to some extent NIH) have fostered PTSD-related research are establishing clear mission statements for research, investing in the research, establishing an action plan, learning how to translate research into practice, and supporting innovation in technology.

Research Missions in DoD, VA, and NIH

DoD, VA, and NIH all conduct or support PTSD research and they have distinct but complementary research missions (Castro et al., 2013). DoD relies to some extent on the expertise and infrastructure of VA and NIH for research in PTSD prevention and treatment interventions. Research in VA tends to be focused on the long-term health of veterans. Its infrastructure can support and leverage clinical trials and epidemiological studies, and it has the capability to translate research findings into clinical care. DoD and VA collaboration in research has increased in recent years; examples include the National Research Action Plan for Improving Access to Mental Health Services for Veterans, Service Members, and Military Families and a research collaboration guidebook, which was created to foster cooperation between DoD and VA investigators in human subjects health care research (VA and DoD, 2013). PTSD research in NIH includes basic and clinical research, funded primarily through the National Institute of Mental Health (NIMH). Results of such basic and clinical research can be used to inform PTSD prevention, diagnosis, and treatment.

Although this chapter focuses on PTSD research funded by DoD, VA, and NIH, the pharmaceutical industry invests in new medications to treat for PTSD, although that investment has declined in recent years (DoD et al., 2013). There are also private efforts by foundations and other organizations to improve care of people who have PTSD. Numerous large centers, consortia, and collaborations funded by DoD, VA, and others, such as the South Texas Research Organizational Network Guiding Studies on Trauma and Resilience, are working toward a better understanding of PTSD prevention, pathogenesis, and treatment. More detailed information on some of those centers, consortiums, and collaborations can be found in Appendix D .

National Research Action Plan for Improving Access to Mental Health Services for Veterans, Service Members, and Military Families

On August 31, 2012, President Obama issued Executive Order 13625, which directs DoD, VA, the Department of Health and Human Services, the Department of Education, and the Department of Homeland Security to “take steps to meet the current and future demand for mental health and substance abuse treatment services for veterans, service members, and their families.” In response, those departments developed a national research

action plan in August 2013, which was organized around an interagency research continuum framework. For each component of the continuum—foundational science, epidemiology, etiology, prevention and screening, treatment, follow-up care, and services research—the interagency group was to undertake a gap analysis and identify short-term, mid-term, and long-term research needs to improve the prevention and diagnosis of and treatment for PTSD in service members and veterans (Castro et al., 2013; DoD et al., 2013). The research plan also considers comorbid conditions as appropriate.

As part of the National Research Action Plan, DoD, VA, and NIH have identified several PTSD research goals (Castro et al., 2013). They also identified several cross-cutting actions to increase transparency and communication among the departments (DoD et al., 2013). For example, “a new commitment will be to move the DoD’s medical research into the NIH Research Portfolio Online Reporting Tools via Electronic Research Administration Commons” (DoD et al., 2013). The committee believes that such a move will increase the transparency of mental health and other research being funded by DoD. The committee commends DoD, VA, and NIH for the thorough review they are undertaking, and it agrees with the gaps and future research goals the departments have identified.

Recent Funding for Mental Health and PTSD Research

Since 2007, DoD has invested $771 million in more than 453 mental health research studies. Of that investment, 60% supports PTSD research, 12% resilience research, 9% family-related research, and the remainder other types of mental health research (Miller, 2014). Since 2009, VA has invested $556.6 million in mental health research 1 (see Table 9-1 ), and its funding of PTSD research has remained steady at around $30 million per year over the past 5 years. However, as a percentage of VA’s mental health research budget, PTSD research funding has decreased from a peak of 32.4% in 2010 to 24.6% in 2013 (Gleason, 2012), despite marked increases in the prevalence and incidence of PTSD in veterans who seek care in VA, as described in Chapter 2 .

In 2011, DoD had 162 active PTSD studies for a total investment of $297.4 million (Defense Health Program and VA, 2011). The greatest funding that year went to treatment (40.0%), basic science (27.6%), and

________________

1 This funding supports research, equipment (typically Year 1 investment), salaries for nonclinical primary investigators, and VA administrative overhead (Gleason, 2012). It does not support research administration at VA medical centers, clinician primary investigator salaries (which are supported by medical care appropriation), animal facility support, research supported by non–Office of Research funding, or research system infrastructure (Gleason, 2012).

TABLE 9-1 VA Funding Amounts for Mental Health Research and PTSD

SOURCE: Data are from Gleason, 2013.

resilience (17.9%). In 2011, VA had 130 active studies on PTSD for a total investment of $155.4 million (Defense Health Program and VA, 2011). The greatest funding went to treatment (42.3%), epidemiology (25.1%), and basic science (17.1%). Those research priorities reflect DoD and VA efforts to understand, prevent, and treat for PTSD in service members and veterans who are exposed to traumatic events.

COMMITTEE’S SUMMARY OF CURRENT RESEARCH ON PTSD

In the committee’s statement of task, it was asked to “consider the status of studies and clinical trials involving innovative treatments for PTSD that are conducted by DoD, VA, or the private sector,” particularly physiological markers, causation, alternative therapies, and the use of pharmaceutical agents to prevent and treat PTSD (see Chapter 1 , Box 1-1 ). The committee was also asked to provide recommendations for future PTSD research. This section presents an overview of PTSD research that is funded by DoD, VA, NIH, and other organizations. The categories of research in this chapter are based on the structure of the committee’s phase 1 report (IOM, 2012).

To identify PTSD research projects, the committee looked at several publicly available research databases. The committee limited its review to studies in adult populations and those on mechanisms, screening, diagnosis, treatment, or barriers related to PTSD in service members and veterans. Studies were excluded if they were specific to traumatic brain injury (TBI), caregiver support, or insomnia, chronic pain, and unexplained illnesses in veterans. The remaining studies were categorized into broad topic areas (see Table 9-2 ). Studies in each category were enumerated by funding agency and summarized to identify gaps and overlaps in the research. The following databases provided most of the research information:

• The NIH Research Portfolio Online Reporting Tools (RePORT) database ( http://report.nih.gov ) contains intramural and extramural research funded by NIH, the Centers for Disease Control and Prevention, the Agency for Healthcare Research and Quality, the Health Resources and Services Administration, the Substance Abuse and Mental Health Services Administration, and VA. The RePORT database was searched on June 6, 2012, using the term PTSD for all active projects. The committee recognizes that this database is not static and that new projects may have been funded since June 2012.
• The VA Health Services Research and Development database “pursues research that underscores all aspects of VA healthcare: patient care, care delivery, health outcomes, cost, and quality” (VA, 2011). The database was searched for all studies that were active during 2007−2012, on November 15, 2012, using the term PTSD .
• The ClinicalTrials.gov database includes information about interventional and observational medical studies in human volunteers. Although it does not include all clinical trials conducted in the United States, it does contain the majority of federally and privately funded studies conducted under investigational new drug applications. The database search was conducted on August 27, 2013, using the term PTSD . Studies were eliminated if they were completed or expected to be completed before 2011, or were withdrawn.

The committee also obtained from DoD a list of PTSD studies it funded 2 because, unlike VA and NIH, it does not have a publicly available database of studies.

Table 9-2 gives an overview of the research categories used by the committee and the number of funded studies in each category. The committee then provides a broad description of why each research category in this chapter is important for understanding and treating for PTSD in DoD and VA. It also provides a general summary of the ongoing research from the NIH RePORT database, the VA Health Services Research and Development database, the ClinicalTrials.gov database, and the information provided by DoD. Because the research is ongoing and not yet published (in most cases), citations could not be provided for some of the summaries below. More detailed descriptions of the ongoing studies reviewed by the committee are given in Appendix E . The level of detail provided in each of the research categories below and in Appendix E are variable and reflect the number

2 A list of these studies can be obtained by contacting the National Academies Public Access Records Office.

TABLE 9-2 Research Categories and Targets a

a This table represents the committee’s search of NIH RePORT, HSR&D, ClinicalTrials.gov , and research studies provided by DoD. Some studies could have been considered under multiple categories but were counted only in the most relevant category to avoid an overestimation of studies. There were also numerous studies that were funded by more than one organization. The committee tried to identify the main funding source so that the study would only be counted once in the table, but this was not always possible and some studies, particularly studies funded jointly by DoD and VA, were counted twice. Because of these caveats, Table 9-2 may underestimate the number of studies under each category or funding source, especially for DoD-, VA-, and NIH-funded research.

b Includes international organizations, U.S. universities, hospitals, nonprofits, and pharmaceutical companies.

of studies and the level of information the committee was able to obtain about those studies.

The database information was variable and there were limitations to the committee’s review of the research. For example, some of the research descriptions had details on the study population, methodology, and even preliminary results, whereas others had only a title and a brief description of the goals and objectives of the study. The databases also varied in how costs and funding information were presented, so the number of studies in each funding column in Table 9-2 may be underestimated. In some cases, it was difficult to determine who was funding a particular study. The table does not reflect ongoing collaborations. Thus, the table should be considered as a general representation of currently or recently funded PTSD research.

Physiology, Neurobiology, and Behavior

As detailed extensively in the committee’s phase 1 report (IOM, 2012), the neurobiology of emotion and defensive responses to fear, anxiety, avoidance, and reward has been extensively investigated for several decades (Charney, 2003; Garakani et al., 2006; Hammack et al., 2012; Hartley and Phelps, 2010; Lanius et al., 2011; Martin et al., 2009; McTeague and Lang, 2012; Quirk at al., 2006). One reason is a desire to understand the brain–behavior interactions from a basic neuroscience perspective. Another is a desire to advance knowledge of the psychopathology of anxiety and mood disorders in general and of PTSD in particular. DoD, VA, and NIMH have set priorities for funding in these topics to elucidate the mechanistic underpinnings of the pathophysiology of fear and anxiety that are commonly observed in people who have PTSD. Some of the research reviewed by the committee is summarized below with a discussion of its relevance to PTSD psychopathology and treatment. The committee notes that other emotions, such as shame and guilt, frequently accompany a diagnosis of PTSD (Lee et al., 2001; Urlic and Simunkovic, 2009; Wilson et al., 2006); these social emotions may play a role in PTSD etiology and persistence and are not necessarily modeled or captured in existing experimental models and paradigms that focus on fear and anxiety.

Mechanistic Research

Understanding the psychological and neurobiological mechanisms by which traumatic experiences result in maladaptive emotional and threat responses is fundamental to basic research and of the translation of research on PTSD (see the section “Translating Research into Practice”). That understanding has been approached from a number of perspectives, from

cellular to cognitive to cultural (Feodorova and Saragian, 2012; Martin et al., 2009; Quirk et al., 2006; Schafe et al., 2001; Zovkic and Sweatt, 2013). Given that PTSD is triggered by experience and is commonly viewed as a disorder that emerges with an inability to cope with or recover from the aftermath of the trauma (Shvil et al., 2013), the primary focus of basic research has been the neurobiology and psychology of emotional learning and memory (Cahill, 1997; Hartley and Phelps, 2010; Kim and Jung, 2006; Maren, 2001; Milad and Quirk, 2012; Pitman et al., 2012; Rudy et al., 2004; Zovkic and Sweatt, 2013). Some people diagnosed with PTSD overgeneralize their fears and exhibit substantial avoidance symptoms, so animal research on passive and active avoidance is helpful. Overgeneralization is another research area that is very active (Dunsmoor et al., 2011; Lissek, 2012). The mechanisms of action by which some experiences can change neural networks are of the utmost importance for understanding the development and persistence of PTSD.

On the cellular level, one approach to understanding mechanisms of action is to study how different types of receptors interact with their ligands to mediate memory formation under normal physiological conditions. That knowledge can inform how malfunction or modification of cellular mechanisms could lead to changes in memory formation that may be relevant to the pathophysiology of PTSD. Over the last several decades, research has generated a wealth of knowledge about the processes by which learning and memory lead to the activation of several types of receptors; this activation triggers intracellular cascades that result in the activation of gene transcription and translation and causes synthesis of new proteins and modification of synaptic connections between neurons (Andero and Ressler, 2012; Gunduz-Cinar et al., 2013; Hauger et al., 2012; Johansen et al., 2011; Lutz, 2007; Shekhar et al., 2005). That line of research has helped to identify some cellular targets that may play a role in the pathophysiology of PTSD, such as corticotrophin-releasing factor, brain-derived neurotrophic factor (BDNF), and N-methyl-D-aspartate receptors. A recent study by Pace et al. (2012) found increased activity of nuclear factor kappa-light-chain-enhancer of activated B cells in women who have PTSD arising from childhood abuse, suggests an enhanced inflammatory system and decreased immune cell glucocorticoid sensitivity. New and promising work in preclinical neuroscience reviewed by the committee includes research to understand BDNF and its receptors (tyrosine receptor kinase B and some potential new targets such as neuropeptide Y and neurosteroids.

Building on the foundation of the cellular and molecular mechanisms of memory requires an understanding of the diverse and interacting brain systems and psychological processes that support adaptive and maladaptive memory formation and expression. One fundamental principle is that several kinds of memory make up distinct brain circuits, each having unique

characteristics. For instance, different memory systems support the conscious retrieval of episodes, habitual actions, and physiological defensive reactions (Luethi et al., 2009). Preliminary research suggests that the impact of trauma and stress on learning and memory depends on the type of memory assessed. One important topic that has not been investigated extensively is how different types of memory systems interact. Given that PTSD is characterized by intrusive and habitual episodic memory retrieval accompanied by heightened learned threat responses and physiological arousal, this might be an important avenue for future research.

Cellular and brain systems that support learning and memory have the potential to elucidate mechanisms of memory storage (consolidation) and restorage (reconsolidation). Traumatic events that result in PTSD could be conceptualized as resulting in memories that are over-consolidated. Knowing how that works, whether and how memories are retained in the absence of retrieval, and how memories are reconsolidated after retrieval are critical for understanding PTSD and could lead to new interventions. Traditional research on learning and memory has focused on memory encoding and retrieval, not the storage process itself, which is a promising topic.

Current nonpharmacological approaches to treating PTSD are based largely on controlling fear through either cognitive regulation or through exposure and extinction (Bisson et al., 2013; Rachamin et al., 2009). Initial studies of fear conditioning and extinction focused on fear learning because patients who have PTSD may overconsolidate traumatic memories (Pitman et al., 1989). However, recent studies suggest that over consolidation of fear memories may not be evident in PTSD—at least using de novo fear conditioning and extinction paradigms—and the extinction of conditioned fear memories may be deficient in PTSD patients (Milad et al., 2008, 2009). Although exploring means to enhance those techniques is useful, the committee identified relatively few ongoing studies of the mechanisms of fear resilience or fear-control techniques beyond extinction or cognitive regulation. In addition, the committee found little research on the relationship between the stress–hypothalamic pituitary axis response and the mechanisms of emotion and fear control. Those mechanisms are inherently intertwined in PTSD, so understanding their interactions is important and research on this topic should be expanded. Although an understanding of basic general psychological and neurobiological principles underlying the development and persistence of PTSD is clinically important, this research cannot be adequately translated into treatment and prevention unless it is known how the mechanisms interact with individual characteristics. For example, an important variability factor for PTSD is sex differences. The incidence of some anxiety and mood disorders is twice as high in women (Kinrys and Wygant, 2005), who seem to have symptoms for longer periods and poorer prognoses compared with men (Breslau et al., 1998; Seedat et

al., 2005). Despite these epidemiological data, relatively little is known about how sex differences may impact the underlying neurobiology and psychology of PTSD. In healthy humans and in clinical populations, studies do not generally exclude women, even if the differences between males and females are not fully explored or characterized (Lebron-Milad and Milad, 2012). However, the vast majority of PTSD-related research is conducted only in male animals, which may potentially limit its relevance to half the human population. Basic research for such physical conditions as heart disease must include an appreciation of sex differences, and this same standard should be extended to basic and translational research for PTSD.

The factors that lead to individual differences in the development of PTSD are both experiential and genetic (Admon et al., 2013; Kremen et al., 2012; Mehta and Binder, 2012). The genomic basis of PTSD is critically important for determining who might be at risk. That includes identifying genotypes implicated in vulnerability or resilience to PTSD, gene pathways that undergo epigenetic modification after trauma exposure, and differential expression of genes in people who have and do not have PTSD (Almli et al., 2014). Because PTSD is fundamentally a brain disorder, identifying epigenetic modifications that result in differential gene expression in brain regions known to be dysfunctional in PTSD patients has a high priority. However, because brain tissue from living people cannot be assayed, brain-focused studies to identify differentially expressed genes are generally conducted in animal models. The committee identified human studies that are investigating whether epigenetic and expression differences observed in peripheral tissues are associated with PTSD.

The genomics of PTSD is in its infancy compared with the genomics of other common psychiatric disorders such as schizophrenia (Koenen et al., 2013). There is a great deal of knowledge to be gained in this field, but whether it will translate into innovative interventions to prevent or ameliorate PTSD is unknown. The most promising research for translation appears to be prospective human studies that integrate multiple levels of biological data. The best method for such studies begins with identifying people before exposure, but studies of people in the acute aftermath of a traumatic event are also likely to produce important translational results. The translational impact of PTSD genomics could be improved by integrating genome-wide data (for example, genotype, epigenetic, and gene expression) into treatment studies of PTSD, as has been done with functional magnetic resonance imaging research. Such studies may provide information on genomic profiles of people who do and do not respond to treat-

ment and information on genomic correlates (for example, gene expression changes) of symptom remission.

A major concern about genomic research on PTSD is the narrow focus on candidate genes—whether for genotype, epigenetic, or gene expression studies—in light of the discrediting of this approach for other psychiatric disorders, such as schizophrenia and bipolar disorder (Pitman et al., 2012). A further concern is the relatively small number of human studies due to current funding constraints. PTSD genomics would benefit from the formation of a PTSD working group in the Psychiatric Genomics Consortium aimed at sharing genotype, epigenetic, and gene expression data among human studies (Koenen et al., 2013). Large consortia have produced robust genomic discoveries related to other psychiatric disorders, such as schizophrenia (Sullivan et al., 2012), and there is no reason to assume that it would be different for PTSD. The major barriers to such a consortium are VA and DoD restrictions on the sharing of genomic data. For example, unlike NIH, which effectively requires data sharing, VA does not allow sharing of individual-level genotype data from genome-wide association studies. Such barriers to data sharing have in effect excluded VA investigators from the large consortia that are necessary for genomic research. Addressing such barriers would help ensure progress in PTSD genomics research.

Ideally the occurrence of PTSD should be prevented. Unlike other psychiatric disorders, PTSD results from a known event, and this allows for immediate intervention and possibly even the prevention of pathological symptoms. It remains unclear why some people are resilient to trauma whereas others develop PTSD. Clarifying the reasons for this difference might improve strategies for enhancing resilience and preventing the development of PTSD. Logistically, this research is challenging to conduct in humans, as it requires recruiting people into studies immediately after a traumatic event and following them longitudinally. Establishing best practices for recruiting people into studies immediately after trauma and improving basic research techniques for early behavioral or neural interventions could result in new methods to prevent PTSD symptoms.

The committee identified some research projects that explore methods for increasing resilience and reducing adverse effects after exposure, such as investigations of early interventions (for example, intervening in the emergency room or as soon as the event occurs), of early behavioral and pharmacological interventions and different delivery systems (for example, telephone or Web-based delivery), and of different populations at risk. An early-intervention study found that a course of three sessions of modified prolonged exposure (PE) therapy in an emergency department was associ-

ated with significantly less depression and PTSD at 1-month and 3-month follow-up than in those who received assessment alone, and the early intervention appeared to mitigate a genetic risk of PTSD (Rothbaum et al., 2014a).

Some research is being done on prevention, but it does not appear to be sufficient. DoD is implementing prevention and resilience training programs, but most of them have yet to be evaluated (IOM, 2014). The committee did not identify any service-specific research that assessed whether existing programs successfully minimize PTSD after trauma or prevent the reemergence of symptoms and other sequelae.

Advances in basic science and PTSD genetics could help to identify social, psychological, or biological markers that might indicate vulnerability to PTSD either before or after trauma exposure. Such research could help to identify modifiable risk factors that might be targets for prevention interventions and people who are at high risk for PTSD and might benefit from enhanced training or early interventions after trauma exposure. Equally important but less studied is the question of whether psychological, social, or environmental variables may increase or decrease the likelihood of PTSD.

Prevention research is examining risk and protective factors for the development of PTSD symptoms. There has been some progress since the committee’s phase 1 report (Biehn et al., 2013; Goldmann et al., 2012; Goodwin et al., 2013a,b; Kok et al., 2012; LeardMann et al., 2013; Marshall et al., 2012, 2013; Walsh et al., 2013; Wilk et al., 2012, 2013), and research continues (see Appendix E ). A challenge for research in this field is that although there are some commonalities in methods, in each study that the committee reviewed investigators focused on “innovative” risk or resilience factors; as a result, there were many factors peculiar to each study that cannot easily be translated among studies. In addition, the application of results to other populations—such as service members, veterans, or women—is questionable. This challenge could provide an opportunity for NIH, VA, and DoD to collaborate to support research that may help to actively build consensus around a specific prevention program, biomarker, or other scientific advancement. A notable gap is the absence of research that pools analyses or meta-analyses of extant studies.

The committee reviewed many research projects that might lead to advances in screening for PTSD and comorbidities (see Appendix E ). A few studies were identified that screen for PTSD in high-risk populations, such as those with chronic pain, burns, mild TBI, accidental injury, and functional somatoform syndromes. New technologies and outreach approaches, such as automated telephone screening and the Army’s Behavioral Health

Data Portal (described in Chapter 4 ), might increase the efficiency and reduce the cost of screening.

Screening serves different purposes and there is no “one-size-fits-all” formula for screening procedures. The type of screening to be conducted depends on the question of interest, for example, whether the intention is to compare those who have PTSD with those who are healthy or to distinguish those who have PTSD from those who have a related diagnosis, such as mild TBI. Research is needed to move beyond the traditional questionnaire-based screening methods to neurobiological and behavioral screening for PTSD. There is also a need for randomized controlled trials that prospectively assess whether large-scale screening results in greater benefits to the population than more traditional approaches.

Much PTSD research has been directed toward improving the diagnostic precision of structured interviews or self-ratings. Those techniques not only assist in diagnosis but are valuable tools for promoting measurement-based care. Efforts that go beyond structured interviews and rating scales have been under way for many years and include the study of physiological measures, neuroimaging, genetic markers, and neurotransmitters; the goal is to enhance diagnostic processes by incorporating neurobiological measures.

The committee identified studies that apply biological measures to address PTSD diagnosis (see Appendix E ). Examples are the differentiation between PTSD and mild TBI, identification of the new symptoms of PTSD as given in the Diagnostic and Statistical Manual of Mental Health Disorders-Fifth Edition (APA, 2013), and the characterization of speech patterns in people who have PTSD compared with those who do not have PTSD. The committee identified a research gap in the area of diagnosis—one potentially useful approach that is not being studied is the use of advanced statistical procedures, such as random forest classification and functional magnetic resonance imaging, to develop a neurobiologically based approach to diagnosis PTSD and to evaluate it against standard (that is, clinically based) diagnostic predictors.

There are effective treatments for PTSD in civilians, as shown in the numerous meta-analyses and treatment guidelines that were described in the committee’s phase 1 report (IOM, 2012). However, although such treatments as PE, cognitive processing therapy (CPT), eye movement desensitization and reprocessing (EMDR), selective serotonin reuptake inhibitors, and

other pharmacotherapies are more effective than placebo or other controls in civilians, they do not work in all people with PTSD. Some patients show only a partial response, others show no response, and some relapse after an initially promising response. There are a limited number of studies that have investigated PTSD treatments in service member and veteran populations. Other treatment challenges include the delayed onset of therapeutic action and adverse effects. Better and safer treatments are needed, not just modifications of current ones.

Research targets for treatment (see Appendix E ) include several that are innovative and promising. Some of the most promising research is the use of new technologies to improve the effectiveness and accessibility of treatment. The combination of various clinical approaches to address the complexity of PTSD issues (for example, concurrent treatment for PTSD and comorbidities or treatments that combine psychotherapies, pharmacotherapies, and complementary and alternative therapies) needs to be studied further in military and veteran populations. Overarching research considerations for PTSD treatment are discussed below.

Pharmacotherapies

Both preclinical pharmacotherapies (for example, pilot studies) and pharmacotherapies are being investigated in military and civilian populations (see Appendix E ). New pharmacotherapies, such as endocannabinoids, are promising and important for research. The committee found research gaps in the study of preclinical pharmacotherapies, such as the use of oxytocin, to identify molecular markers of reconsolidation and of hippocampal adult neurogenesis as related to pattern separation and pattern completion.

A broad array of new and established pharmaceuticals are being studied; some are being given as monotherapy and some to augment other therapies. Some are believed to work through different neurotransmitter pathways and should add valuable information to the knowledge base on PTSD pharmacotherapy. Particularly promising are the clinical investigation of low doses of anesthetic drugs, such as ketamine, and the increasing evidence base on prazosin. For example, a study looking at treatment with prazosin in active-duty Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) soldiers found that prazosin was superior to placebo in measures of sleep and total PTSD symptoms (Raskind et al., 2013). This study is the first major placebo-controlled trial of pharmacotherapy in active-duty service members who had been exposed to combat.

On the basis of an extensive review of current studies and a brief review of research published since its phase 1 report (IOM, 2012), the committee identified several gaps in PTSD-treatment research. First, studies of drug

effects on brain structure and chemistry, such as effects of escitalopram on BDNF, are valuable, and more studies of this type are needed. Second, hydrocortisone holds promise both for the prevention of PTSD and the understanding of the neurobiology of PTSD; further studies of antipsychotics as a treatment for PTSD are needed. Third, pharmacotherapy for PTSD comorbid with bipolar disorder, attention deficit disorder, and mild TBI is not well studied but should be. Fourth, polypharmacy is a continuing concern; it may result in improvement in PTSD symptoms, but it can also result in more side effects and be a factor in noncompliance to treatment.

Psychotherapies

Research that compares the efficacy of new psychotherapies with that of established evidence-based treatments is essential for a high-performing system of PTSD management. It is important to continue to develop and evaluate new psychotherapy options because there is currently no evidence-based treatment that is effective for everyone who has PTSD and no treatment that is so appealing, engaging, and pragmatically deliverable to patients that it breaks down all barriers to care. Thus, the rigorous study of new psychotherapies is essential for maximizing the treatment options to address each patient’s unique needs and preferences. Once efficacy is established, primary treatments can be studied in combination with other treatments to determine the added value of combination treatments or how treatment-protocol modifications can improve benefits.

Various treatment methods are being evaluated, most often to compare them with CPT or PE (see Appendix E for more detail). Rather than research gaps, there appears to be considerable diversity in the approaches being tested, including both trauma-focused and non-trauma-focused approaches. Examples are controlled studies to assess the value of adding components to evidence-based treatments. Various new treatments are being tested in randomized controlled trials, such as acceptance and commitment therapy, adaptive disclosure therapy, behavioral activation therapy, interpersonal psychotherapy, trauma-management therapy, and relatively new and untested cognitive training approaches to enhance modulation of emotion. The committee did not identify any studies of the value of combining cognitive training methods with traditional cognitive behavioral therapy (CBT) or exposure therapies, such as CPT, PE, and EMDR. That may constitute a research gap inasmuch as psychotherapy approaches may be more effective when combined to address both cognitive control of emotional regulation and extinction-based cognitive and behavioral concerns. Overall, current psychotherapy research reflects a diverse mixture of efforts. Some experimental methods for studying PTSD treatments involve computer-delivered approaches, which are discussed later in this chapter.

Combining Psychotherapy and Pharmacotherapy

The combined use of pharmacotherapy and psychotherapy is an important approach in the management of PTSD. A combined approach might result in greater therapeutic gains in two ways. In the first, a single dose of a drug is administered immediately before or after a psychotherapy session either to hasten the onset of therapeutic action or to produce greater therapeutic gains than psychotherapy alone. This model uses drugs that are cognitive enhancers—such as D-cycloserine (DCS), yohimbine, methylene blue, and hydrocortisone—or drugs that disrupt memory (such as propranolol) or facilitate therapy, such as 3,4-methylenedioxy- N -methylamphetamine (MDMA or “ecstasy”). In the second, a drug is administered chronically with psychotherapy, and the combined treatment may result in a greater gain than either treatment alone. In this model, use of the drug might precede the introduction of psychotherapy, be started simultaneously, or be added after the start of psychotherapy. The antidepressant drug sertraline and the anticonvulsant drug zonisamide (see Appendix E ) are being studied as enhancements of psychotherapy.

Several trials of medication-enhanced psychotherapy have been reported recently. For example, Oehen et al. (2013) investigated MDMA in association with psychotherapy in treatment-resistant noncombat PTSD patients; greater improvement was observed in the higher-dose group. The use of single-dose DCS in combination with PE therapy has also been studied; mixed results have been reported. Litz et al. (2012) compared DCS and placebo with behavior therapy in OEF veterans and found inferior results in the DCS groups. De Kleine et al. (2012) reported significantly greater improvements with DCS than with placebo in civilians but only in those who required more sessions; Difede et al. (2013) showed reduced anger and PTSD symptoms compared with placebo in civilians who were given DCS combined with virtual-reality exposure therapy. Rothbaum et al. (2014b) found no reduction in overall PTSD symptoms in OEF and OIF veterans who were given a combination of DCS and virtual-reality exposure therapy but did find a significant decrease in cortisol and psychophysiological startle response in general.

Somatic Treatments

Neurostimulatory treatments for depression and obsessive compulsive disorder have shown benefit in some people who are resistant to first-line treatments. The U.S. Food and Drug Administration has approved devices for the use of repetitive transcranial magnetic stimulation (rTMS) in treatment-resistant depression. More recently, the literature has shown promise for rTMS in treating PTSD (Karsen et al., 2014; Nam et al., 2013; Oznur

et al., 2014; Watts et al., 2012). The committee identified several current studies that are funded by DoD, VA, and others to investigate rTMS, cranial electrotherapy stimulation, stellate ganglion block, trigeminal nerve stimulation, and bright-light therapy (see Appendix E ). Those and other stimulatory and somatic interventions are promising treatments for PTSD and clearly warrant further study.

Couple Therapy

In the last several years, research projects have assessed the effectiveness of couple therapy for PTSD (Fredman et al., 2011; Meis et al., 2012; Monson and Fredman, 2012; Monson et al., 2009; Sautter et al., 2009; Taft et al., 2011). In a small randomized controlled trial of cognitive-behavioral conjoint therapy for PTSD, Monson et al. (2012) found that this couple therapy model reduced PTSD symptoms and enhanced relationship satisfaction. Schumm et al. (2013) reported similar findings in a small study of OEF and OIF veterans who had PTSD and their female partners. The veterans’ PTSD symptoms and their partners’ relationship distress were reduced. Meis et al. (2013) found that OEF and OIF veterans were more interested in couple therapy than veterans of Vietnam and Korea, although both groups wanted more partner involvement.

Complementary and Alternative Therapies

As part of its statement of task, the committee was asked to look at complementary and alternative therapies for PTSD, particularly animal-assisted therapy. Surveys have demonstrated that the use of complementary and alternative therapies is substantial in the U.S. population and in the military (see Chapter 7 ). The more frequently studied complementary and alternative therapies are meditation, acupuncture, yoga, and biofeedback. Less studied therapies include animal-assisted therapy, mantram repetition, and music therapy. The former studies are being conducted in a variety of PTSD populations, including veterans, and they are being evaluated in combination with treatment as usual. Their value as stand-alone treatments for PTSD is unknown.

The committee identified different types of meditation—including mindfulness-based, loving-kindness, self-compassion, and transcendental meditation—that are being studied for PTSD. Most such studies were being conducted as randomized controlled trials with either an active or an inactive control (see Appendix E ). The committee found that there were as many mindfulness projects in the NIH RePORT database as there were projects for treating for PTSD with a combination of pharmacotherapy and psychotherapy approaches—an indication that research on mindfulness

is growing. There is a lack of well-controlled studies on animal-assisted therapy and on acupuncture for PTSD; more research is needed on both. The study of psychobiotics (for example, gut microbiota) is a new field of medicine that is relevant to stress and related psychological disorders. Some researchers have suggested that preclinical and clinical studies of psychobiotics could inform treatment for stress-related conditions (Burnet and Cowen, 2013; Dinan et al., 2013).

Models of Care Delivery

A high-performing PTSD management system should expedite the translation of positive research findings into practice. Optimally, the translation would take advantage of proven methods for the delivery of clinical services in a way that breaks down barriers to care. The best evidence-based treatments will have little value without a model for promoting their effective and widespread delivery.

New models for delivering evidence-based treatments that focus on improving access to care must take into account patients’ sociocultural context as well as available technology-based delivery options. Research is being conducted on the structure or context in which evidence-based treatment is delivered, such as in primary care and in deployment settings (see Appendix E for more details) and on the use of technology to expand the reach and appeal of evidence-based treatment to maximize its clinical efficacy (see the section “Technology” below).

The committee identified a research gap with regard to the use of mobile communication devices and their applications. There appears to be little research to determine how much applications such as VA’s PTSD Coach are used once installed and what effect they have on improving treatment outcomes and reducing barriers to care. However, considering the relatively recent availability and adoption of mobile devices and applications, it is perhaps understandable that they are the subject of little research.

Modality of Treatment Intervention

The committee identified several studies that focused on treatment modality—that is, whether a treatment is given in a group setting, a couple setting, or an individual setting. Varied treatment modalities are being tested, either by delivering treatment in groups or in conjoint therapy or by adjusting the pace at which treatment is administered (for example, moving from one session per week to two sessions per week). More research is needed to determine the characteristics of patients who can benefit from treatment delivered in a group or from combinations of individual and group or conjoint treatment. More research is needed to determine the

role of the family in different treatment settings and the benefits of family involvement. Research is also needed to determine whether providing more choices of treatment modalities for service members and veterans helps to reduce barriers to care. And research is necessary to understand whether a patient who has initial involvement in a group setting with a non-evidence-based treatment (such as yoga or psychoeducation) is more likely to engage in an evidence-based treatment later.

Treating Different Sex and Racial Groups

Sex, ethnicity, and culture can all affect the risk of PTSD, its presentation, a patient’s (and the patient’s family’s) attitudes to treatment, the type of treatment that is preferred and received, and possibly the response to treatment. The committee identified current research that is aimed at assessing the potentially different needs of men and women who have PTSD and alcohol or substance use disorders, or who have experienced military sexual trauma. Some studies are focused on making PTSD treatment more accessible to members of minority groups, on adapting manualized PE for Hispanic patients, and on developing culturally relevant treatment for American Indians.

Concurrent Treatment of Comorbidities

As noted in Chapter 2 , people who have PTSD are often diagnosed with one or more comorbidities, including other anxiety disorders, depression, and alcohol and substance use disorders (Brown and Wolfe, 1994; IOM, 2012; Jacobsen et al., 2001; Kaufman and Charney, 2000; Pompili et al., 2013). To better understand the pathophysiology of PTSD, some studies have focused solely on it as the primary diagnosis and often excluded patients from studies if they present with comorbidities. Excluding certain patients may be important for studying the psychopathology of PTSD itself, but research examining the interactions between the pathophysiology of PTSD and other psychiatric conditions is as important as research that explores the psychological and neural processes underlying the interaction of drug addiction or TBI with the development and treatment of PTSD. Not only can understanding how alcohol, drugs, and brain injuries may interact to alter the brain circuitry implicated in PTSD provide information on why PTSD is linked to addiction and TBI, but these types of studies might also help identify new PTSD treatments (Brady et al., 2013; Kaplan et al., 2010). Some literature published since the phase 1 report shows an improvement in PTSD symptoms and a reduction in comorbid alcohol use when the disorders are treated together. Foa et al. (2013) compared PE, both with and without naltrexone, with supportive counseling in patients

who had PTSD and alcohol use disorder, and found that participants who received naltrexone had fewer drinking days (those who received both PE and naltrexone had the lowest rate of posttreatment relapse), that all patients had a reduction in PTSD symptoms, and that PE did not exacerbate alcohol use disorder. Kaysen et al. (2014) observed that CPT was well tolerated in veterans who had PTSD and comorbid alcohol use disorders and that CPT treatment was associated with decreased symptoms of PTSD and depression.

The committee found a variety of current studies of psychotherapy, most of which are CBT-based, for PTSD and comorbidities. There is an emphasis on promoting adherence to treatment and maintenance of long-term treatment gains by using motivational interviewing and relapse-prevention strategies. There is little redundancy in the research being conducted in this area. The committee noted one study designed to generate comorbidity clusters to predict outcomes. Other treatment approaches included physiological response-tailored exposure therapy, imagery rehearsal with or without CBT, and group CBT. The diversity of the study targets and clinical approaches suggests that DoD and VA recognize the importance and challenge of treating for PTSD and comorbid conditions.

Most research on barriers is related to individual, provider, and institutional obstacles to the delivery of high-quality, evidence-based PTSD care. It includes barriers to awareness, accessibility, availability, and acceptability; the role of leaders in reducing stigma; adherence to evidence-based treatments, and the dissemination of the outcomes. Two studies are looking at military culture, operational tempo, and institutional processes that impede research (for example, variations in institutional review board functioning and recruitment challenges). Two studies are identifying barriers to the delivery of such new treatments as acupuncture. Some studies ask about family functioning and a service member or veteran’s relationships with his or her family, but only one study was identified in which the family is considered specifically as a barrier to or asset for PTSD treatment. There is no research on overcoming barriers to translation of basic research to treatment and clinical practice. The potential for new interventions (for example, Web-based approaches or after-care telephone monitoring) to break down access barriers is increasing (see the section “Technology”). The research portfolio is top-heavy with studies on OEF and OIF cohorts, including several studies of National Guard and reserve cohorts, but the committee identified very few studies that included Vietnam-era veterans.

Long-Term Outcomes

As noted in Chapter 2 , PTSD can be a long-term, chronic, and even lifelong disorder. Longitudinal studies can advance the understanding of how aging affects PTSD and comorbidities and can help to elucidate whether some interventions are beneficial in altering the course of the disorder. Thus, long-term follow-up of large DoD and VA cohorts might shed light on the effectiveness of prevention programs, early screening, and a variety of treatment interventions for PTSD. See Appendixes D and E for examples of long-term studies.

Intimate Partner Violence

Intimate partner violence is an often overlooked research topic with regard to PTSD, but it can have substantial impact on families. Some service members or veterans who have PTSD may perpetrate intimate partner violence (Meis et al., 2010), but what distinguishes those who do from those who do not is not fully understood. There is a continuing need to conduct research that identifies effective ways to assess intimate partner violence and to determine what factors encourage potential or actual perpetrators (or their partners) to seek access to mental health care. Several recent research efforts are designed to validate intimate-partner violence treatment interventions (Taft et al., 2013), but there are still few empirically supported interventions.

The committee identified promising innovative studies that focused on racial and ethnic factors associated with PTSD and intimate partner violence; the intersections of TBI, intimate partner violence, and PTSD; and the effects of PTSD and intimate partner violence on children in military and veteran families. Continuing research is needed to develop and validate couple, family, and group interventions that address intimate partner violence in military and veteran families.

Provider training is important for diagnosing and for disseminating and implementing evidence-based treatments. The committee divided research on training into training providers to improve the diagnosis of and treatment for PTSD and administering training grants for career development (see Appendix E ). The committee considered efforts to train providers to be particularly important. One innovative study is under way on the use of virtual patients for training providers. Another study is attempting to develop and evaluate a Web-based CBT training system that expands on existing content and incorporates live online training. Considering the need

for well-trained providers of evidence-based treatments and the ubiquitous penetration of high-bandwidth Internet connectivity, the absence of more studies on online clinical training appears to be a gap in research and practice. If current or recently completed studies on developing Web-based or new training curricula or tools are effective, they could be used to reach a larger audience.

TRANSLATING RESEARCH INTO PRACTICE

Translating research into practice can be thought of in different ways, depending on the context. For example, a laboratory scientist may be interested in how the basic science of cell lines or animals can be translated to humans. A researcher conducting a clinical trial may be interested in how the results in a controlled experimental setting are translated to the general population in a real-world setting. A health care administrator may be interested in taking a body of evidence and translating it to clinical practice guidelines. To distinguish between types and contexts of translation, investigators sometimes think of translation as a continuum of activities (see Table 9-3 ). All research does not have to go through each stage of translation, nor does the translation have to be linear; some research may move directly from an early stage to direct application.

The committee recognizes the importance of conducting basic research that translates from animal models to healthy humans and to clinical and trauma-exposed populations. Basic research on physiological and biologi-

TABLE 9-3 The Continuum of Translation Research

SOURCE: Modified from Khoury et al., 2007, with permission.

cal mechanisms potentially relevant to PTSD has used primarily animal models (Almli et al., 2014; Neumann et al., 2011; Pitman et al., 2012) because this research could not be ethically conducted in humans. These models are vitally important to understanding many of the neurobiological principles governing learning, memory, trauma, and stress. However, this research has limited usefulness if its applicability to and modification by the complex cognitive, social, and emotional factors typical of human experiences cannot be explored. Animal models also cannot capture the impacts of social factors, including such emotions as shame and guilt; social structures; cultural attitudes; or the complex cognitive abilities in people that may change the expression and persistence of PTSD symptoms. Basic research that explores the psychological and biological mechanisms of learning, memory, trauma, and stress in people should be expanded to include psychological and neurobiological mechanisms in healthy people and in trauma-exposed military populations. Unless a broad range of researchers can access relevant populations to conduct studies on how trauma exposure and PTSD influence the brain or behavior, the applicability of basic research to treatments for PTSD will continue to be limited. New research models—for example, pragmatic trials, practical clinical trials, and hybrid effectiveness–implementation trials—may be useful for addressing the common translational gap between randomized controlled trials and clinical practice (Curran et al., 2012; Tunis et al., 2003). Translational research can provide feedback from population-based studies of new interventions that lead to their modification and eventual implementation as evidence-based interventions for a variety of populations (Glasgow et al., 2012; Zatzick and Galea, 2007).

NIH has made an effort to streamline the translation of mental health research to the clinic. The NIMH Research Domain Criteria Project is defining functional dimensions, such as fear circuitry or working memory, that will be studied in multiple dimensions, including genes, neural circuits, and behavior. The project’s goal is to translate progress in basic neurobiological and behavioral research to an improved and integrated understanding of psychopathology and the development of new and optimally matched treatment for mental disorders (NIMH, 2013a). In addition, NIH is revising its clinical trials process to make NIH-funded research more efficient, to encourage data sharing and publication, and to have a greater impact on the burden of illness. Emphasis is being placed on target validation and experimental therapeutic studies instead of traditional efficacy trials in an effort to identify new targets for treatment and to improve knowledge of the disease process (NIMH, 2013b). The committee commends NIH for these efforts, and it encourages DoD and VA to use best practices learned from NIH to improve the efficiency and transparency of their own mental

health research and to continue to use such collaborative mechanisms as the National Research Action Plan.

The last decade has seen a dramatic increase in the use of innovative digital technologies, such as mobile devices, high-speed network access, smart televisions, social media, hyperrealistic computer and video games, and new interaction and behavioral sensing devices. The power of these technologies to automate processes and create engaging user experiences has led to health care applications that leverage off-the-shelf technology and push the boundaries of new technological development.

An increased focus has been placed on the use of technology to enhance the management of and treatment for PTSD and comorbid health conditions. DoD and VA have driven advances in mental health care technology by supporting research to improve the delivery of evidence-based treatments for mental health conditions and to reduce barriers to care by investigating ways to improve the awareness of, availability of, access to, appeal of, acceptance of, and adherence to evidence-based treatments and services (IOM, 2012). Technology-based advances in mental health care include telehealth, informational and self-help websites, mobile smartphone applications, virtual reality and online virtual worlds, intelligent health care agents, and interactive clinical training systems.

One of the more widely studied applications of technology in mental health is the use of telehealth (sometimes referred to as teletherapy or telemental health) to expand the accessibility of and adherence to evidence-based treatments. Telehealth refers to an approach that uses technology (typically videoconferencing) for the delivery of clinical care by a provider who is geographically distant from the patient (Schopp et al., 2006). The number of published reports on telehealth outcomes has grown exponentially since 2000, and the number of trials continues to grow (Backhaus et al., 2012). Since the committee’s phase 1 report, new studies have shown encouraging results (Backhaus et al., 2012; Strachan et al., 2012), and a substantial number of projects have been funded by DoD, VA, and others to investigate the telehealth delivery of both evidence-based treatment and emerging non-evidence-based interventions that target the needs of service members and veterans who have PTSD and comorbid conditions. The research needs to be assessed to determine whether telehealth approaches for both screening and treatment offer a preferable and cost-effective approach to PTSD care (Jones et al., 2012).

Self-Help and Informational Websites

DoD and VA have supported the development of online self-help and informational websites. These efforts are intended to break down barriers to care by building user awareness of PTSD and treatment options, promoting accessibility to care with self-help content, encouraging acceptance of seeking treatment with persuasive information, and enhancing adherence by providing self-help treatment options or between-session support. Receiving PTSD-relevant content privately via the Internet may encourage those who are initially reluctant to seek help to reach out eventually to a mental health care professional.

Another new form of online deliverable treatment is the use of computerized training programs to build the cognitive skills that may help to modulate emotions. Often termed cognitive remediation therapy, this approach is a standardized intervention that involves performing cognitive exercises to improve attention, processing speed, executive function, and memory through practice by using various software packages. The committee identified six projects that evaluate cognitive remediation therapy programs as an alternative intervention for PTSD in combat veterans. One study compared a commercial program called CogPack with playing Tetris. Two projects evaluated similar computer-based systems to retrain negative attentional bias in people who have a diagnosis of PTSD and to address comorbid mild TBI. All the cognitive remediation therapy projects test the hypothesis that this form of care will promote home-based practice by using cognitive training programs that are available online.

Other DoD and VA websites intended for service members, veterans, and their families present less structured treatment activities and are generally information-rich, reviewed, and regularly updated, and present a wide array of PTSD resources, including some self-assessment materials and information on where to access treatment. Examples of the sites are the VA’s National Center for PTSD ( http://www.ptsd.va.gov ), the National Center for Telehealth and Technology (T2) ( http://www.t2.health.mil ), and T2’s flagship PTSD and comorbidity AfterDeployment ( http://www.afterdeployment.org ). T2 also hosts the Moving Forward site ( http://startmovingforward.t2.health.mil ), an online educational life-coaching program focused on resilience and prevention for service members and veterans who are experiencing challenges but are not yet engaged in mental health care. DoD supports the wider-ranging Military OneSource site ( http://www.militaryonesource.mil ), and there are numerous private foundation “gateway” sites, such as the Dart Foundation’s Gateway to Post Traumatic Stress Disorder Information ( http://www.ptsdinfo.org ). Screening for PTSD and other psychological disorders is available for all veterans through VA’s My Health e Vet website (VA, 2013), which allows all registered users of VA

health care services to access their clinical records and provides a number of wellness and health-enhancement options.

Two novel online approaches leverage interactions with virtual human characters to engage users with PTSD-related content. One project is Kognito Interactive’s site Family of Heroes ( http://www.familyofheroes.com ), which offers an interactive role-playing game that teaches motivational interviewing skills to family members and helps them to recognize when their service member or veteran is exhibiting signs of PTSD, depression, or suicidal ideation. A small randomized controlled trial showed that 22% of the veterans who were approached by their family members during the study sought help for postdeployment stress. Another virtual human site is the DoD-funded SimCoach ( www.simcoach.org ), which engages users in an interactive discussion to provide information, advice, and conversationally delivered self-assessment.

Considering the expense and effort of creating those websites, there is a lack of knowledge about how they are used and what outcomes they produce. However, because anonymity may be a primary selling point for the sites, researchers studying the sites need to ensure that real-world users’ identities are protected. As the general population increasingly views the Internet as an acceptable and natural option for shopping, education, health care information, and social interaction and bonding, the committee believes that research will continue to focus on whether and how evidence-based mental health treatment can be delivered to service members and veterans via online tools and websites. Research needs to evaluate which treatments can be delivered to which patients who have which health conditions to maximize safe access to evidence-based treatment for service members, veterans, and their significant others.

Virtual Reality

DoD and VA have supported research to create and evaluate virtual-reality exposure therapy applications. Avoidance of trauma reminders is symptomatic of PTSD and some patients are unable or unwilling to visualize traumatic events and memories effectively (Difede and Hoffman, 2002). To address the avoidance issue, virtual reality delivery of PE is one way to immerse users in personalized simulations of trauma-relevant environments in which the emotional intensity of the scenes can be controlled by a clinician. Thus, virtual-reality exposure therapy offers a way to circumvent a natural avoidance tendency by directly delivering multisensory and context-relevant cues that aid in the confrontation and processing of traumatic memories.

Favorable outcomes have been reported in several PTSD populations treated with virtual reality therapy (Difede and Hoffman, 2002; Difede

et al., 2007; Gerardi et al., 2008; McLay et al., 2011; Miyahira et al., 2012; Reger and Gahm, 2008; Reger et al., 2011; Rizzo et al., 2010; Rothbaum et al., 2001, 2014b), and five randomized controlled trials of virtual-reality exposure therapy in active-duty service member and veteran populations are under way. Those studies are assessing virtual reality alone or in combination with other enhancing treatments, such as imaginal PE, DCS, and trauma management therapy (Beidel et al., 2011; Difede et al., 2013; Reger et al., 2011). In addition to providing more and better options for PTSD treatment, virtual-reality exposure therapy may be useful for overcoming barriers to care by improving treatment appeal, acceptability, and adherence. Young service members, many of whom have grown up with digital gaming technology, may be attracted to and comfortable with participation in virtual reality therapy (Reger et al., 2009; Wilson et al., 2008).

In spite of DoD and VA efforts to foster adoption of PE as a first-line treatment, its dissemination has been a challenge, in part owing to clinician hesitancy to adopt and use it (Becker et al., 2004; IOM, 2012). Virtual reality can also be used to help meet this challenge through the use of virtual reality systems that allow a mental health care provider to create customized simulated scenarios to support patient trauma narratives more easily with a computer control interface. DoD is supporting research on training social workers to work with military families using conversational interactions with life-size, voice-interactive, high-fidelity virtual military patients and is developing a toolkit for clinical educators so that they can create virtual patients for training others. Other virtual reality projects seek to train primary care providers to screen, treat, and refer patients who have PTSD using a series of challenging menu-driven, role-play conversations with virtual patients (Albright et al., 2012). However, the attraction and adoption of virtual-reality exposure therapy still requires controlled research to determine how and to what extent this approach may break down barriers to PTSD care and enhance treatment dissemination. It also requires research to determine best practices for training providers to use and to implement the technology in DoD and VA settings.

Mobile Applications

Mobile devices, including mobile telephones, tablets, computers, e-readers, and wearable body sensors that can record various physiological measurements, can be used to wirelessly deliver health care services. Mobile applications can potentially be used to motivate and inform people and to monitor and track health measures and activities. Many of the applications (such as fitness applications and calorie counters) focus on providing information to the end user, and others provide information to clinicians via a network connection. The availability of mobile health care applications

has grown at a dramatic pace, in large part owing to the massive adoption of smartphone and tablet technology and the ubiquitous access to network connections. DoD and VA have recognized that growth and produced several PTSD and other mental health–related applications, including PTSD Coach, PE Coach, Mood Tracker, Breathe2Relax, BioZen, LifeArmor, Positive Activity Jackpot, and Tactical Breather. All the applications attempt to extend the reach of currently used practices—such as self-monitoring, self-assessment, biofeedback, CBT tactics, and relaxation strategies—via mobile devices. T2 has worked with VA to develop, test, and conduct research on the PE Coach, a smartphone application. And the center is distributing the CBT-I Coach application as an adjunct treatment for the insomnia associated with PTSD (National Center for Telehealth and Technology, 2013) and the PTSD Coach application as an educational tool. Those programs require evaluation as they are further developed and disseminated.

VA is also investing substantial effort in its Mobile Health program to evolve its mobile application portfolio. It is piloting the use of iPads that have a suite of 10 applications to 1,000 seriously injured veterans (Miller, 2013). VA applications that are available or in development include CBT-I (insomnia-focused), Acceptance and Commitment Therapy Coach, Cognitive Processing Therapy Coach, Mindfulness Coach, and PTSD Family Coach. Although much of the content in the new mobile applications is similar to that on existing informational webpages, such as AfterDeployment and the VA’s National Center for PTSD, research on their use and effectiveness in a mobile format is still needed. There are practical challenges to studying the use of the technologies in DoD and VA with regard to development, dissemination, sustainability, and privacy protection, but current research efforts fit in well with the DoD and VA visions for using mobile health technologies to expand care options for service members and veterans. The creation of engaging and effective mobile health technologies will require an interdisciplinary effort by clinicians, device manufacturers, application developers, communication service providers, and patient and consumer end users, who appreciate the need to integrate portable computing devices, cloud infrastructures, network capabilities, data analytics, and human factors.

Online Clinical Training and Virtual Patients

Although human “actor” patients are the gold standard for training in medical schools, such live standardized patients are rarely available for clinical training with psychologists, social workers, and other mental health care providers. In most training, direct patient-interaction skills are acquired via role-playing with supervising clinicians, fellow graduate students, and closely supervised “on-the-job” training. Virtual patient

systems offer a novel technological approach to address the training needs of health care providers, and these systems take many forms (Talbot et al., 2012). Basic applications can be as simple as providing trainees with static patient images and accompanying text-based case summaries and tests. Simple computer animations can also be used, with interactions driven by trainee menu choices. More recently, virtual human conversational agents have been created that can credibly fill the role of standardized patients by simulating diverse varieties of clinical presentations. These agents can be available for anytime–anywhere training via computer.

As mentioned in the section on training, DoD and VA are funding a few studies to assess the use of virtual reality for training (see also Appendix E ). Such prototype systems, designed for interacting with highly realistic and natural-language-capable virtual patients, do not yet have an evidence base for their effectiveness for training. However, if found to be effective, virtual patient technology could have a considerable impact by supplementing existing in-person training approaches.

Executive Order 13625 and The National Research Action Plan for Improving Access to Mental Health Services for Veterans, Service Members, and Military Families established PTSD as a high national research priority. The committee found the ongoing PTSD research portfolios of DoD and VA to be broad, diverse, and complementary. Over the last few decades, the departments have spent hundreds of millions of dollars on PTSD research. Much of DoD’s currently funded PTSD research centers on treatment, basic science, and prevention. VA’s PTSD research portfolio focuses on treatment, barriers, and basic science. Those research priorities reflect the mental health needs of the service member and veteran populations that each department serves and are reflected in the types and numbers of studies that are funded (see Table 9-2 ). In DoD, PTSD research represents approximately 60% of the mental health research portfolio (Miller, 2014). VA funding for PTSD has been stagnant over the past 5 years (Gleason, 2012), despite the growing prevalence of PTSD in veterans seeking care in VA.

The committee identified areas of research that are critical to improving PTSD management for service members and veterans—basic research, use of technology, PTSD treatment, and overcoming system-level barriers. Much work is being accomplished in basic research, but the scientific community still lacks an understanding of the biological mechanisms that lead to PTSD, factors that may prevent or promote its development, and biomarkers that could improve PTSD prevention, diagnosis, and treatment.

PTSD researchers are trying to identify more and better treatments, such as psychotherapies, pharmacotherapies, combinations of therapies,

and complementary and alternative therapies. Identifying treatments for PTSD and any comorbidities is particularly important, considering the high prevalence of mental health disorders, such as depression and substance use disorder, and physical ailments, such as TBI and chronic pain, in many service members and veterans who have PTSD. Such comorbidities as cardiovascular disease, are likely to increase as the veteran population ages.

The use of technology to improve the management and treatment of PTSD has potential to improve treatment options, clinical practice, and real-time contact with service members and veterans. Technology is also expanding the use of system-wide approaches to better capture and monitor patient treatments and outcomes in a systematic and continuous manner, but questions remain as to whether such technological enhancements will achieve improved treatment delivery and outcomes.

Given the current and growing number of service members and veterans who have PTSD symptoms and the availability of effective treatments for PTSD, a topic of research that is often overlooked but would be beneficial in the short term is methods to overcome barriers that prevent the widespread use of effective treatments in DoD and VA health care systems. This may include research on health services, effective models for PTSD management, the establishment of evidence-based practice competencies, provider training, and the effective implementation and dissemination of evidence-based care. The committee encourages research on all those subjects and new efforts to be undertaken.

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Posttraumatic stress disorder (PTSD) is one of the signature injuries of the U.S. conflicts in Afghanistan and Iraq, but it affects veterans of all eras. It is estimated that 7-20% of service members and veterans who served in Operation Enduring Freedom and Operation Iraqi Freedom may have the disorder. PTSD is characterized by a combination of mental health symptoms - re-experiencing of a traumatic event, avoidance of trauma-associated stimuli, adverse alterations in thoughts and mood, and hyperarousal - that last at least 1 month and impair functioning. PTSD can be lifelong and pervade all aspects of a service member's or veteran's life, including mental and physical health, family and social relationships, and employment. It is often concurrent with other health problems, such as depression, traumatic brain injury, chronic pain, substance abuse disorder, and intimate partner violence.

The Department of Defense (DoD) and the Department of Veterans Affairs (VA) provide a spectrum of programs and services to screen for, diagnose, treat for, and rehabilitate service members and veterans who have or are at risk for PTSD. The 2010 National Defense Authorization Act asked the Institute of Medicine to assess those PTSD programs and services in two phases. The Phase 1 study, Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment , focused on data gathering. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations Final Assessment is the report of the second phase of the study. This report analyzes the data received in Phase 1 specifically to determine the rates of success for each program or method.

Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations Final Assessment considers what a successful PTSD management system is and whether and how such a system is being implemented by DoD and VA. This includes an assessment of what care is given and to whom, how effectiveness is measured, what types of mental health care providers are available, what influences whether a service member or veteran seeks care, and what are the costs associated with that care. This report focuses on the opportunities and challenges that DoD and VA face in developing, implementing, and evaluating services and programs in the context of achieving a high-performing system to care for service members and veterans who have PTSD. The report also identifies where gaps or new emphases might be addressed to improve prevention of, screening for, diagnosis of, and treatment and rehabilitation for the disorder. The findings and recommendations of Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment will encourage DoD and VA to increase their efforts in moving toward a high-performing, comprehensive, integrated PTSD management strategy that addresses the needs of current and future service members, veterans, and their families.

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Get 10% off with 24start discount code, i. reactions to traumatic events, a. acute reactions, b. posttraumatic stress disorder, c. course of ptsd, ii. measures of ptsd, a. interviews, b. self-report measures, iii. prevalence of ptsd, iv. vulnerability and resiliency factors in ptsd, v. concomitant problems following trauma, vi. theories on the development and maintenance of ptsd, a. psychoanalytic theories, b. cognitive and behavioral theories, c. psychobiological approaches, vii. psychological and pharmacological interventions in ptsd, a. early interventions, b. cognitive-behavioral therapies, 1. prolonged exposure (pe), 2. stress inoculation training (sit), 3. cognitive therapy, 4. cognitive processing therapy (cpt), 5. eye movement desensitization and reprocessing (emdr), c. pharmacotherapy, d. hypnotherapy and psychodynamic psychotherapy.

VIII. Bibliography

Psychologists and physicians have long been interested in vulnerability and resilience factors in reaction to extreme stress. Earlier accounts of posttrauma reactions focused on descriptions of cases. Spurred by inclusion of Post-traumatic Stress Disorder (PTSD) in the psychiatric diagnosis nomenclature in 1980, experimental research has examined many facets of the phenomenon.

In the Diagnostic and Statistical Manual (DSM-IV) published by the American Psychiatric Association in 1994, a trauma is defined as an experienced or witnessed event that involves threat of death or serious injury, and which evokes feelings of terror, horror, or helplessness. Thus, events such as anticipated death of a loved one, job loss, or divorce would not qualify as a trauma in this formulation. The International Classification of Diseases (ICD-10), published by the World Health Organization in 1992, describes a traumatic event as having an exceptionally threatening or catastrophic nature, which would be likely to cause pervasive distress in almost anyone.

The most common traumas studied are combat, sexual assault, sexual abuse in childhood, criminal victimization, torture, accidents, and natural disasters. Larger-scale traumas, such as mass migration, refugee camp experiences, and holocausts, have not yet been thoroughly researched. Clearly, such mass traumas would be expected to have considerable impact on those individuals directly affected as well as on their children, communities, and cultures.

A number of physical and psychological symptoms are considered common reactions immediately after a traumatic experience. Many trauma victims report being disoriented and anxious after a trauma and have difficulty sleeping and concentrating. Victims are often reluctant to talk about the trauma or deliberately contemplate it; nevertheless the traumatic memory intrudes on their thoughts quite frequently. In recognition of the severe distress and psychological dysfunction that often occur immediately after a trauma, a new diagnostic classification called Acute Stress Disorder (ASD) was adopted in the DSM-IV in 1994. The focus of this disorder is on dissociative features, and, consequently, the symptom criteria include at least three of the following: a sense of numbing, detachment, or lack of emotional responsiveness, a reduction in awareness of surroundings (e.g., being in a daze), derealization, depersonalization, and dissociative amnesia. Reexperiencing of the trauma, avoidance, and arousal, as defined in the criteria for PTSD, must also exist. A diagnosis of Acute Stress Disorder is warranted when such symptoms last between 2 days and 1 month, occur within 1 month of the trauma, and interfere significantly with daily functioning.

Posttraumatic Stress Disorder, as described in DSM-IV, is a set of symptoms that begins after a trauma and persists for at least 1 month. The symptoms fall into three clusters. First, the individual must reexperience the trauma in one of the following ways: nightmares, flashbacks, or intrusive and distressing thoughts about the event; or intense emotional distress or physiological reactivity when reminded of the event. Second, the individual must have three of the following avoidance symptoms: avoidance of thoughts or feelings related to the trauma, avoidance of trauma reminders, psychogenic amnesia, emotional numbing, detachment or estrangement from others, decreased interest in leisure activities, or a sense of foreshortened future. Third, the individual must experience two of the following arousal symptoms: difficulty falling or staying asleep, difficulty concentrating, irritability or outbursts of anger, hypervigilance, or an exaggerated startle response. To meet diagnostic criteria for PTSD, the symptoms must cause significant impairment in daily functioning. These criteria provide a good operational definition of PTSD, as they describe the symptoms seen in most cases. However, the three categories of symptoms are not empirically validated as distinct symptom clusters. For instance, it is not clear that the symptoms of behavioral avoidance and emotional numbing are similar and belong in the same category.

The ICD-IO criteria for PTSD also include some reexperiencing symptoms (nightmares, flashbacks, distress on exposure to reminders), actual or preferred avoidance of trauma reminders, and either an inability to recall important aspects of the trauma or sustained psychological sensitivity and arousal (sleep disturbance, hypervigilance, difficulty concentrating). These three criteria must all be met within 6 months of the traumatic event for a diagnosis to be given.

Several differences between the two definitions can be identified. First, the DSM-IV specifies a minimal number of symptoms that need to be observed to receive the diagnosis, whereas the ICD-IO leaves more freedom for clinical judgment. The advantage of the former approach is its utility in clearly operationalizing the concept of PTSD. The disadvantage is its rigidity and the possibility that one symptom can determine diagnostic membership. Second, the ICD-IO does not recognize the numbing symptoms, which together with flashbacks and nightmares are thought to be cardinal features of PTSD. Third, arousal symptoms are optional in the ICD-IO but are required in the DSM-IE Clinical observation and theoretical accounts of PTSD support the importance of these symptoms and render the ICD-IO diagnostic criteria less satisfactory.

The course of PTSD is variable. For the majority of individuals, symptoms begin immediately after the trauma, although some appear to have a delayed reaction. During the first 3 months after the trauma, the individual is said to have acute PTSD, whereas chronic PTSD is defined as symptoms persisting beyond 3 months. Symptoms can fluctuate over time between diagnosis of PTSD, subthreshold symptoms, and few or no symptoms. Recovery is affected by a number of factors, including perception of oneself and one’s surroundings, actual social support, life stress, coping style, and personality.

A number of measures have been developed to assess PTSD, including clinical interviews and self-report instruments. These measures vary widely in terms of the target symptoms, administration time, and the samples used for ascertaining psychometric properties. Adult assessment tools are reviewed in the next section. Although some measures have also been developed for children, they are outside the scope of this paper.

The Structured Clinical Interview for DSM (SCID) is believed to be the most widely used diagnostic interview. Its major disadvantage, however, is that it does not provide a measure of symptom severity. Several other interviews that provide information of both diagnostic status and symptom severity are available. Two interviews are becoming quite widely used in PTSD research. The first is the Clinician-Administered PTSD Scale (CAPS) that yields separate scores for frequency and intensity for each symptom. Disadvantages of this interview include a long administration time and validation on military veterans only. The second interview, the PTSD Symptom Scale Interview (PSS-I), includes a combined frequency/severity rating for each of the 17 PTSD symptoms in the DSM-IV and thus yields both a diagnosis and a continuous severity rating. Unlike the CAPS, the PSS-I takes only about 15 to 20 minutes to administer and was validated on female assault victims.

Several self-report scales have been developed to assess symptoms of PTSD. The first was the Revised Impact of Events Scale (RIES), which yields two factors: intrusion and avoidance. A revised version of the RIES added hyperarousal items, but has shown mixed results in reliability studies and, like its predecessor, does not correspond fully to the DSM-IV PTSD symptoms. Two scales, the Mississippi Scale and the Penn Inventory, have excellent psychometric properties in veteran samples but do not provide information about diagnostic status because they do not fully correspond to the DSM-IV defining symptoms.

The PTSD Symptom Scale-Self-Report (PSS-SR) and its successor, the PTSD Diagnostic Scale (PDS), provide information about each of the 17 DSM-IV symptoms, yielding both diagnostic and severity information. The PDS is the only self-report instrument that assesses all DSM-IV criteria, including information about the nature of the traumatic event and the level of functional interference, in addition to information about PTSD diagnosis and symptom severity. It was validated in a sample of victims of a wide range of traumas and evidenced sound psychometric properties, and thus can be used in studies of various trauma populations.

Lifetime prevalence of PTSD in the general population is estimated at 9%, with up to a third of these cases having chronic PTSD. Among trauma victims, the rate is much higher, estimated at 24 %. However, the rates of PTSD tend to vary considerably among different types of trauma. For instance, estimates of the lifetime prevalence of PTSD in Vietnam War veterans range from 27 to 65%; in civilian populations exposed to terrorism and torture, prevalence ranges from 33 to 54%. Between 35% and 94% of victims of violent assaults manifest PTSD. In contrast, accidents and natural disasters appear to produce lower rates of PTSD, 4.6 to 59%, depending on the event studied and the degree of exposure. Even individuals with little or no direct exposure to the trauma can develop PTSD; this phenomenon has been referred to as the “ripples outward” effect. Importantly, certain occupations are at risk for PTSD by virtue of increased probability of repeated direct exposure to trauma; between 9% and 26% of professionals such as police, nurses, and firefighters develop PTSD in reaction to stressors experienced on the job.

Prevalence in certain vulnerable populations is much higher than in the general population, presumably because individuals in these groups have been exposed to more traumatic experiences. These include populations seeking outpatient psychotherapy and those in substance abuse clinics. Women appear to be somewhat more likely than men to develop PTSD after trauma, 10.4 % versus 5 %, respectively. As noted earlier, the prevalence of emotional difficulties after mass traumas, such as refugee camp experiences or holocausts, has not been systematically studied.

Factors implicated in posttrauma reactions can be divided into three categories: pretrauma variables, variables related to the trauma itself, and posttrauma variables.

Research on pretrauma demographic variables has not identified reliable predictors of who will develop chronic PTSD with one exception: women are somewhat more likely to manifest PTSD than men after experiencing a similar trauma. In contrast, it appears that poor psychological and social functioning prior to the trauma renders the individual vulnerable to developing chronic symptoms. For instance, prior hospitalization and a history of drug abuse were found to be associated with a more severe posttrauma reaction. Also, a history of traumatic events in childhood or adulthood predicts a more severe response to a new trauma.

The nature of the trauma itself also appears to affect recovery. First, traumas differ in their likelihood of producing PTSD; rape, for example, is more likely to produce persistent symptoms than a natural disaster. Second, given a specific trauma (e.g., rape), injury and perceived threat of death produce more severe and persistent reactions.

Several posttrauma factors have been found to exacerbate symptoms. It appears that dissociation (emotional numbing, amnesia, depersonalization) shortly after a trauma hinders recovery. Also, on average, assault victims who exhibit more severe initial reactions to the trauma also show more symptoms later on. Thus, individuals seem to differ in how strongly they are affected by a similar trauma, and their initial reaction is associated with later psychopathology.

Evidence on the role of social support as facilitating or hindering recovery is equivocal. It seems that negative reactions from others, such as blame, increase posttrauma psychopathology, but, unfortunately, positive reactions do not show the expected positive effects. Excessive anger or guilt after the trauma also appears to block readjustment. Additional longitudinal research on the factors that promote resilience to trauma are clearly needed.

Traumatized individuals not only exhibit ASD or PTSD symptoms, but also depression, substance abuse, anxiety, dissociation, and physical health problems.

The rate of use and abuse of drugs and alcohol, including nicotine, in traumatized individuals is higher than in the general population. There are at least two explanations for this finding. First, traumatized individuals may choose to cope with their symptoms by increasing substance use. Second, substance abuse may increase the risk of being exposed to a traumatic experience.

Many individuals report symptoms of depression after a traumatic event, such as sadness, lack of energy, diminished interest in leisure activities, hopelessness, sleeplessness, and eating disturbances. Although some of these symptoms overlap with the defining symptoms of PTSD (e.g., markedly diminished interest in activities), the two disorders are separate entities and both can develop independently as a response to a traumatic experience.

The incidence of comorbid anxiety disorders is also elevated among individuals with PTSD. For example, lifetime comorbidity of panic disorder in Vietnam veterans with PTSD was 21% in females and 8% in males, versus 1.5 to 3.5% in the general population. The lifetime prevalence of obsessive-compulsive disorder was found to be 13% in females and 10% in males, as compared with 2.5 % in the general population.

There is a greater frequency of physical health problems among trauma victims than in the general population, especially among those who develop chronic PTSD. Trauma victims have higher rates of gastrointestinal disorders and pelvic or abdominal pain, and visit the doctor more often than the general population. In the aftermath of rape and child sexual abuse, gynecological and psychosexual problems such as vaginal discharge, dysmennorhea, dyspareunia, vaginismus, and pelvic pain have also been noted.

Reactions to trauma have long captured the interest of theorists of psychopathology. Janet’s 1889 theory of reactions to trauma has influenced both early and contemporary conceptualizations. Janet proposed that when confronted with a traumatic event that besieges the victim with an overabundance of intense thoughts and feelings, too numerous or intense to integrate, some individuals selectively attend away from the trauma to trauma-irrelevant thoughts and feelings. Thus, ideas related to the trauma remain split off or dissociated from normal consciousness and become “fixed.” Although out of consciousness, these “fixed ideas” remain part of the victim’s ideational content, and therefore continue to exert influence over his or her thought, mood, and behavior in the form of fragmented reliving of the trauma such as visual images, somatic states, emotional conditions, or behavioral reenactment.

Freud wrestled with understanding the influence of traumatic experiences on the individual’s psyche. In early writings, he was influenced by Janet’s theory on the strength of the emotional reactions that are produced by a traumatic experience and that force the victim to become fixated on the trauma. Later, Freud abandoned the dissociation view and proposed that the persistence of trauma reactions reflects an association between the traumatic event and childhood repressed conflicts, ideas, or impulses, and the efforts to prevent conscious awareness of them. He also coined the concept of “repetition compulsion” to explain trauma reexperiencing, proposing that because of the need to keep it away from consciousness, the individual is forced to repeat aspects of the trauma as a contemporary experience rather than as a memory of it. Influenced by World War I experiences, Freud refocused on the external reality, and, in the spirit of Janet, viewed the emotional upheaval generated by the trauma as the source of traumatic neurosis. He suggested that the intensity of the trauma, the inability to find conscious expressions for it, and the unpreparedness of the individual cause a breach to the stimulus barrier and overwhelm the defense mechanisms. More recent theorists have proposed that the developmental level and ego resources available to the victim are central to the manner in which the trauma is experienced and to the production of symptoms. For instance, a young child, easily overwhelmed and flooded with emotion, may experience complete helplessness in the face of trauma, whereas a mature adult would be more likely to respond through emotional numbing and cognitive constriction. Psychoanalytic theorists and practitioners focus on the need to help the victim acknowledge and bear the trauma and the resulting psychic damage, and develop coping mechanisms such that the memories of the trauma are incorporated into his or her current experience.

Several schools of thought inspired cognitive-behavioral theories of PTSD. The first is learning theory, which explains PTSD symptoms in terms of instrumental and classical conditioning. The learning model that most directly influenced cognitive-behavioral treatments (CBT) aimed at anxiety reduction was Mowrer’s two-factor theory. First, Mowrer proposed that fear is acquired through classical conditioning, where a neutral stimulus comes to evoke fear through its pairing with an aversive stimulus. Applying this theory to explain PTSD symptoms, neutral stimuli (e.g., supermarket) that were present during the trauma are presumed to acquire the ability to elicit fear through their associations with the danger stimuli (e.g., gun). Through the processes of generalization and second-order conditioning, stimuli similar to those present during the trauma also come to evoke fear. For instance, the stimuli all men, being alone, and the word rape can all acquire the capacity to cause anxiety. In Mowrer’s second stage, avoidance behavior is established through the process of operant conditioning. That is, an individual learns to reduce trauma-related anxiety through avoidance of, or escape from, the feared stimuli. Escape and avoidance behaviors are negatively reinforced because avoidance diminishes the aversive fear state.

Cognitive-behavioral therapy of PTSD has also been influenced by cognitive theory. Cognitive theory assumes that the interpretation of events, rather than events themselves, underlies emotional reactions. Accordingly, an event can be interpreted in different ways and consequently can evoke different emotions. Aaron Beck and colleagues suggest that trauma victims who manifest chronic persistent anxiety are unable to discriminate between safe and unsafe signals, and consequently their thinking is dominated by the perception of danger. They also suggest that traumatic fear can be maintained through a sense of incompetence to handle stressful events.

Other cognitive theorists have postulated that cognitive schemas are disrupted after victimization. A schema is a meaning structure that guides the perception, organization, and interpretation of incoming information. Common to these theories is the supposition that a traumatic experience requires cognitive modification and that such modification is accomplished by assimilation and accommodation. Accordingly, the victim must either assimilate the traumatic experience into preexisting schemas, or, more often, change schemas to accommodate the traumatic experience. In her 1992 book, Janoff-Bulman took the position that people in general hold the assumptions: “the world is benevolent, the world is meaningful, and self is worthy,” and these assumptions are incompatible with a traumatic experience. Building on Janoff-Bulman’s ideas, other theorists suggest that the following areas are of particular relevance: safety, dependency/trust of self and others, power, esteem, intimacy, and independence.

Coming from the psychoanalytic tradition, Horowitz integrated psychoanalytical and information processing notions in his 1986 book, suggesting that people have a basic need to match trauma-related information with their “inner models based on old information.” The process of recovery entails the repeated revision of both trauma-related information and the inner models until they agree, which Horowitz referred to as the “completion tendency.”

Foa and Kozak integrated cognitive and learning theories to explain the development and maintenance of pathological anxiety in what they called emotional processing theory. In their 1986 paper, fear is conceived as a cognitive structure or a program for escaping danger which includes representations of fear stimuli, fear responses, and their meaning. Pathological fear, they suggested, is distinguished from normal fear in that it includes erroneous associations and evaluations. Emotional processing theory views anxiety disorders as representing distinctive fear structures in memory, and the persistence of anxiety symptoms is conceived as reflecting impairment in emotional processing. Accordingly, PTSD is construed as reflecting a fear memory that contains erroneous associations and evaluations, whereas a normal trauma memory reflects associations and evaluations that better match reality. First, a pathological PTSD structure contains excessive response representations that are reflected in the PTSD symptoms. Second, this structure includes erroneous stimulus-stimulus associations that do not accurately represent the world. For example, the pathological fear structure of a woman who was raped at gunpoint by a bald man would contain an association between “bald men” and “gun.” In reality, however, bald men are not more likely to carry guns or to rape than men with a full head of hair. Third, the structure also includes erroneous associations between harmless stimuli such as “bald,” “home, …. suburbs,” and the meaning of “dangerous.” Being raped one time while at home in the suburbs does not tangibly increase the chance of encountering violence in that environment. Fourth, the structure includes erroneous associations between harmless stimuli and escape or avoidance responses. For example, the victim who was raped by the bald man would tend to run away from such men. In reality, however, running away from “bald men” is not likely to enhance safety. These erroneous associations would lead to mistakenly interpreting the world as entirely dangerous.

Another set of erroneous associations and evaluations is the interpretation of the victim’s response representations. It is thought that the victim’s responses during and after the trauma, and in particular the PTSD symptoms, are interpreted to mean self-incompetence. In summary, emotional processing theory hypothesizes that two major pathological concepts underlie PTSD: the world as entirely dangerous, and the self as entirely inept.

Psychophysiological, neurohormonal, neuroanatomical, and immunological changes have been observed in animals exposed to extreme stress and in trauma victims who developed PTSD (van der Kolk, McFarlane, & Weisaeth, 1996). These changes have been hypothesized to disregulate responses to incoming information and to inhibit successful processing of traumatic memories.

The normal stress response upon exposure to a high-magnitude stressor is a complex neurohormonal response, including the release of catecholamines (e.g., epinephrine and norepinephrine), serotonin, endogenous opioids, and hormones of the hypothalamus, pituitary, or adrenal gland (e.g., cortisol, vasopressin, oxytocin). Normally, the introduction of a stressor produces intense and rapid stress responses, and these dissipate quickly after the removal of the stressor. However, after prolonged exposure to stress, the stress responses become disregulated.

Theorists propose that PTSD reflects a failure to regulate autonomic reactions to stimuli such that the individual either experiences hyperreactivity or “shutting down” and emotional numbing. Individuals with PTSD show hyperreactivity, as measured by heart rate, skin conductance, and blood pressure, in reaction to reminders of traumatic events. This disregulation of the emotional and physiological responsiveness occurs with specific reminders of the trauma as well as in reaction to intense but neutral stimuli, signifying a loss of stimulus discrimination. In addition, the individual may come to fear his or her emotional reactions because of being able to do little to control them.

Neurohormonal changes in individuals with PTSD have also been found. First, prolonged stress causes depletion of the noradrenergic system, such that receptors become hypersensitive to any new release of norepinephrine. This noradrenergic hyperreactivity is linked to the increased arousal and startle of PTSD. The high levels of norepinephrine are proposed to inhibit the release of corticotrophin-releasing hormone and thereby inhibit the entire hypothalamic-pituitaryadrenocortical axis. This inhibition, in turn, produces a deficiency in endogenous opioids. Some theories postulate that the reexperiencing symptoms of PTSD cause a burst in the release of endogenous opioids and therefore make up for this deficiency. These endogenous opioids are thought to produce an artificial numbing or calmness, another hallmark of PTSD. Additional theories propose that cortisol responses are lowered in retraumatized individuals and that serotonin levels may decrease in response to prolonged inescapable stress.

In addition to psychophysiological and neurohormonal factors, specific brain abnormalities have recently been detected in individuals with PTSD. One system that is implicated in the disorder is the limbic system, which is thought to function in memory and in emotional reactions to incoming stimuli. One area in the limbic system, the hippocampus, is presumed to record spatial and temporal aspects of experiences in memory. Researchers have noted decreased hippocampal volume in trauma victims with PTSD compared with those without PTSD. One possible explanation for this finding is that individuals with smaller hippocampuses are more likely to develop PTSD; a more likely interpretation of these results is that increased cortisol activity causes shrinkage, because cortisol is toxic to the hippocampus.

A second area in the limbic system, the amygdala, also appears to be altered in individuals with PTSD. The amygdala is thought to assign meaning to incoming stimulation by integrating memory images with emotional experiences associated with those memories, guiding emotional behavior. A single intense stimulation of the amygdala appears to alter the limbic physiology such that a “kindling” effect occurs. That is, the behavior that follows may be predominantly either “fight” or “flight,” and a pattern of conditioned behavior is set up such that there is limited processing of incoming information before the response is initiated.

Several psychological interventions have been used with trauma victims, including supportive counseling individually or in groups, brief dynamic psychotherapy, hypnotherapy, pharmacotherapy, and cognitivebehavioral therapy. As recently reviewed by Foa and Meadows, although a variety of psychological interventions are used routinely with trauma victims, controlled outcome studies have tended to focus on cognitive-behavioral treatments such as systematic desensitization, exposure, and anxiety management. Nevertheless, hypnotherapy and psychodynamic therapy have also shown promise in the few studies examining their efficacy.

The popular supposition among trauma theories is that for recovery to occur after a traumatic experience, special processing efforts should take place. This view has prompted the development of early intervention programs. These programs have focused on education, debriefing after trauma, and training professionals at risk (e.g., police). Usually, “critical incident stress debriefing” is conducted in groups, such as emergency workers, and focuses on education about common reactions to traumatic experiences, encouraging trauma victims to process their experiences in a group setting. Although such programs have become routine in many places, little is known about their efficacy. In fact, some experts have raised concerns that such programs could interfere with rather than facilitate the natural recovery process.

The recognition that victims who exhibit severe reactions immediately after the trauma are more likely to develop chronic dysfunction has prompted researchers to implement interventions that aim to prevent chronic PTSD. Foa and colleagues conducted a study to compare PTSD severity of female assault victims, who received a brief prevention program (four individual therapy sessions), to that of victims who underwent an assessment procedure. Victims who received the brief prevention program had less severe PTSD and depressive symptoms 2 months after the assault. Clearly, more studies of this type are needed before confidence in prevention efforts can be established.

Currently, five cognitive-behavioral interventions are in use for PTSD: Prolonged Exposure, cognitive therapy, Stress Inoculation Training, Cognitive Processing Therapy, and Eye Movement Desensitization and Reprocessing.

This is a set of procedures that involves confrontation with feared stimuli, either in vivo or in imagination. With PTSD, exposure therapy typically includes repeated reliving of the traumatic event in imagination and actual confrontation with feared situations and objects that have been avoided because they are reminders of the trauma but are not intrinsically dangerous.

As discussed earlier, the theoretical basis of PE lies in learning and emotional-processing theories. Foa and Kozak have proposed that successful therapy involves correcting the pathological elements of the fear structure, and that this corrective process is the essence of emotional processing. They further suggest that regardless of the type of therapeutic intervention used, two conditions are required for fear reduction. First, the fear structure must be activated through introduction of fear-relevant information. If the fear structure is not activated (fear is not evoked), the structure would not be available for modification. Second, during exposure, information that is incompatible with the existing pathological elements (e.g., fear reduction) must be provided so that the pathological fear structure can be corrected. Specifically, exposure researchers hypothesize that repeated reliving promotes several cognitive changes. First, it promotes habituation of anxiety associated with the trauma memory, and this habituation disconfirms the victim’s erroneous belief that anxiety will stay forever and therefore lead to disastrous consequences. Second, reliving promotes discrimination between “remembering” the trauma and “encountering” it again, thus reinforcing the realization that remembering itself is not dangerous. Third, repeated exposure promotes differentiation between the trauma and similar but safe situations, disconfirming the idea that the world is extremely dangerous. Fourth, it promotes the association between PTSD symptoms and a sense of mastery, rather than incompetence. Finally, repeated recounting of the trauma narrative helps to organize the narrative and thereby to facilitate the integration of the trauma memory.

Several controlled studies on exposure have shown their usefulness in treating PTSD. Whereas studies on veterans showed only modest improvement, two studies with female rape victims showed more improvement. Foa and colleagues found that exposure (imaginal and in vivo) was effective in eliminating PTSD in 55% of rape victims with chronic PTSD compared with 45% of those who received supportive counseling. Superior results were found in a second study: about 70% of victims who received Prolonged Exposure lost their PTSD diagnosis, and none of the women in a wait-list group lost their diagnosis. These treatment effects were maintained at 6-month follow-up.

This intervention consists of training victims to handle anxiety with several skills for anxiety management: relaxation, thought stopping, assertiveness, cognitive therapy, coping self-statements, and guided imagery. Although the direct goal of anxiety management techniques is to teach patients techniques to manage their anxiety, the successful acquisition of such techniques can have indirect effects on the victim’s schemas of self and the world. Specifically, the victim’s experience of being able to control the anxiety fosters a more positive self-image and thereby modifies the perception of the world as overwhelmingly dangerous. Several studies point to the efficacy of this program used alone or in combination with other techniques. For example, the two studies on rape victims reported earlier found that SIT significantly reduced PTSD, to a degree comparable to that of exposure.

Researchers believed that if PE and SIT are quite, but not completely, successful in ameliorating PTSD symptoms, a program that combined these two treatments would yield superior results. However, research does not support this view: combined programs were helpful for female assault victims, but not more than exposure or stress inoculation alone.

Cognitive techniques are often incorporated into anxiety management programs that teach patients to examine and change systematically maladaptive thoughts that can lead to negative responses. Cognitive therapy involves the use of discourse, in which the patient is taught to identify the beliefs underlying the fear, to examine whether they are distorted or accurately reflect reality, and to replace mistaken or dysfunctional beliefs with more realistic, functional ideas about the ability of the patient to cope with stress and the dangerousness of the world. One possible benefit of cognitive restructuring is that it addresses directly beliefs underlying emotions other than fear, such as anger and guilt. Early investigations of this technique revealed some promise in the use of this therapy to reduce symptoms of PTSD in rape victims.

Another cognitive-behavioral program called Cognitive Processing Therapy is described in Resick and Schnicke’s 1992 book. It involves cognitive restructuring and exposure through writing about the trauma. The cognitive therapy is geared toward correcting maladaptive cognitions associated with rape, such as power, safety, and esteem. In one study, on the average, victims who received CPT reported 40% symptom reduction, and these gains were maintained over time. More studies are needed to establish the efficacy of this relatively new treatment.

This therapy, described by Shapiro in 1995, is a form of exposure with a cognitive emphasis, accompanied by guided eye movements. The studies that have evaluated the efficacy of this treatment produced equivocal results. Some show good results, but others show no improvement. Because these studies have many methodological problems, it is difficult to determine the validity of the findings. Further well-controlled studies are needed before a definite conclusion about the value of EMDR can be made.

Many medications have been used for the treatment of PTSD, but only a few have been systematically studied. Most of these have used male combat veterans, and thus the efficacy of pharmacotherapy for other traumatized populations is largely unknown. Tricyclic antidepressants have been used in an attempt to reduce locus coeruleus overactivity and noradrenergic disregulation found in PTSD, with equivocal results. Amitriptyline and imipramine have shown modest reductions in PTSD symptoms in comparison with placebo in double-blind studies with male veterans. In contrast, desipramine failed to show efficacy. One study of fluoxetine, a selective serotonin reuptake inhibitor used to regulate serotonergic dysfunction in individuals with PTSD, found it to be effective in reducing symptoms of PTSD, especially in trauma victims other than Vietnam veterans.

Other medications that have been tested include anticonvulsants such as carbamazepine and valproic acid; but no double-blind studies have been conducted to date. Beta-adrenergic blockers such as propanolol have shown promise in reducing aggressivity and arousal symptoms in open studies, and alpha2-adrenergic agonists, such as clonidine, appear to be effective through their suppression of locus coeruleus activity.

Finally, benzodiazepines have been widely used to suppress anxiety and are believed to reduce PTSD symptoms by reducing limbic system kindling and reversing neurochemical changes in the locus coeruleus and hypothalamus. However, the rebound anxiety and withdrawal symptoms associated with benzodiazepines can be problematic.

In summary, most of our knowledge about efficacy of pharmacotherapy for PTSD is confounded by the restricted samples used in existing studies. Most were conducted on Vietnam veterans, whose symptoms are particularly resistant to all types of treatments, and therefore the present results may underestimate the efficacy of this treatment.

Hypnotherapy uses heightened concentration and focused attention to facilitate treatment related to trauma. It is based on the supposition that individuals with PTSD are unknowingly entering trance states when they reexperience the trauma and that hypnotherapy can help them learn how to control their trance states and digest the dissociated traumatic experience in a controlled manner. One study found hypnosis to be as effective as psychodynamic psychotherapy and a type of exposure called systematic desensitization. More studies of this technique are needed before conclusions can be drawn about the usefulness of hypnotherapy.

Psychodynamic psychotherapy has also been used to help individuals recover from trauma. It focuses on intrapsychic conflict about the trauma rather than on resolution of specific symptoms of PTSD. The methods used are in some respects similar to those used in cognitive-behavioral therapy, as these interventions focus on helping the victims process the traumatic experience and on teaching them how to tolerate anxiety. Both individual and group therapies have been used, and some preliminary studies suggest the utility of these interventions.

Bibliography:

• American Psychiatric Association. (1994). Diagnostic and statistical manual (4th ed.). Washington, DC: American Psychiatric Press.
• Davidson, J. R. T., & Foa, E. B. (Eds.). (1993). Post-traumatic stress disorder: DSM-IV and beyond. Washington, DC: American Psychiatric Press.
• Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99, 20-35.
• Foa, E. B., & Meadows, E. A. (1997). Psychosocial treatments for post-traumatic stress disorder: A critical review. In J. Spence (Ed.), Annual review of psychology. Palo Alto, CA: Annual Reviews, Inc.
• Foa, E. B., & Riggs, D. S. (1993). Post-traumatic stress disorder in rape victims. In J. Oldham, M. B. Riba, & A. Tasman (Eds.), American psychiatric press review of psychiatry (Vol. 12, pp. 273-303). Washington, DC: American Psychiatric Press.
• Horowitz, M. J. (1986). Stress response syndromes (2nd edition). Northvale, NJ: Jason Aronson, Inc.
• Janet, P. (1889). L’Automatisme psychologique. Paris: Felix Alcan. (Reprinted 1973, Paris, Societe Pierre Janet.)
• Janoff-Bulman, R. (1992). Shattered assumptions: Towards a new psychology of trauma. New York: Free Press.
• Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Post-traumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048-1060.
• Resick, P. A., & Schnicke, M. K. (1992). Cognitive processing therapy for sexual assault survivors: A treatment manual. Newbury Park, CA: Sage.
• Shapiro, F. (1995). Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures. New York: Guilford Press.
• van der Kolk, B. A., McFarlane, A. C., & Weisaeth, L. (Eds.). (1996). Traumatic stress: The effect of overwhelming experience on mind, body, and society. New York: Guilford Press.
• World Health Organization. (1993). ICD- I O: The ICD- IO classification of mental and behavioural disorders: Diagnostic criteria for research. Geneva, Switzerland: Author.

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117 PTSD Research Topics & Essay Examples

📝 ptsd research papers examples, 👍 good ptsd essay topics to write about, 🏆 best ptsd essay titles, 🎓 simple research topics about ptsd, ❓ ptsd research questions.

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The 12 Best Research Paper Topics On The Post Traumatic Stress Disorder

Post-traumatic stress disorder is a disorder that effects millions of people around the world. Often, it develops following a traumatic experience or an event. War veterans, domestic abuse victims and other individuals typically have to deal with the last effects of this disorder for years after the onset of PTSD. In schools, many English classes and psychology papers will require papers on this topic. Rather than writing a basic essay about the topic, students can use the following research paper ideas for a more interesting paper.

• Post-Traumatic Stress Disorder and Veterans

One of the most common topics relates to how veterans deal with PTSD. An estimated one out of five soldiers that go on a combat tour end up returning with symptoms.

• The Connotations of Having Post-Traumatic Stress Disorder

How is PTSD perceived by the media and society? Is it accurately portrayed in movies and television shows?

• Shell Shock and PTSD

How has the scientific understanding of PTSD changed over time? How were soldiers treated for shell shock in previous wars?

• The Hidden Sufferers

People often focus on soldiers and PTSD, but many other people develop it. How do abuse victims and domestic violence survivors deal with PTSD? Are they treated with similar techniques as soldiers?

• An Overview

For a basic research paper on post-traumatic stress disorder, students can write about the basic symptoms and treatments for the disorder.

• Changing Treatments

How have treatments for PTSD changed over the last century? How has the medical understanding of this illness gradually shifted?

• Freud and PTSD

What was Sigmund Freud's view of PTSD? Is it still relevant today?

• The Immune System

Are post-traumatic stress disorder sufferers more likely to experience illness? How does having PTSD effect the immune system? What is the current state of research on this question?

• Gender and PTSD

Do men and women experience PTSD differently? Could a gender difference in the experience of having PTSD be related to the different reasons why each gender may develop PTSD? Are there other reasons to justify a gender-based difference existing?

What are the psychological tests used to identify PTSD? Are these tests always accurate? What are the symptoms of PTSD?

What major novels and literary works include individuals who have PTSD? How is this disorder portrayed in literature?

• Get Personal

For an English essay, students can write about their personal experience with post-traumatic stress disorder. They can discuss how this disorder affected the lives of their family and friends.

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A Public Health Perspective of Post-Traumatic Stress Disorder

Ghazi i. al jowf.

1 Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNs), Faculty of Health, Medicine and Life Sciences, Maastricht University Medical Centre, 6200 MD Maastricht, The Netherlands; [email protected] (N.A.); [email protected] (R.A.R.); [email protected] (B.P.F.R.); [email protected] (L.d.N.)

2 Department of Public Health, College of Applied Medical Sciences, King Faisal University, Al-Ahsa 31982, Saudi Arabia

3 European Graduate School of Neuroscience, Maastricht University, 6200 MD Maastricht, The Netherlands

Ziyad T. Ahmed

4 College of Medicine, Sulaiman Al Rajhi University, Al-Bukairyah 52726, Saudi Arabia; gro.segellocrs@040011171

Rick A. Reijnders

Elena ambrosino.

5 Institute for Public Health Genomics, Department of Genetics and Cell Biology, Research School GROW (School for Oncology and Reproduction), Faculty of Health, Medicine and Life Sciences, Maastricht University, 6200 MD Maastricht, The Netherlands; [email protected]

Bart P. F. Rutten

Laurence de nijs, lars m. t. eijssen.

6 Department of Bioinformatics—BiGCaT, School of Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, 6200 MD Maastricht, The Netherlands

Associated Data

Not applicable.

Trauma exposure is one of the most important and prevalent risk factors for mental and physical ill-health. Prolonged or excessive stress exposure increases the risk of a wide variety of mental and physical symptoms, resulting in a condition known as post-traumatic stress disorder (PTSD). The diagnosis might be challenging due to the complex pathophysiology and co-existence with other mental disorders. The prime factor for PTSD development is exposure to a stressor, which variably, along with peritraumatic conditions, affects disease progression and severity. Additionally, many factors are thought to influence the response to the stressor, and hence reshape the natural history and course of the disease. With sufficient knowledge about the disease, preventive and intervenient methods can be implemented to improve the quality of life of the patients and to limit both the medical and economic burden of the disease. This literature review provides a highlight of up-to-date literature on traumatic stress, with a focus on causes or triggers of stress, factors that influence response to stress, disease burden, and the application of the social-ecological public health model of disease prevention. In addition, it addresses therapeutic aspects, ethnic differences in traumatic stress, and future perspectives, including potential biomarkers.

1. Introduction

According to the Diagnostic and Statistical Manual (DSM) and the International Classification of Diseases (ICD), a traumatic experience is an event that can pierce into the integrity of an individual or a group causing distress, feeling of helplessness, horror, or intense fear reaction [ 1 ].

As reported by Terr (1991), trauma is categorized into two levels/domains, type 1 trauma and type 2 trauma. Type 1 trauma usually originates in childhood following unanticipated single events, typical in inducing post-traumatic stress disorder (PTSD). On the other hand, type 2 trauma follows repeated exposure to long-standing external events [ 2 ]. Importantly, type 2 trauma can also lead to the development of PTSD and other trauma-related reactions. It is worth mentioning that, while as much as 90% of the general population experience traumatic stress, only 20–30% of them develop PTSD [ 3 ].

The lifetime prevalence of traumatic stress ranges from 0.56% to 6.67% in Europe, with high prevalence rates in the Netherlands, the UK, France, and Germany [ 4 ]. Exposure to traumatic events is recognized as the essential key to developing stress-related disorders [ 5 ]. The most frequent disorder resulting from traumatic stress is PTSD [ 6 ]. In general, PTSD is a severe, chronic, and disabling disorder, which develops after exposure to a traumatic event in susceptible individuals, involving actual or threatened injury to themselves or others [ 7 , 8 ]. The most common stressor associated with PTSD is usually war and combat and witnessing, while in women, it appears to be sexual assault and rape [ 9 ]. Many models are developed aiming to predict the development of PTSD. A common aspect between these models is the interaction between the stressor, the peritraumatic condition, and the person’s susceptibility [ 10 , 11 , 12 ].

In the DSM-1, PTSD was not categorized as it is today; rather, it was categorized as a gross stress reaction, one of the transient personality reactions (along with adult situational reaction, adjustment reaction of infancy, adjustment reaction of childhood, adjustment reaction of adolescents, and adjustment reaction of late-life). Subsequently in the DSM-3 (introduced in 1980), PTSD was then recognized (for the first time as post-traumatic stress disorder) as “war neurosis” or “shell shock” as it was commonly seen during times of war. As the requirement for a person’s subjective negative response (defined as psychological distress or physiological reactivity to trauma-related cues) was eliminated as a diagnostic criterion, PTSD is no longer considered as fear- and anxiety-based disorder in the DSM-5 (introduced in 2013). Rather, it is categorized as a disorder arising in response to traumatic or stressful events preceding the emergence of its symptoms. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), PTSD has four components: intrusion symptoms, avoidance, alterations in cognitive function and mood, and arousal that impairs the individual’s functioning [ 1 ].

There are two sets of diagnostic criteria in the DSM-5 for PTSD, one for those of six years of age and older, and the other for children under six years of age. This discrimination was based on evidence that children below six years of age have a lower diagnostic threshold [ 13 , 14 ].

Differences in diagnostic definition and criteria of PTSD might hinder a precise and equal detection and diagnosis and can thereby limit effective and timely management [ 15 ]. In addition, it has been reported that declarative and short-term memory deficits may be susceptibility factors for PTSD [ 16 ]. Moreover, and as mentioned earlier, comorbidities (e.g., major depression disorder, anxiety disorders, and substance use disorders) further complicate the diagnosis and management of these comorbidities, demonstrating the need for the development of reliable diagnostic markers, such as biomarkers [ 17 , 18 , 19 , 20 , 21 ].

As part of management and patient care, prevention plays an important role in averting the disease before it develops or minimizing complications and morbidity if the disease already ensued. One way of doing so is by the implementation of prevention models, through which different levels of prevention (primary, secondary, and tertiary) can be enforced. Although out of the scope of this paper, it is worth mentioning that genetics and epigenetics have an important role in the interindividual differences in response to traumatic stress [ 22 , 23 ].

This review provides an insight into the burden of traumatic stress and its complications, some of the known causes of traumatic stress, factors believed to influence the response to stress, and integrating with the public health prevention model applied for traumatic stress. A literature search was performed using keywords to finds papers in PubMed, EMBASE, and SCOPUS. The report of literature in this paper aims to provide a general perspective of public health that demonstrates the importance of the early recognition of traumatic stress.

2. The Burden of Stress-Related Mental Disorders and PTSD

As mentioned earlier, PTSD remains the most frequently encountered disorder as a result of traumatic stress. Due to the high lifetime prevalence and significant consequences, the burden of the disease, both on the patient and the community, is expected to be high. Besides the burden on the patient, an economic burden and medical burden also exist.

2.1. Economic Burden

Stress-related mental disorders often have their onset gradually and at an early age [ 24 ], and are expected to cost the world USD 16 trillion by 2030 [ 25 , 26 ]. The economic burden can be mainly categorized into direct healthcare costs, productivity loss, societal cost, and non-healthcare costs. The general cost of diseases is usually classified into three types: direct, indirect, and intangible cost [ 27 ]. Direct costs include healthcare costs (diagnosis, treatment, and rehabilitation) and non-healthcare costs related to consuming non-healthcare resources, such as transportation, household expenditures, relocating, property losses, and informal care [ 27 ]. Indirect cost is productivity losses due to morbidity and mortality, borne by the individual, family, society, or the employer [ 27 , 28 ]. While intangible cost is not monetary but relates to function loss, increased pain, and reduced life quality, it can be regarded as an indirect economic burden and cost of illness [ 29 ].

The cost of psychiatric contact and outpatient treatment is surprisingly higher when compared to drug treatment and rehabilitation services [ 30 ]. The annual mean direct costs of PTSD per individual were much lower in South-Eastern European countries (USD PPP (purchasing power parities) 198–7110) compared to UK, Germany, and Northern Ireland (USD PPP 2337–26,991), probably due to the difference in healthcare spending between these countries. As expected, these numbers are negatively influenced by the severity of symptoms [ 30 ].

In Northern Ireland, the total economic burden in patients with PTSD as another example was GBP 172.8 million in 2008 values, including GBP 33.0 million in direct cost and GBP 139.8 million in indirect cost [ 31 ]. In Germany, the overall economic burden costs for PTSD account are EUR 43,000 per person. Mental disorders occupy 59%, which is the largest portion, and 18% of this value is for PTSD, with at least twofold more costs than a control group in 2013 [ 32 ].

Nearly all previous researchers found that indirect cost weighs similar or more in magnitude in the overall economic burden than direct costs [ 31 , 33 , 34 ].

2.2. Medical Burden

The medical burden is the impact a disease has on a population, which can be measured by indicators such as morbidity, mortality, and cost. The medical burden includes health care burden, comorbidity, and substance abuse, which also needs further treatments [ 35 ]. The medical burden of illnesses can be quantitatively measured by a cumulative illness rating scale [ 36 ]. This scale is a tool prevalently used as a criterion to evaluate medical burden in older adults as well as veterans [ 37 , 38 ].

Co-occurrence of mental as well as the general medical disorders are among the most common and disabling combinations, with approximately 30% of individuals with comorbidity having both a mental and a physical disorder [ 39 ]. In addition, 68% of adults with mental disorders have physical medical conditions [ 40 ]. Patients with medical comorbidity are in greater need of medical services with the loading healthcare system. For example, PTSD is exacerbated by comorbid medical illness, accounting for cumulative service utilization.

Returning veterans with PTSD, as an example, have a higher medical burden than those without mental health conditions [ 41 ]. In addition, these medical burdens are conditional on gender. Women tend to have more medical burdens than men. The median number of medical conditions for women with PTSD was seven, while for men was five [ 41 ].

Substance abuse disorders and social disadvantages can contribute to comorbidity and exacerbate its effect [ 39 ]. For example, co-occurring substance use and mental disorders are common among adults with opioid use disorder [ 42 ]. Thus, the soaring medical burden is associated with treatment resistance, medical comorbidity, and related substance abuse.

3. Types of Stressors

A stressor, or a stressful event, is the prime causative factor of PTSD, and is one of the criteria for diagnosing PTSD [ 43 , 44 ]. There are numerous types of stressors that may give rise to PTSD, including sexual assault, war and combat, child abuse and neglect, medical illnesses and disasters, in addition to others ( Table 1 ).

Main types of stressors related to PTSD.

3.1. Sexual Assault

Sexual assault is defined as “any form of sexual contact without voluntary consent, and that violates a person’s sense of autonomy, control and mastery over their body” [ 45 ]. The prevalence of PTSD due to sexual assault is 50%, making it the most common trauma resulting in PTSD in women [ 46 ]. Among those, rape is the most common form of sexual assault, but other forms also contribute to the trauma [ 46 ]. The dilemma of sexual assault is that it is a personal, individualized challenge to overcome and has a societal aspect that complicates the recovery process [ 46 , 47 ].

3.2. War and Combat

PTSD in military personnel is a common subject of psychiatric and psychological research, and tends to be correlated to the severity of the injury experienced [ 48 ]. Hoge et al. surveyed PTSD in US soldiers returning from Iraq months after returning from deployment. Their study showed that the prevalence of PTSD increased over the months, but interestingly, the severity of the physical injury was correlated to the earlier development of disease [ 49 ]. Additionally, some factors can affect disease development and progression. Of importance is deployment with combat experience, childhood adversity (adversity relating to family relationships and childhood antisocial behavior), leaving service, and serious accidents, as demonstrated by a study on British military personnel [ 50 ]. Important to note is that the effect of war is not only on soldiers that are deployed to the battlefield; the civilians are affected too. A systematic review on mental health outcomes among populations exposed to mass conflict and displacement found an overall prevalence of PTSD of 30.6% across all included studies (15.7% in studies > 1000 participants only). The main contributing factors retrieved were reported torture, cumulative exposure to potentially traumatic events, time since conflict, and assessed level of political terror [ 51 ]. Children are also strongly affected, not only by war trauma, but also by the effects this has on socio-ecological factors at family (parenting) and community levels [ 52 ]. This can also be seen in the 2022 Ukraine invasion, where multiple traumatic exposures have a critical impact on mental health [ 53 , 54 ].

3.3. Child Abuse and Neglect

In a prospective cohort study, children were followed up until their young adulthood, and both physical and sexual abuse increased the risk of developing PTSD. Another significant finding was that childhood neglect similarly increased the risk, and these factors independently contributed to the risk of the disease [ 55 ]. In 2009, Koenen et al. investigated whether there is a sex difference regarding these risk factors. They found a twofold difference in the risk of developing PTSD after childhood trauma, as women were found to have the highest increased risk among all the risk groups [ 56 ]. Additionally, those who experienced childhood trauma showed greater somatic symptoms, affect dysregulation, and suicidal behavior as compared with those without PTSD [ 57 ].

3.4. Medical Illness

It is becoming more evident than before that severe medical illnesses contribute to the risk of developing PTSD. Studies have been conducted on individuals with a specific disease to assess the degree of this risk. In a study on patients with Acute Coronary Syndrome (ACS), the prevalence rate of PTSD among 24 individuals was 12%, giving it the name ACS-induced PTSD [ 58 ]. Furthermore, patients with symptoms of PTSD that presented to the emergency room (ER) were more likely to be more worried about future stroke and have worries about medications, while not being adherent to medications [ 59 ]. Lastly, patients who experienced an intensive care unit stay showed a 24% PTSD prevalence 1–6 months after, as demonstrated in a meta-analysis [ 60 ].

3.5. Disasters

Disasters are traumatic events experienced by individuals that commonly lead to physical and mental consequences [ 61 ]. There are different types of disasters: natural disasters, such as tornados, floods, and hurricanes, and human-made/technology disasters, such as the Chernobyl disaster, terrorism, and torture [ 62 ]. The prevalence of PTSD was found to be higher in studies that focused on individual victims of disasters than on the general population [ 63 ]. Being female is considered to be a risk factor for the initiation of PTSD after disasters [ 64 ]. Other factors that found to be correlated with the initiation of PTSD after disasters included weak coping skills, external locus of control, history of previous trauma, low social support, media exposure, and others [ 65 , 66 , 67 , 68 ]. Furthermore, the degree of individual exposure to disaster is associated with PTSD likelihood [ 65 ]. The prevalence of PTSD is higher among the individuals who were directly exposed to the disaster and lower among individuals who rescued disaster victims [ 62 ].

3.6. Other Factors

While the causes mentioned above represent the main and most important ones, it must be acknowledged that the causes of traumatic stress are diverse. Furthermore, it is worth mentioning that some factors are considered risk factors, and they include a low social-economic status, female gender, family history of mental illness, and prior mental disorders [ 69 ]. The COVID-19 pandemic deserves a mention here, as some authors attempted the assessment of its impact on mental health. A meta-analysis was conducted on the prevalence of post-traumatic stress symptoms and psychological stress with a pooled prevalence of 23.88% and 24.84%, respectively [ 70 ]. Bridgland et al. found that participants in their study had PTSD symptoms when directly (COVID-19 diagnosed) or indirectly (e.g., media coverage and lockdown) exposed [ 71 ]. Surprisingly, patients had symptoms in response to anticipated events, giving a new view that traumatic stress could be to anticipated future rather than only impact of past events [ 71 ]. Additionally, the sequential exposure to multiple stressors, such as the Ukrainian war trauma with the stress from the global pandemic of COVID-19 not completely over, can have disastrous effects [ 53 ].

4. Factors Moderating the Impact of the Stressor

4.1. emotional care.

Children during infancy should receive consistent and constant emotional care because it is a critical period of emotional, social, and cognitive development. The opposite of emotional care can be classified into two subtypes: one is active emotional abuse, which receives much attention, and the other is passive emotional neglect [ 72 ]. If emotional neglect occurred early in life, social and emotional rehabilitation deficiencies could be seen after being inflicted with traumatic stress [ 73 , 74 , 75 ]. A four-year longitudinal research on adopted children who experienced emotional neglect showed that children were in the clinical or borderline ranges for symptoms of post-traumatic stress arousal (19%), avoidance (14%), and intrusion (8%) [ 76 ]. Figure 1 provides a general overview of the information about emotional care discussed in this section.

The impact of emotional care, emotional neglect, or abuse in early life on mental health in response to traumatic stress later in life.

Of all types of abuse, including childhood emotional abuse, physical abuse, and sexual abuse, only emotional abuse was independently associated with depressive symptoms, emotion dysregulation, and interpersonal problems in a cross-sectional study of 276 female college students [ 77 ]. In contrast, an emotionally responsive environment is found to possibly protect from severe traumatic stress even in those with genetic vulnerabilities [ 73 , 78 ].

Trauma-experienced youths tend to have emotional problems. A systematic review indicated that traumatized youths showed emotional regulation difficulties, including affect dysregulation, mood swings, affective and mood instability, or lability [ 79 ].

An earlier age of trauma exposure is associated with an increased risk of PTSD development [ 73 , 80 ]. Within PTSD, youth age (9–17) is positively associated with the volumes of brain structures (amygdala), but this is not observed in the non-PTSD youth controls [ 81 ]. Thus, severe stress may influence age-related variation in brain structures. Furthermore, a study on combat veterans showed age-accelerated shrinking of the cortical surface area in some regions when combat-related mild traumatic brain injury and PTSD are present, a pattern that was not consistently found in those with mild traumatic brain injury only [ 82 ].

4.3. Number and Impact of Traumatic Events

Besides age, other modifiable risk factors, such as earlier traumatic events, have been associated with increased perceived severity of current traumas [ 69 , 73 , 83 , 84 ]. An investigation on 444 refugees from the 1994 Rwandan genocide showed that higher numbers of different lifetime traumatic event types were associated with a higher probability of lifetime PTSD [ 85 ]. One additional traumatic event experienced was associated with a 19% increase in the probability of developing lifetime PTSD [ 85 ]. This increase indicated an accumulative effect of traumatic events on the onset of PTSD. Besides, 314 college students were asked to rate the importance of different events, including interpersonal or non-interpersonal ones. The results show that perceived importance was higher for interpersonal than non-interpersonal events [ 86 ]. Therefore, both the traumatic event number and event type impact mental health in response to stress.

4.4. Education

Lower levels of education render subjects at higher risk of PTSD in a study investigating emergency health care personnel in Italy [ 87 ]. Another study showed that a lower education level with other factors, such as race and age of combat exposure, predicts the current PTSD symptoms and symptom exacerbation in the longitudinal study on Vietnam veterans 40 years after the combat [ 88 ]. People with lower education levels have higher scores on the Kessler 10 scale, indicating more anxiety and depression than people with higher education in a cross-sectional study that included people who lived in Syria in different governorates [ 89 ].

4.5. Gender

The lifetime prevalence of PTSD is different between genders with higher rates among females (10–12% vs. 5–6% among males). Explanations for this are both psychosocial (e.g., type of trauma, as women are exposed to high-impact trauma, e.g., sexual assault, as described earlier) and biological (e.g., lower oxytocin release, a hormone that has been shown to reduce PTSD development as discussed later) [ 90 ]. Women veterans reported the highest lifetime and past-year PTSD rates compared with women civilians, men veterans, and men civilians [ 91 ]. However, another study on US military personnel deployed in support of the operations in Iraq and Afghanistan showed no significant gender differences for the likelihood of developing PTSD or for PTSD severity scores [ 92 ].

Race has been reported as an impact factor mediating traumatic stress (race-based traumatic stress), largely due to race discrimination rather than biological reasons [ 93 ]. A study on 421 community-based adult respondents showed that race-based traumatic stress is significantly related to trauma symptoms, especially in people who consider negative race-based experiences stressful [ 93 ]. Empirical data in 2012–2017 suggests that, in the US, Latino Americans, African Americans, and Native Americans tend to present with the highest rates of PTSD, while Asian Americans tend to present with the lowest [ 94 ].

To our knowledge, African Americans have the highest prevalence rate of PTSD across all ethnicities [ 95 , 96 , 97 ]. Although not fully understood, this disparity between ethnicities might arise from a difference in traumatic exposure or the pre-exposure vulnerability [ 96 , 98 , 99 ]. Research has been conducted in this regard, but several factors are implicated in this difference. For example, higher PTSD among African Americans might be due to racism and verbal assault, stigmatization, and the discrimination perceived by themselves [ 100 , 101 , 102 ].

On the other hand, some factors might account for the lower PTSD prevalence among other ethnicities, such as better socioeconomic status, higher education, and higher income [ 69 , 103 ]. Additionally, other psychiatric disorders, such as depression and anxiety, were associated with a higher risk of developing PTSD, and although these disorders are more prevalent in other populations, the risk of developing PTSD is found to be higher in African Americans [ 104 , 105 ]. It also appears that sociopathy alcohol and drug abuse, which are seen to be lower in Asians, could contribute to the ethnic difference and might explain the lower PTSD prevalence in that group [ 106 ].

In 2017, Alexander and his colleagues investigated the ethnic difference in PTSD vulnerability following hurricane Katrina [ 107 ]. The two-fold higher odds of African Americans compared to other populations to screen positive for PTSD was related to some factors, including worse prior mental distress, more stressful events, and less social support. Between these factors, only pre-hurricane mental distress has been shown to reduce this ethnic disparity. This might mean that hurricanes trigger the manifestation of PTSD of delayed onset, presumptively [ 107 ]. Overall, the retrospective nature of these studies might be seen as a limitation to the investigation of this ethnic association, and future prospective studies need to investigate the differences and arrive at a more solid conclusion.

Besides the likelihood of race discrimination exposure, ethnic origin can be a risk factor of traumatic stress mediated by culture. A study including Shanghai and Hong Kong residents and Americans showed the cultural differences in dialectical thinking, self-construal, and familyism in mediating resilience capacity. Dialectical thinking is the cognitive tendency toward attempts to reconcile two opposing perspectives or acceptance of contradiction [ 108 ]. Self-construal can be the independent self-construal common in the West or the interdependent self-construal common in East Asian countries. Similarly, tendency towards familyism (which means interests and gains are conceived at the level of the familial group rather than at the individual level) is present more in East Asian countries [ 94 ]. The study on three regions showed that independent self-construal, familyism, and dialectical thinking significantly mediated the relationship between culture and resilience capacity [ 108 ].

5. Public Health Model for Prevention and Intervention

5.1. the social-ecological model.

From a public health perspective, approaching a disease starts by identifying the causes and triggers, after which prevention (rather than treatment) can be applied at different stages of the disease development, with the aim of decreasing the disease burden at all levels. One model is the social-ecological model, a four-level model that aims to identify the factors contributing to disease development and poor health outcome at these levels: individual, relationship, community, and society [ 109 , 110 ] ( Figure 2 ).

The social-ecological model of disease prevention as applied to PTSD. For each of the four levels, examples of primary, secondary, and tertiary prevention are given.

At the core of the model, the individual level is found, which includes personal characteristics, including biological and others (e.g., genetics, comorbidities, education level, and economic status). The next level, which is the relationship, includes one’s close social connections that exert influence over the individual (parents, partners, family, close friends, etc.). The third level is the community, which explores one’s contact with one’s community, which happens at a wider social level (e.g., schools, universities, meeting places, and workplace). The final level, the societal level, looks at how the society in which the individual lives can affect his health outcome, and is usually a cultural and political level (e.g., cultural habits, norms, societal education, economy, and policies). At each one of these levels, prevention is feasible, and if suitable, intervention can also be applicable [ 109 ].

The prevention applied at each level can be primary, secondary, or tertiary. Primary prevention focuses on recognizing individuals at risk and preventing disease development in a disease-free individual. Secondary prevention aims at intervening early after disease occurrence, to achieve cure if possible, or to control disease progression. Tertiary prevention aims at reducing disabilities resulting from the disease to maintain a better quality of life [ 111 ]. While it is easier to define a clear onset in medical (or physical) diseases, disorders resulting from traumatic stress are diagnosed based on specific criteria, which are sets of symptoms with duration. This might present a challenge to differentiate between primary and secondary prevention, as asymptomatic disease might be the case in many individuals [ 43 ].

5.2. Examples of Preventive Measures at the Multilevel Social-Ecological Model

As primary prevention aims at preventing disease occurrence, in a trauma situation, it aims at preventing exposure to trauma. As discussed earlier, there are many causes of trauma, and specific interventions can be directed at these causes. At the individual level, interventions can be in the form of educational programs on the risk of alcohol drinking and firearm acquisition for the youth and parental guidance for young children, as well as college programs to educate young adults about traumatic experiences [ 112 ]. Additionally, psychoeducation programs target military personnel prior to deployment on trauma reaction [ 113 ]. At the relationship level, parental and caregiver guidance and education can aim at reducing traumatic experiences for the children, for example, bullying at school or programs to reduce assaultive violence. At the community level, interventions include community support services, neighborhoods, and streets surveillance campuses. At the societal level, policies can target reducing the acquisition of firearms and alcohol consumption, as well as recalling defective motor vehicles and street maintenance [ 114 ] ( Figure 2 ).

Secondary prevention is implemented after exposure to trauma and disease development, but the key is early intervention to prevent disease progression. At the individual level, and for trauma-exposed individuals, preventing ongoing exposure to stressors can halt disease progression [ 115 ]. Additionally, building prediction tools based on the susceptibility to develop PTSD after trauma exposure can identify high-risk patients, and hence, provide opportunities for intervention [ 43 ]. In addition, early psychological interventions can be effective [ 116 ]. At the relationship level, caring for relatives of domestic violence or children who are victims of child neglect can be useful. Medical intervention (e.g., cortisol and adrenergic medication administration) immediately after trauma exposure can take part in the secondary intervention, but weighing the harms and benefits should be determined carefully [ 117 ]. At the community level, providing shelters in the aftermath of disasters and making rehabilitation programs are strategies taken. Not only these, but also preparedness and measures in anticipation of disasters and traumatic experiences can be considered secondary prevention [ 118 ]. At the societal level, policies addressing early medical intervention, as well as screening campuses can limit disease progression ( Figure 2 ).

When interventions are aimed at preventing the progression of disease and development of disabilities, they are considered part of the standard care and treatment of the disease. At the individual level in tertiary prevention, seeking medical care and compliance with treatment, as well as better knowledge of the disease and complications helps to prevent disabilities. At the relationship level, special training for care from parents, relatives, and friends to patients undergoing therapy can be helpful. As demonstrated by Leve and colleagues, foster parents training for the care of trauma-exposed children with psychological illness halts disease progression [ 119 ]. Both community and societal levels fall under political influence, and measurements to promote community understanding of the disease, reducing stigma, and ensuring peace and fighting violence all play an important role in preventing disability [ 118 , 119 , 120 ] ( Figure 2 ).

5.3. Secondary Prevention and Treatment and Modalities

While the absolute avoidance of traumatic stress is often not a matter of control, the prevention of its complications can be pursued. After exposure to traumatic stress, individuals become vulnerable to complications, with PTSD being the most common. Several interventions are currently either implemented or under research to prevent such complications. These include behavioral therapy (e.g., cognitive behavioral therapy (CBT), prolonged exposure (PE), and eye movement desensitization and reprocessing (EMDR)) as well as pharmacological agents.

Being an effective and important therapeutic modality, CBT aims to give patients a sense of control over their fears, using different methods, such as exposure, to achieve fear extinction and support cognition to change the patient’s perception about the trauma [ 121 ]. Several clinical studies have been conducted on the effect of CBT early after trauma exposure to reduce complications and the appearance of symptoms. In 2021, Rothbaum and her colleagues investigated the effect of prolonged exposure CBT on patients who experienced traumatic stress, such as rape and motor vehicle accidents. It appeared that exposure-based CBT reduced PTSD symptoms at the assessment, especially for victims of sexual assault [ 122 ]. In a population of cardioverter defibrillator patients, CBT in less than two months for eight weeks significantly lowered the development of symptoms and promoted patient improvement in the CBT group [ 123 ]. Besides CBT, other therapies, such as PE in which the patient processes the traumatic event, as to decrease distress at further recall [ 124 ], and EMDR in which eye movements can reduce the intensity of traumatic memories [ 125 ], were the most utilized therapies in evidence [ 126 , 127 ]. The new consolidation/reconsolidation therapy is based on memory processing and the modulation of this process by pharmacologically interfering with this process during the recall of the disturbing memory, and to date, it has shown promise [ 128 ]. In this systematic review, Forneris et al. assessed the efficacy and comparative effectiveness of different psychological and pharmacological interventions in reducing the incidence or severity of PTSD symptoms. Interventions such as CBT reduced symptoms severity, while other interventions, such as debriefing, did not show evident benefit. The evidence for several other approaches appears to be limited and insufficient due to shortcomings in many included studies [ 129 ].

The other intervention modality is the pharmacological one, and many drugs have been tested to prevent complications. In addition, the findings from meta-syntheses showed that selective serotonin reuptake inhibitors (paroxetine and sertraline) and noradrenaline were effective and thus are highly recommended in the current guidelines [ 1 , 130 ].

Interestingly, propranolol helps to reduce traumatic recall in patients, given that it is administered early within hours after the traumatic exposure to affect memory formation and reduce traumatic recall [ 131 ]. A study on 64 trauma patients tested the effect of hydrocortisone compared to a placebo group. The symptom severity in the hydrocortisone group was lower than the placebo group, as the patients reported lower scores on the clinician-administered PTSD Scale (CAPS) [ 132 ].

The effects of oxytocin in the prevention of PTSD seem complex. A single administration had adverse effects on symptoms as it increased fear processing, while repeated administration reduced the development of PTSD symptoms [ 133 ]. The recreational drug 3,4-methylenedioxymethamphetamine (MDMA), when combined with psychotherapy, was associated with improved symptoms and lower functional compromise greater than psychotherapy and placebo [ 134 ]. Although trials showed controversial results, the alpha-blocker agent prazosin is used in clinical practice, as it appears to reduce symptoms [ 135 ].

The clinical implementation of the interventions above is harder than it seems, and the choice of a single standard therapy modality might not be effective. For that, a tailored and collaborative strategy for patients at risk is recommended. Zatzick et al. (2013) developed a randomized trial in which trauma survivors underwent stepped combined care management, psychopharmacology, and cognitive behavioral therapy compared to the usual care control condition. As expected, this therapy strategy reduced PTSD symptoms and improved functioning compared to the usual care group [ 136 ]. However, CBT is the mainstay of early prevention modality, but the challenging nature of implementation elicits the need to develop other modalities suitable for the needs of the particular subjects.

6. Future Perspectives: Biomedical Markers

Although PTSD is often a highly debilitating psychiatric disorder, no medical tools are currently available to prevent or minimize the impact of traumatic stress on mental health. PTSD symptoms prevent suffering individuals from leading a healthy lifestyle and are debilitating on a personal, societal as well as a professional level. Moreover, the economic burden of PTSD is substantial. There is thus a pressing need to develop additional tools to help PTSD prevention and treatment, such as biomarkers. We focus on biomarkers that aid the processes of diagnosis as well as determining therapy and response to treatment, supporting stratified precision medicine.

Integrating biomarkers along with the clinical assessment would provide a powerful means of managing PTSD and other psychiatric disorders. In addition to the role of biomarkers in the diagnosis and prediction of the onset of disorder, first (relative small scale) studies on biomarkers related to response to treatment are under investigation for possible future applicability [ 137 ]. For example, Felmingham et al. found reduced right amygdala activity and increased right anterior cingulate cortex activity in patients successfully treated with CBT [ 138 ]. Another example is the association between rostral anterior cingulate cortex (rACC) volume and the reduction in PTSD symptoms [ 139 ]. The same study demonstrated that activation of the ventral anterior cingulate and amygdala predict a better response to therapy [ 139 ]. On the side of pharmacotherapy, a promoter-region polymorphism, namely the LL 5HTTLPR genotype, was associated with a better responsiveness to sertraline (SSRI) [ 140 ]. Snijders et al. investigated the diagnostic potential of miRNA in a pilot study of patients with PTSD. In their pilot study, miR-138-5p was found to be significantly higher in PTSD patients as compared to controls. Additionally, only miR-1246 was significantly downregulated in PTSD cases compared to resilient subjects [ 141 ]. Although biomarkers showed promising initial results in predicting and diagnosing PTSD, further dedicated research is needed to determine the applicability of these biomarkers. Additionally, ethical considerations related to biomarkers for PTSD should be given attention: whereas prevention of avoidable harm and suffering can be considered a moral duty, the availability of such markers can also raise some concerns as to whether a test can be made obligatory and what the social and professional consequences of a susceptible or resilient status will be [ 142 ].

7. Conclusions

This paper provided a literature review of PTSD with the focus on traumatic stress prevention form a public health perspective. A traumatic experience is an event that can pierce into the integrity of an individual or a group causing distress, feelings of helplessness, horror, or intense fear reaction. The cause of this traumatic experience might range from war, terrorism, and disasters to sexual assault and child abuse. A well-recognized complication of such experience is PTSD. Current descriptive and empirical evidence showed race, gender, and age differences in the risk of developing PTSD, resulting in interindividual differences in disease manifestation. Early recognition and diagnosis help in the application of different levels of prevention (primary, secondary, and tertiary prevention), improving the course of the disease and limiting the complications, while reducing costs and burden of the disease.

Additionally, the implementation of preventive measures according to public health models of disease prevention can be seen as a means to achieve these goals effectively. A widely accepted model, the socio-ecological model, was implemented to study prevention at the levels of the individual, relationship, community, and society. While a variety of different prevention and treatment modalities exist for PTSD, including behavioral and pharmacological interventions, the identification of the suitable strategies is important to avoid treatment failure and relapses.

The earlier described differences in PTSD definition and lack of definitive diagnostic tools may be a contributing limitation to research on PTSD as well, which as such leads to some differences among studies and their conclusions and, thereby, our reporting thereof. A more detailed mapping of the definitions used across the several studies and possible inclusion of such criteria in a meta-analysis or systematic review could be a valuable future endeavor. The finding of biomarkers may help to synchronize diagnostic criteria, but also depends on the definition of disease classes for their discovery.

Although biomarkers showed promising initial results in predicting, diagnosing, and treating PTSD, further dedicated research is needed to replicate and validate these and (if successful) test for the clinical applicability of these biomarkers. Integrating biomarkers along with the clinical assessment may provide added value for diagnosing PTSD and prediction its course.

Acknowledgments

We would like to thank our colleague, Ibrahim Hassan Juraiby, for his support and exchange of thoughts in preparation of this paper.

Funding Statement

Ghazi I. Al Jowf was supported by personal funding from King Faisal University, Employees Scholarship Program from the Saudi Arabian Government (no. 1026374049). The work of Bart P.F. Rutten was funded by a VIDI award (no. 91718336) from the Netherlands Scientific Organization.

Author Contributions

G.I.A.J. drafted the initial manuscript; L.d.N. and L.M.T.E. contributed equally to the final manuscript. Moreover, Z.T.A., N.A., R.A.R., E.A. and B.P.F.R. reviewed the manuscript and provided comments/suggestions. G.I.A.J. and L.M.T.E. are the corresponding authors. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Informed consent statement, data availability statement, conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

99 PTSD Essay Topics

🏆 best essay topics on ptsd, 🌶️ hot ptsd essay topics, 👍 good ptsd research topics & essay examples, 🎓 most interesting ptsd research titles.

• Post-Traumatic Stress Disorder in Vladek From “Maus” by Art Spiegelman
• Post-Traumatic Stress Disorder (PTSD) and Its Features
• Posttraumatic Stress Disorder in the Fearless Film
• Lady Gaga’s Post-Traumatic Stress Disorder
• The Post-Traumatic Stress Disorder: Case Study
• PTSD in Modern Society: Misinterpretation and Misuse of the Term
• Post-Traumatic Stress Disorder: The Case Study
• Disaster, PTSD, and Psychological First Aid Psychological first aid should be consistent and evidence-based, practically applicable in the field, appropriate, and culturally flexible.
• Post-Traumatic Stress Disorder During and After World War I The paper examines the causes and manifestations of PTSD during and after World War I, despite the absence of this term at that time, and how diagnosis and treatment are made.
• Post Traumatic Stress Disorder: Characteristics Central Nervous System associated disorders represent one of the health issues globally. The description is aimed at highlighting research related to Posttraumatic stress disorder
• Exploring and Storming Phase for Veterans with PTSD The paper addresses the peculiarities of the storming stage as applied to the therapeutic group designed for male combat veterans with PTSD.
• Psychological Therapy of Post-Traumatic Stress Disorder Posttraumatic Stress Disorder (PTSD) is a distressing condition that leads to brain disturbance due to exposure to dreadful situations.
• Post-Traumatic Stress Disorder’s Treatment The paper present bibliography which review different psychotherapy interventions that can be applied in treating Post Traumatic Stress Disorder among adults.
• Case Study for Agnes: Post-Traumatic Stress Disorder According to the case scenario, Agnes is most certainly suffering from post-traumatic stress disorder (PTSD). She was traumatized by the previous account of the storm.
• PTSD Treatment: Evidence-Based Practice This annotated bibliography reviews three articles devoted to the topic of PTSD treatment and its methodology through evidence-based analysis.
• Secondary Traumatization of PTSD Among Children in Military Families Military officers and veterans work in highly stressful environments, hence, experiencing different levels of PTSD depending on the armed nature of a given conflict.
• Post-Traumatic Stress Disorder in Military Militants experience a significant number of traumatic events that subject them to PTSD. The culture of the military plays a significant role in promoting veteran mental wellness.
• Posttraumatic Stress Disorder in Military Veterans Both in the military and civilian life, people encounter traumatic occurrences that challenge their perception of the world or themselves.
• Anxiety, Depression, and Post-Traumatic Stress Disorder Currently, many people experience anxiety, depression, and post-traumatic stress disorder that affect their general health.
• PTSD: Prolonged Exposure Therapy Foa and colleagues developed Prolonged Exposure, a standardized treatment, 90-minute, weekly therapy procedure for the management of PTSD.
• Military Sexual Trauma: PTSD in Female Veterans The following paper suggests a literature review on the subject of post traumatic stress disorder associated with military sexual trauma in female veterans.
• Relationship Between PTSD and Religion The relationship between religion and PTSD could have both positive and negative outcomes. Religious leaders are exposing their weaknesses in helping their followers to manage such issues.
• Posttraumatic Stress Disorder Concept Posttraumatic Stress Disorder (PSTD), a type of anxiety disorders, is a mental health condition that occurs as a result of terrifying, distressing or stressful events.
• Prevalence of PTSD and PTG in Soldiers From Ethnic Minorities The paper states that PTSD and PTG are widespread diseases that affect soldiers from ethnic minorities. These combat veterans are more likely to have disabilities.
• MDMA-Assisted Therapy for Severe PTSD Post-traumatic stress disorder is a body condition that occurs when a stressful event happens. It is the period that does not mean that the person stays in a dangerous situation.
• Antisocial Personality Disorder and Post-Traumatic Stress Disorder The patient has an antisocial personality disorder and post-traumatic stress disorder owing to the experience of the brutal murder of his mother at a tender age.
• Treatment Options for Post-Traumatic Stress Disorder Using psychological interventions as treatment is a productive tool that is used everywhere. Trauma-focused therapy has reduced PTSD symptoms.
• Hypnotherapy in the Treatment of Post-Traumatic Stress Disorder Post-traumatic stress disorder refers to a behavioral disorder that occurs as a result of being subject to a shocking event or situation.
• Racism, Ethnoviolence, and Post-Traumatic Stress Disorder The paper states that experiencing racism can induce post-traumatic stress disorder. Most people do not draw a link between racism and PTSD.
• Post-Traumatic Stress Disorder: A Critical Perspective Post-traumatic stress disorder (PTSD) is a relatively common condition affecting individuals who have experienced severe trauma.
• Post-Traumatic Stress Disorder in a Raped Girl The patient has a strained connection with her cocaine-addicted mother, who has been emotionally and physically abusive to her since she was three years old.
• Migration Crisis & Post-Traumatic Stress Disorder Trump’s anti-migration actions have significantly affected the psychological state of the people striving to get protection from the US.
• Post-Traumatic Stress Disorder and Substance Addiction Treatment The paper presents the case study of a client struggling with PTSD and substance addiction, including disposition, suggested treatment protocol, and resources for treatment.
• Psychological Post-Traumatic Stress Disorder Traumatized people are more likely to acquire PTSD, a condition in which the victim’s consciousness is dominated by the recollection of the traumatic incident.
• Navigating PTSD: Diagnostic Approaches and Tools Posttraumatic stress disorder (PTSD) is a serious mental health condition that needs treatment due to its potential negative implications.
• PTSD Group Counseling The paper discusses PTSD. It is a psychiatric disorder that can manifest itself in people that witnessed or experienced a traumatic event.
• Prevalence of Combat Post-traumatic Stress Disorder Among Veterans The paper argues combative nature of military personnel contributes to the Post-traumatic Stress disorder experienced by officers.
• Kolcaba’s Comfort Theory in Regard to Military Veterans With PTSD To sum up, if the experiment proves reliable and valid, the application for those who have PTSD may be improved or facilitated for everyday use.
• Post-Traumatic Stress Disorder in Various Populations In this paper, the authors explore the prevalence of post-traumatic stress disorder among different populations. They compare this prevalence between genders and veterans.
• Post-Traumatic Stress Disorder: Pharmacological Treatment Approved medications can help treat PTSD symptoms and improve patient outcomes. SSRIs, such as sertraline, have been shown to reduce anxiety and increase concentration.
• PTSD: Coping Mechanisms and Recovery Paths The purpose of this paper is to discuss PTSD. Also, this paper introduces the assessment and factors associated with PTSD.
• Posttraumatic Stress Disorder: Triggers, Clinical Manifestations, and Therapy Posttraumatic stress disorder (PTSD) is a mental condition that originates from experiencing terrifying events and getting haunted by them long after they happened.
• Investigating Post-Traumatic Stress Disorder Most people experience traumatic events during their lifetime. For the first time, the phenomenon of post-traumatic stress disorder was examined among the participants of the wars
• The Post-Traumatic Stress Disorder Many people suffer from post-traumatic stress disorder, and it is very important to know more about its symptoms and treatment.
• Incidence of Posttraumatic Stress Disorder After Motor Vehicle Accidents In recent years, a global surge in the number of posttraumatic stress disorder (PTSD) occasioned by motor vehicle accidents has been witnessed in the United States of America.
• PTSD Among Motor Vehicle Accident Victims The literature review will discuss the predictors, assessment, and factors associated with PTSD and screening and diagnosis of PTSD using the distress thermometer.
• Posttraumatic Stress Disorder: Approaches and Symptoms The report presents that several investigations indicate a negative relationship between mindfulness-based approaches and PTSD symptoms acuteness.
• Posttraumatic Stress Disorder Risk Factors Crisis workers need to understand risk factors associated with PTSD. The disorder may cause serious diseases that are expensive and complex to cure, such as heart diseases.
• Posttraumatic Stress Disorder Diagnostic Categorization In the case study, the client was grief-stricken, disheartened, apprehensive, culpable, and irritated. From the case study, the client suffers from continual stress.
• Psychotherapy Treatment for Combat Veterans Suffering From PTSD The symptoms of PTSD based on combat experience include flashbacks, nightmares, tries to suppress the memories, irritability, hyperarousal, sleep disorders, numbing.
• Pathways to PTSD: Sexually Abused Children The objective of the paper was to build and analyze a probable model of posttraumatic stress symptoms in sexually abused juveniles.
• Combat Fatigue or Post-Traumatic Stress Disorder in Soldiers Events in a war like bombs noise, disaster, deaths, and killing, bloodstains, firings produce very frightening and threatening scenes that affect the brains of soldiers.
• Post Traumatic Stress Disorder Symptoms and Causes Adults’ symptoms of PTSD include flashbacks, nightmares, emotional blunting, detachment from people, inability to feel pleasure, unable to work in the real world.
• Posttraumatic Stress Disorder in Combat Veterans The aim of this essay is to review briefly yet, comprehensively the recent advances in assessment and treatment of PTSD.
• Post-Traumatic Stress Disorder in Children Post-traumatic stress disorder is a psychological disorder, which can be viewed as a response to such traumatic events as witnessing or committing homicide, surviving pain or extremely harsh physical conditions.
• Post-Traumatic Stress Disorder in Children After Tsunami The paper studies children who have post-traumatic stress disorder due to the Indian Ocean tsunami that struck the shores on 26th December 2004.
• Post-Traumatic Stress Disorder and Life Quality The paper revolves around post-traumatic stress disorder (PTSD), its primary symptoms, consequences, and approaches to treatment aimed at the improvement of patients’ lives.
• Posttraumatic Stress Disorder: Diagnosis and Tratment The posttraumatic stress disorder requires increased attention as the disease with a sufficiently large spectrum of associated problems and non-standard approaches to identification and intervention.
• Individuals With Post-Traumatic Stress Disorder Neurodevelopmental disorders are particularly different to treat in young patients since the latter’s nervous system has not developed yet.
• Posttraumatic Stress Disorder: Definition and Diagnosis Posttraumatic stress disorder is a condition, which potentially happens in individuals that had experienced an event that was threatening to their lives, for example, an accident.
• PTSD-Related Intervention in the Hurricane Context The aftermath of the hurricane is expected to bring about posttraumatic stress disorder (PSTD) symptoms among the millions of affected victims.
• Psychotherapeutic Intervention: Veterans with PTSD This group manual is written for a brief psychotherapeutic intervention developed for combat veterans with PTSD. The paper includes a description of the intervention, its major phases.
• Posttraumatic Stress Disorder and Substance Use The posttraumatic stress disorder (PTSD) can often be complicated by substance use disorders (SUDs) or the manifestations of both conditions can be simultaneous.
• Post Traumatic Stress Disorder: Systemic Psychotherapy People with PTSD experience heightened anxiety caused by memories of traumatic events. Such attacks often result when the patient encounters specific triggers or irritants.
• Post Traumatic Stress Disorder Diagnostics The paper studies the case of the patient exhibited the essential key features of Posttraumatic Stress Disorder. It presents the justification for DSM 5 Diagnosis.
• Combat-Related Posttraumatic Stress Disorder The paper outlines the temporal dynamics and elements of attentional bias for threat cues in combat-related posttraumatic stress disorder.
• The Treatment of Posttraumatic Stress Disorder PTSD can be defined as a mental disorder that develops as a result of the exposure to a particular situation or information that may endanger a person’s life.
• Early PTSD Interventions in the Event of a Hurricane Debriefing is a kind of psychological treatment offered to survivors of natural disasters in order to reduce their psychological morbidity that may appear as a natural reaction to the trauma.
• Post-Traumatic Stress Disorder: Group Therapy This paper studies a case involving a 13-year-old girl, who suffers from post-traumatic stress disorder and requires psychological interventions to avert her undesirable behaviors.
• Posttraumatic Stress Disorder and Treatment Centers The Nation Center for Posttraumatic Stress Disorder is a center for information on PTSD. The center’s key mandate is to do research, educate, and treat those affected by trauma.
• Post Traumatic Stress Disorder: Case Analysis 27-year-old man who has been experiencing posttraumatic stress disorder (PTSD) for two years after his wife disappeared.
• “Post-Traumatic Stress Disorder” by Bisson et al. Posttraumatic stress disorder is a specific condition of a patient, which was provoked by a one-time or recurring strong external traumatic impact on the individual’s psyche.
• Veterans’ Post Traumatic Stress Disorder: How a Game Can Help? This research paper will analyze how veterans suffering from PTSD stand to benefit from the game Human versus Zombies by using the skills they learned in war.
• Psychology Issues: Post-Traumatic Stress Disorder Post-Traumatic Stress Disorder is one of the main challenges that people deal with after a traumatizing event. PTSD should be treated as soon as any of the symptoms start to be recognized.
• Psychological Treatment: Posttraumatic Stress Disorder The universal condition of Posttraumatic Stress Disorder (PTSD) that emanates from the exposure to traumatic events continues to pose health concerns to the victims.
• What Is Post-Traumatic Stress Disorder? Posttraumatic stress disorder or PTSD is a psychological and emotional response to a traumatic event. There is a higher probability to develop PTSD if a person went through a disaster.
• Post-Traumatic Stress Disorder Diagnosis People who work in risky environments have a high propensity of developing PTSD than their counterparts in safer working environments.
• Post-Traumatic Stress Disorder: Cognitive Therapy Psychological therapies have been used to offer assistant to psychological patient. Post-Traumatic Stress Disorder is a disorder that is associated with traumatic experience.
• Potential of Eye Movement Desensitization and Reprocessing Therapy in the Treatment of Post Traumatic Stress Disorder The concept of Eye Movement Desensitization and Reprocessing (EMDR) has the potential to support the needs of different PTSD patients.
• PTSD Holism and Cognitive Behavioral Therapy
• The Davidson Trauma Scale for Post-Traumatic Stress Disorder
• Depression and Post-Traumatic Stress Disorder Treatment
• Child Sexual Abuse and Post-Traumatic Stress Disorder
• Combat PTSD and Other Forms of Mental Illness
• Treating PTSD and Depression With Medical Marijuana
• PTSD: Posttraumatic Stress Disorder and Hypnosis
• Inclusion and Diversity With Post-traumatic Stress Disorder (PTSD)
• Relationship Between Hypertension and Post-Traumatic Stress Disorder
• Anger and Hostile Behavior as It Relates to PTSD Symptoms in Afghan and Iraq War Veterans
• Post-Traumatic Stress Disorder and Its Effects on Society
• Cognitive Behavior Therapy for PTSD
• Psychological Factors Associated With PTSD
• Anger, PTSD, and the Nuclear Family: A Study of Cambodian Refugees
• Trauma-Focused Therapies for Decreasing PTSD and Depression
• The Biological Process That Causes PTSD
• Impact of Drug Abuse on Post-Traumatic Stress Disorder
• Post-Traumatic Stress Disorder and Employee Management
• Care and Support for Veterans With PTSD
• Development, Diagnosis, and Symptoms of PTSD

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Post Traumatic Stress Disorder Essay Examples

Ptsd essay topics and outline examples, essay title 1: understanding ptsd: causes, symptoms, and treatment.

Thesis Statement: This essay explores Post-Traumatic Stress Disorder (PTSD) by examining its root causes, the range of symptoms experienced by those affected, and various therapeutic approaches and treatment options available to individuals struggling with PTSD.

• Introduction
• Defining PTSD and Its Diagnostic Criteria
• Common Causes and Triggers of PTSD
• Symptoms and Psychological Effects on Individuals
• Treatment Modalities: Therapy, Medications, and Alternative Approaches

Essay Title 2: The Impact of PTSD on Veterans: Addressing the Mental Health Crisis

Thesis Statement: This essay focuses on the prevalence of PTSD among military veterans, the unique challenges they face, and the importance of providing comprehensive mental health support, including therapy, peer counseling, and community resources.

• PTSD in Military Context: Causes and Traumatic Experiences
• Challenges Faced by Veterans: Reintegration and Mental Health Stigma
• Promoting Veteran Well-Being: Accessible Mental Health Services
• Community and Government Initiatives to Support Veterans with PTSD

Essay Title 3: PTSD in Children and Adolescents: Recognizing and Healing Childhood Trauma

Thesis Statement: This essay sheds light on the prevalence of PTSD in children and adolescents exposed to trauma, emphasizing the importance of early intervention, trauma-informed care, and support systems for young individuals experiencing post-traumatic stress.

• Childhood Trauma and Its Impact on Mental Health
• Signs and Symptoms of PTSD in Children and Adolescents
• Treatment Approaches: Play Therapy, Counseling, and Family Support
• Educational and Community Resources to Address Childhood PTSD

Ptsd and Its Implications Among Law Enforcement Officers

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Analysis of The Cognitive Impacts of Ptsd

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Researchers studying MDMA-assisted treatment for PTSD

by Jeremy Redmon, The Atlanta Journal-Constitution

Therapists have discovered a variety of effective treatments for patients with post-traumatic stress disorder: Talk therapy, narrative writing, medication and a system that involves discussing painful experiences while focusing on blinking lights and vibrations.

But not everything works for everyone living with PTSD, a serious mental health problem that affects 5% of adults in the United States, many of them military veterans, according to the U.S. Department of Veterans Affairs.

Now researchers at the Emory Brain Health Center are studying how MDMA—a psychedelic drug commonly known as ecstasy—could help PTSD patients when combined with a proven form of psychotherapy called prolonged exposure treatment.

"We need treatment options ," said Barbara Rothbaum, a clinical psychologist at Emory and one of the study's investigators. "People are able to approach distressing memories with less distress when they are on MDMA—with less anxiety."

The research at Emory comes as the U.S. Food and Drug Administration weighs an application for MDMA-assisted therapy. That application was submitted by Lykos Therapeutics, a corporation created by the psychedelic studies association.

An FDA advisory committee concluded the available data do not show MDMA is effective for patients with PTSD and that the benefits of such treatment would not outweigh the risks to patients. The FDA, which is not bound by the advisory panel's recommendations, is expected to make a decision by Aug. 11.

Military veterans and women are more likely to develop PTSD, which can be caused by life-threatening events, such as combat, and sexual trauma, according to the VA's National Center for PTSD, which says about 13 million Americans had PTSD in 2020.

Symptoms can include nightmares, flashbacks, hypervigilance and difficulty concentrating and sleeping. Patients might avoid situations or people that remind them of their traumatic experiences. Meanwhile, according to the VA, studies show the risk of suicide is higher for people with PTSD.

In searching for other ways to treat patients with mental health problems, researchers have turned to psychedelics. For example, experts at Emory and across the nation are learning in clinical trials that drugs derived from fungi—sometimes called magic mushrooms—can help people experiencing PTSD, pain and addiction.

MDMA, a synthetic drug also called midomafetamine, can cause hallucinogenic and stimulant effects. It is listed as a Schedule I substance in the United States, meaning it has no accepted medical uses and is known to have a high potential for abuse, according to the U.S. Drug Enforcement Administration.

Lykos submitted to the FDA data from four 18-week studies of how MDMA—combined with psychotherapy—works to help PTSD patients. The results showed participants appeared to experience "rapid, clinically meaningful, durable improvements in their PTSD symptoms," according to an FDA report.

Because MDMA can profoundly alter mood, sensation and suggestibility, most of Lykos' trial participants were able to accurately guess whether they were given the drug or a placebo, according to the FDA report. That could have introduced what the FDA report called "expectation bias" in which participants who believed they received MDMA expected they would get better, while those who believed they received a placebo fared worse because of disappointment.

A nonprofit research group called the Institute for Clinical and Economic Review underscored concerns about bias in a report it released last month, adding "the publicly available evidence is insufficient to assess the balance of benefits and harms."

Nese Devenot, a senior lecturer at Johns Hopkins University, joined more than 70 fellow college educators, researchers and others in submitting a petition to the FDA, citing ICER's report and asking for an extended public hearing.

"The FDA must take action to ensure that this does not amount to another regulatory scandal like the opioid crisis, where widespread harm retroactively illuminated substantial regulatory failures," the petition says.

Before it voted, the FDA's advisory panel heard from many proponents, including some of Lykos' study trial participants. Among them was Cristina Pearse, a Colorado resident who leads a nonprofit organization focused on helping women recover from trauma. Pearse told the panel she was sexually assaulted as a young child and was diagnosed with PTSD when she was 45.

"I nearly died from PTSD—this trial saved my life," she told The Atlanta Journal-Constitution. "All of my work now underscores the fact that I believe this therapy works. The FDA advisory committee is wrong. We need it now for those whose life also hangs in the balance. It will save lives."

Lori Tipton, a writer and public speaker based in New Orleans, told the panel she participated in one of Lykos' studies after living with PTSD for more than a decade. She lost her brother to an overdose in 1999 and said her mother killed two women and herself in 2005. Tipton added that her life was filled with anxiety and hypervigilance.

"I no longer endure the symptoms that tormented me for years, experiencing a newfound ease in laughter and a profound sense of lightness, calmness and reduced agitation," she said. "What's most significant to me is the presence it has granted me, enhancing my enjoyment of motherhood. I am deeply thankful to MDMA-assisted therapy for reshaping and enriching my bond with my child."

The committee also heard from patients who said they had troubling experiences with MDMA-assisted treatment. One man warned about what could happen with inept or inexperienced therapists. Without naming his therapist or saying whether he was part of a study, he said the treatment he underwent last year "completely derailed my life," adding he now experiences extreme exhaustion and severe cognitive impairment.

"I have been unable to work for the last 15 months," he told the panel. "And I have had to live with a family member while I attempt to recover on my own."

Rothbaum, who also leads the Emory Healthcare Veterans Program, emphasized her university's study was approved by the FDA and the DEA and that its patients are being screened for safety.

She also underscored that Emory's study is shorter and different than what Lykos is proposing. Patients at Emory, for example, receive only one MDMA dose during 10 days of psychotherapy treatment followed by assessments. Lykos is proposing three medication sessions with MDMA during a four-month treatment.

Two patients—both military veterans —have completed MDMA-assisted therapy as part of Emory's study. A third patient is enrolling. The researchers plan to study at least a dozen more, including civilians, and hope to report results by next year.

"We have been able to do the treatment as we planned," said Jessica Maples-Keller, a clinical psychologist and one of the Emory study's investigators. "And the initial results are very promising."

2024 The Atlanta Journal-Constitution. Distributed by Tribune Content Agency, LLC.

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Post-traumatic Stress Disorder in Children

All children may experience very stressful events that affect how they think and feel. Most of the time, children recover quickly and well. However, sometimes children who experience severe stress, such as from an injury, from the death or threatened death of a close family member or friend, or from violence, will be affected long-term. The child could experience this trauma directly or could witness it happening to someone else. When children develop long term symptoms (longer than one month) from such stress, which are upsetting or interfere with their relationships and activities, they may be diagnosed with post-traumatic stress disorder (PTSD).

Examples of PTSD symptoms include

• Reliving the event over and over in thought or in play
• Nightmares and sleep problems
• Becoming very upset when something causes memories of the event
• Lack of positive emotions
• Intense ongoing fear or sadness
• Irritability and angry outbursts
• Constantly looking for possible threats, being easily startled
• Acting helpless, hopeless or withdrawn
• Denying that the event happened or feeling numb
• Avoiding places or people associated with the event

Because children who have experienced traumatic stress may seem restless, fidgety, or have trouble paying attention and staying organized, the symptoms of traumatic stress can be confused with symptoms of attention-deficit/hyperactivity disorder (ADHD).  Read a guide for clinicians on deciding if it is ADHD or child traumatic stress.

Examples of events that could cause PTSD include

• Physical, sexual, or emotional maltreatment
• Being a victim or witness to violence or crime
• Serious illness or death of a close family member or friend
• Natural or manmade disasters
• Severe car accidents

Learn more about PTSD

Treatment for PTSD

Learn about the guidelines for diagnosing and treating PTSD

The first step to treatment is to talk with a healthcare provider to arrange an evaluation. For a PTSD diagnosis, a specific event must have triggered the symptoms. Because the event was distressing, children may not want to talk about the event, so a health provider who is highly skilled in talking with children and families may be needed. Once the diagnosis is made, the first step is to make the child feel safe by getting support from parents, friends, and school, and by minimizing the chance of another traumatic event to the extent possible. Psychotherapy in which the child can speak, draw, play, or write about the stressful event can be done with the child, the family, or a group. Behavior therapy, specifically cognitive-behavioral therapy , helps children learn to change thoughts and feelings by first changing behavior in order to reduce the fear or worry.  Medication may also be used to decrease symptoms.

Get help finding treatment

Here are tools to find a healthcare provider familiar with treatment options:

• Psychologist Locator , a service of the American Psychological Association (APA) Practice Organization.
• Child and Adolescent Psychiatrist Finder , a research tool by the American Academy of Child and Adolescent Psychiatry (AACAP).
• Find a Cognitive Behavioral Therapist , a search tool by the Association for Behavioral and Cognitive Therapies.
• If you need help finding treatment facilities, visit FindTreatment.gov .

Prevention of PTSD

It is not known exactly why some children develop PTSD after experiencing stressful and traumatic events, and others do not. Many factors may play a role, including biology and temperament.  But preventing risks for trauma, like maltreatment, violence, or injuries, or lessening the impact of unavoidable disasters on children, can help protect a child from PTSD.

Learn about public health approaches to prevent these risks:

• Protect the ones you love: Childhood injury prevention
• Bullying prevention
• Child maltreatment prevention
• Youth violence prevention
• Caring for children in a disaster

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PTSD Treatments Are Falling Short for Many Patients

Therapy and medication can help people recover from trauma, but many struggle to access the care they need.

By Dani Blum

Post-traumatic stress disorder closes people off. They withdraw — often reluctant to talk about what they’ve experienced and unable to trust others or themselves. But many leading treatments for the condition require just that.

The treatments for PTSD — including several forms of psychotherapy and medication — are effective for many patients, but they don’t work for everyone. They can be expensive. Sometimes, they can be so distressing that patients stop the treatment before it’s complete.

“The field has acknowledged for years that we need to do better for our patients,” Dr. Jerry Rosenbaum, a professor of psychiatry at Harvard Medical School, said Tuesday at a meeting of experts tasked with advising the Food and Drug Administration on whether to approve the first new medication in decades for PTSD. The treatment combines the psychoactive drug MDMA with talk therapy to treat PTSD.

The expert panel voted against endorsing the therapy, which was developed by Lykos Therapeutics, citing concerns about safety and issues in clinical trials. The F.D.A. is not required to follow the guidance of these advisory panels, but often does.

But even in rejecting the use of MDMA-assisted therapy, the experts emphasized the need for new and better treatments for PTSD, which can cause intrusive thoughts, flashbacks and nightmares and increases the risk of suicide or death from other causes.

Roughly six percent of the American population will develop PTSD at some point in their lives. Only a fraction of those patients currently recover, Dr. Tiffany R. Farchione, director of the F.D.A.’s Division of Psychiatry Products, said at the meeting Tuesday. And many people with PTSD symptoms struggle to get diagnosed in the first place .

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4-legged lifesavers: Service dogs are working wonders for veterans with PTSD, study shows

TOMS RIVER, N.J. − Before Anthony Certa began talking about his three deployments in Iraq as a U.S. Marine and military police officer , he gave a gentle command to his service dog.

"Mando, on my lap," the veteran said. Mando, a black 2½-year-old England Labrador, hoisted his massive paws onto Certa's legs, then Certa lifted the dog all the way into his lap and began petting the dog, who remained still and quiet.

It was obvious the effect the dog had on Certa, who recalled his experiences guarding convoys and protecting explosives ordnance disposal (EOD) personnel as they worked. Emotional as he spoke of losing comrades, Certa remained calm and spoke softly, in measured tones.

While for years there has been anecdotal evidence of the benefits of emotional support dogs for veterans such as Certa, a new national study offers more definitive proof.

Maggie O'Haire , one of the study's co-authors and a researcher with the University of Arizona College of Veterinary Medicine, and her colleagues followed 156 veterans over three months. The study, funded in part by the National Institutes of Health and released June 4, found veterans with dogs reported decreased severity of PTSD symptoms, anxiety and depression and higher psychosocial functioning. The dogs were provided by a nonprofit, K9s for Warriors .

"We know veterans are struggling," O'Haire said. "They have much higher rates of depression, anxiety and suicidal thoughts (than the general population)."

'Really rough coming home' after combat in Iraq

Certa, who enlisted shortly after the terrorist attacks on Sept. 11, 2001, was just 19 when he was first deployed to Iraq in 2003. He was in Fallujah during the most intense fighting of the war; his final deployment ended in 2005.

After seeing the human cost of war, from service members killed by improvised explosive devices (IEDs) to urban warfare and house-to-house "cordon and knock" operations, Certa found it difficult to adjust to civilian life.

"It was really tough coming home," he said. "You had certain expectations. When you’re in the Marines, you don’t really talk about things."

He struggled, engaging in what he called "reckless behavior" and leaning on alcohol. "You mask a lot of the problems," Certa said, petting and squeezing Mando. "You get reckless; you feel invincible. You feel like, well, you didn't die (in combat), but you also feel guilty that you didn't die, and other guys did."

The 40-year-old, who was worried about becoming a statistic, is not alone. According to a 2023 report by the U.S. Department of Veterans Affairs , suicide is the second-leading cause of death among veterans under the age of 45. In 2021, 6,392 veterans died by suicide – an average of more than 17 lives lost per day.

'Something in me wasn't right'

In 2007, Certa followed the advice of concerned family members and stopped drinking. It helped. He went back to school, earned a graduate degree in education and began teaching.

But a few years ago, he found himself struggling again. The then-superintendent of the Matawan School District, Joseph "Jay" Majka, was himself a Marine Corps veteran and understood the struggles vets sometimes face.

"I didn't realize how far I was spinning out of control," Certa said. "But my colleagues saw something in me wasn't right, and (Majka) came to me and said, 'Let's get you some help.'"

Mighty Oaks, a faith-based program for military veterans , helped Certa get his life back as he reconnected with his Christian faith. He learned to forgive himself and let go of past mistakes. He still gives back through his church and charities such as Semper Fi & America's Fund and Dylan's Wings of Change .

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Saving lives 'at both ends of the leash'

K9s for Warriors, which paired Certa with Mando, is one of several nonprofits that helps veterans obtain service dogs. It was founded in 2011 by a mom who saw her son struggle with PTSD when he returned from Iraq – but she also noticed he seemed more relaxed when he was with his dog.

Most of the animals K9s for Warriors pairs with veterans are rescue dogs, spokesperson Dani Bozzini said.

"We say we are saving lives at both ends of the leash," she said. "(Rescue dogs) have so much love to give; they're smart and cuddly and we believe in second chances, for the veterans we serve and the dogs."

Dogs are screened for temperament and their ability to obey commands and trained for six to eight months.

The dogs' training includes three main cues: "Look," which tells the dog, in military parlance, to "watch my six," helpful for people wary of enclosed spaces or being unable to see all around themselves; "on my lap," in which the dog acts as a comforting weight and calming presence; and "front," which tells the dog to form a buffer between the veteran and others, mitigating hyper-vigilance they might feel in crowds.

Caring for animals: Veterinary care, animal hospitals are more scarce. That's bad for pets (and their owners)

Veterans, too, go through a screening process, Bozzini said. Once they're matched, veterans and dogs spend three weeks at one of two K9s for Warriors sites, in Florida and Texas, bonding and learning to work together. There's no cost to vets; the expense of training the dogs (around $70,000 for each dog, Bozzini said) and hosting veterans is supported by donors and philanthropic organizations.

Mando and Certa have been together for a year, and Certa said they're nearly inseparable. Mando accompanies him to work each day – the dog has his own school ID card – and he's a hit with students at the middle school where Certa teaches and members of the church youth group Certa leads. About the only time they're apart is when Certa, an ultramarathon runner, is on a long run.

"He helps me so much and it’s awesome that he brings such a positive element to wherever he’s at," Certa said. "There’s no crummy attitude around a dog, you know? He's the best."

Positive outcomes for veterans with dogs

O'Haire said using dogs to help people with physical challenges is nothing new, but having dogs ease mental health conditions such as PTSD and anxiety is a relatively recent innovation. That's part of the reason it hasn't really been studied in depth, she said.

But research was needed, O'Haire said, because funding sources, policy makers and insurance companies all rely on evidence and data. The dogs might not work for everyone, she noted, and they're not the only intervention – talk therapy, medications and continued support also help people struggling with mental health – but dogs can be part of the solution, the study shows.

"As I reflect on almost a decade that I've been studying veterans and service dogs, it's not uncommon for me to hear veterans tell me they wouldn't be alive if not for their dog," O'Haire said.

Certa, who married and became a stepdad to two boys in 2022, said Mando is more than a pet. The dog, along with faith and family, helps sustain him.

"The way he looks at me, the way he nudges me," he said, his voice trailing off a bit. "He needs me as much as I need him."

If you or someone you know needs help, the national suicide and crisis lifeline in the U.S. is available by calling or texting 988. There is also an online chat at  988lifeline.org . Veterans can also visit www.veteranscrisisline.net/ or text 838255 . You do not need to be enrolled in VA benefits or services to receive help.

Contact Phaedra Trethan by email at [email protected], on X (formerly Twitter) @wordsbyphaedra, or on Threads @by_phaedra

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Build a Corporate Culture That Works

There’s a widespread understanding that managing corporate culture is key to business success. Yet few companies articulate their culture in such a way that the words become an organizational reality that molds employee behavior as intended.

All too often a culture is described as a set of anodyne norms, principles, or values, which do not offer decision-makers guidance on how to make difficult choices when faced with conflicting but equally defensible courses of action.

The trick to making a desired culture come alive is to debate and articulate it using dilemmas. If you identify the tough dilemmas your employees routinely face and clearly state how they should be resolved—“In this company, when we come across this dilemma, we turn left”—then your desired culture will take root and influence the behavior of the team.

To develop a culture that works, follow six rules: Ground your culture in the dilemmas you are likely to confront, dilemma-test your values, communicate your values in colorful terms, hire people who fit, let culture drive strategy, and know when to pull back from a value statement.

Start by thinking about the dilemmas your people will face.

Idea in Brief

The problem.

There’s a widespread understanding that managing corporate culture is key to business success. Yet few companies articulate their corporate culture in such a way that the words become an organizational reality that molds employee behavior as intended.

What Usually Happens

How to fix it.

Follow six rules: Ground your culture in the dilemmas you are likely to confront, dilemma-test your values, communicate your values in colorful terms, hire people who fit, let culture drive strategy, and know when to pull back from a value.

At the beginning of my career, I worked for the health-care-software specialist HBOC. One day, a woman from human resources came into the cafeteria with a roll of tape and began sticking posters on the walls. They proclaimed in royal blue the company’s values: “Transparency, Respect, Integrity, Honesty.” The next day we received wallet-sized plastic cards with the same words and were asked to memorize them so that we could incorporate them into our actions. The following year, when management was indicted on 17 counts of conspiracy and fraud, we learned what the company’s values really were.

• EM Erin Meyer is a professor at INSEAD, where she directs the executive education program Leading Across Borders and Cultures. She is the author of The Culture Map: Breaking Through the Invisible Boundaries of Global Business (PublicAffairs, 2014) and coauthor (with Reed Hastings) of No Rules Rules: Netflix and the Culture of Reinvention (Penguin, 2020). ErinMeyerINSEAD

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Greening the food supply chain: Developing sustainable food systems through interdisciplinary collaboration

by University of Connecticut

Sustainability is a hot topic in just about every field that engages with the environment, including agriculture. An interdisciplinary group of researchers in UConn's College of Agriculture, Health and Natural Resources has published a paper outlining the current state of sustainable food production research in the Journal of Agriculture and Food Research .

The group includes Yangchao Luo, associate professor of nutritional sciences; Zhenlei Xiao, associate professor-in-residence of nutritional sciences; and Abhinav Upadhyay, assistant professor of animal science. Bai Qu, Luo's Ph.D. student, is the lead author on the paper.

Sustainable food production focuses on creating food systems that are environmentally sound, economically viable, and socially equitable.

"It focuses on the entire food supply chain, from farm to table, ensuring that each step is sustainable, minimizes waste, and reduces the carbon footprint," Luo says.

The paper outlines the key features of sustainable food production including environmental stewardship , economic vitality, innovation and adaptation, and social responsibility.

The paper also reviews green technologies like urban agriculture , food nanotechnology, and plant-based foods, all of which play a role in reducing the negative impacts of food production.

"This is not a new concept, but I think with the development of emergent technology, a lot of things are going on now, it is very important to revisit this concept," Luo says.

This publication provides a holistic and interdisciplinary perspective on the topic.

"Sustainable food production is a very collaborative topic," Luo says. "You cannot do everything on your own."

Sustainable food production encompasses the concept of a circular economy in which the waste from one process or product can be reused elsewhere.

"People have not cared about the waste generated, the impact to the environment, whether it's sustainable or not," Luo says. "People are pretty much profit driven. Now we have to change the whole concept or else the entire agricultural industry cannot be sustainable."

This paper reflects the College and UConn's broader commitment to sustainability, Luo explains.

"There's many things in the College and at the University, campus-wide, that flow into this area that really inspire me to dive deeper into this topic," Luo says.

Luo, co-chair for CAHNR's committee for sustainable agriculture and food production, is currently working with a group of students to develop an organic poultry feed additive made from microalgae.

"You cannot think about sustainable agriculture from a single discipline," Luo says. "It has to be highly collective and collaborative from all three areas—society, environment, and community health. You have to connect all three angles together."

Provided by University of Connecticut

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A technique for more effective multipurpose robots

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Let’s say you want to train a robot so it understands how to use tools and can then quickly learn to make repairs around your house with a hammer, wrench, and screwdriver. To do that, you would need an enormous amount of data demonstrating tool use.

Existing robotic datasets vary widely in modality — some include color images while others are composed of tactile imprints, for instance. Data could also be collected in different domains, like simulation or human demos. And each dataset may capture a unique task and environment.

It is difficult to efficiently incorporate data from so many sources in one machine-learning model, so many methods use just one type of data to train a robot. But robots trained this way, with a relatively small amount of task-specific data, are often unable to perform new tasks in unfamiliar environments.

In an effort to train better multipurpose robots, MIT researchers developed a technique to combine multiple sources of data across domains, modalities, and tasks using a type of generative AI known as diffusion models.

They train a separate diffusion model to learn a strategy, or policy, for completing one task using one specific dataset. Then they combine the policies learned by the diffusion models into a general policy that enables a robot to perform multiple tasks in various settings.

In simulations and real-world experiments, this training approach enabled a robot to perform multiple tool-use tasks and adapt to new tasks it did not see during training. The method, known as Policy Composition (PoCo), led to a 20 percent improvement in task performance when compared to baseline techniques.

“Addressing heterogeneity in robotic datasets is like a chicken-egg problem. If we want to use a lot of data to train general robot policies, then we first need deployable robots to get all this data. I think that leveraging all the heterogeneous data available, similar to what researchers have done with ChatGPT, is an important step for the robotics field,” says Lirui Wang, an electrical engineering and computer science (EECS) graduate student and lead author of a paper on PoCo .      

Wang’s coauthors include Jialiang Zhao, a mechanical engineering graduate student; Yilun Du, an EECS graduate student; Edward Adelson, the John and Dorothy Wilson Professor of Vision Science in the Department of Brain and Cognitive Sciences and a member of the Computer Science and Artificial Intelligence Laboratory (CSAIL); and senior author Russ Tedrake, the Toyota Professor of EECS, Aeronautics and Astronautics, and Mechanical Engineering, and a member of CSAIL. The research will be presented at the Robotics: Science and Systems Conference.

Combining disparate datasets

A robotic policy is a machine-learning model that takes inputs and uses them to perform an action. One way to think about a policy is as a strategy. In the case of a robotic arm, that strategy might be a trajectory, or a series of poses that move the arm so it picks up a hammer and uses it to pound a nail.

Datasets used to learn robotic policies are typically small and focused on one particular task and environment, like packing items into boxes in a warehouse.

“Every single robotic warehouse is generating terabytes of data, but it only belongs to that specific robot installation working on those packages. It is not ideal if you want to use all of these data to train a general machine,” Wang says.

The MIT researchers developed a technique that can take a series of smaller datasets, like those gathered from many robotic warehouses, learn separate policies from each one, and combine the policies in a way that enables a robot to generalize to many tasks.

They represent each policy using a type of generative AI model known as a diffusion model. Diffusion models, often used for image generation, learn to create new data samples that resemble samples in a training dataset by iteratively refining their output.

But rather than teaching a diffusion model to generate images, the researchers teach it to generate a trajectory for a robot. They do this by adding noise to the trajectories in a training dataset. The diffusion model gradually removes the noise and refines its output into a trajectory.

This technique, known as Diffusion Policy , was previously introduced by researchers at MIT, Columbia University, and the Toyota Research Institute. PoCo builds off this Diffusion Policy work. 

The team trains each diffusion model with a different type of dataset, such as one with human video demonstrations and another gleaned from teleoperation of a robotic arm.

Then the researchers perform a weighted combination of the individual policies learned by all the diffusion models, iteratively refining the output so the combined policy satisfies the objectives of each individual policy.

Greater than the sum of its parts

“One of the benefits of this approach is that we can combine policies to get the best of both worlds. For instance, a policy trained on real-world data might be able to achieve more dexterity, while a policy trained on simulation might be able to achieve more generalization,” Wang says.

Because the policies are trained separately, one could mix and match diffusion policies to achieve better results for a certain task. A user could also add data in a new modality or domain by training an additional Diffusion Policy with that dataset, rather than starting the entire process from scratch.

The researchers tested PoCo in simulation and on real robotic arms that performed a variety of tools tasks, such as using a hammer to pound a nail and flipping an object with a spatula. PoCo led to a 20 percent improvement in task performance compared to baseline methods.

“The striking thing was that when we finished tuning and visualized it, we can clearly see that the composed trajectory looks much better than either one of them individually,” Wang says.

In the future, the researchers want to apply this technique to long-horizon tasks where a robot would pick up one tool, use it, then switch to another tool. They also want to incorporate larger robotics datasets to improve performance.

“We will need all three kinds of data to succeed for robotics: internet data, simulation data, and real robot data. How to combine them effectively will be the million-dollar question. PoCo is a solid step on the right track,” says Jim Fan, senior research scientist at NVIDIA and leader of the AI Agents Initiative, who was not involved with this work.

This research is funded, in part, by Amazon, the Singapore Defense Science and Technology Agency, the U.S. National Science Foundation, and the Toyota Research Institute.

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