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 ====== Posttraumatic Stress Disorder (PTSD) ====== ====== Posttraumatic Stress Disorder (PTSD) ======
 +{{INLINETOC}}
 +
 ===== Primer ===== ===== Primer =====
 **Posttraumatic Stress Disorder (PTSD) ** is a mental disorder diagnosed after an exposure to trauma, including actual or threatened death, serious injury, or sexual violation. It is characterized by intrusive and distressing memories or dreams, dissociative reactions, and substantial psychological or physiological distress related to the event. A diagnosis of PTSD requires evidence of exposure to trauma, and is characterized by intrusive and dissociative symptoms. **Posttraumatic Stress Disorder (PTSD) ** is a mental disorder diagnosed after an exposure to trauma, including actual or threatened death, serious injury, or sexual violation. It is characterized by intrusive and distressing memories or dreams, dissociative reactions, and substantial psychological or physiological distress related to the event. A diagnosis of PTSD requires evidence of exposure to trauma, and is characterized by intrusive and dissociative symptoms.
  
 == Epidemiology == == Epidemiology ==
-The lifetime prevalence of PTSD is around 6-9%, and up to 30% in US Vietnam veterans.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC5047000/​|Reisman,​ M. (2016). PTSD Treatment for Veterans: What’s Working, What’s New, and What’s Next. Pharmacy and Therapeutics,​ 41(10), 623.]])] It is more frequent in women than in men, with an onset generally in the mid to late 20s. PTSD is associated with high rates of functional impairment, somatic complaints, suicide risk, and comorbid psychiatric disorders. ​+  * The lifetime prevalence of PTSD is around 6-9%, and up to 30% in US Vietnam ​War veterans.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC5047000/​|Reisman,​ M. (2016). PTSD Treatment for Veterans: What’s Working, What’s New, and What’s Next. Pharmacy and Therapeutics,​ 41(10), 623.]])] 
 +    * Rates are also higher in emergency service personnel, including fire fighters, police officers, and paramedics 
 +    * Survivors of rape, military combat, captivity, and wars are also at increased risk.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)] 
 +  * It is more frequent in women than in men (2:1), with an onset generally in the mid to late 20s. PTSD is associated with high rates of functional impairment, somatic complaints, suicide risk, and comorbid psychiatric disorders. 
 + 
 +== Prognosis == 
 +  * PTSD can occur at any point in life, beginning after age 1.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)] 
 +  * Symptoms usually begin within the first 3 months after trauma, although for some there may be a delay of months or years before the criteria for a full diagnosis is met. 
 +  * PTSD symptoms can be chronic, lasting years to decades after the initial trauma.[([[https://​pubmed.ncbi.nlm.nih.gov/​1575259/​|Breslau,​ N., & Davis, G. C. (1992). Posttraumatic stress disorder in an urban population of young adults: risk factors for chronicity. The American journal of psychiatry.]])][([[https://​pubmed.ncbi.nlm.nih.gov/​21220059/​|North,​ C. S., Pfefferbaum,​ B., Kawasaki, A., Lee, S., & Spitznagel, E. L. (2011). Psychosocial adjustment of directly exposed survivors 7 years after the Oklahoma City bombing. Comprehensive Psychiatry, 52(1), 1-8.]])] 
 +  * However, individuals generally have substantially improved occupational functioning at work, relationships,​ and social interactions.[([[https://​pubmed.ncbi.nlm.nih.gov/​20305079/​|Rasco,​ S. S., & North, C. S. (2010). An empirical study of employment and disability over three years among survivors of major disasters. Journal of the American Academy of Psychiatry and the Law Online, 38(1), 80-86.]])] 
 +  * Long-term employment disability related to PTSD is also rare. In general, clinicians and patients should expect that functioning will improve significantly over the long term, even if posttraumatic stress symptoms remain. 
 +  * Individuals with PTSD are at an increased risk for suicidal ideation and suicide attempts, and the risk is increased by 2 to 3-fold.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)][([[https://​pubmed.ncbi.nlm.nih.gov/​25081580/​|Katzman,​ M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., & Van Ameringen, M. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC psychiatry, 14(1), 1-83.]])] 
 + 
 +== Comorbidity == 
 +  * Individuals with PTSD and 80% more likely than those without PTSD to meet criteria for another mental disorder, including depressive disorders, anxiety disorders, substance use disorders (in particular alcohol use disorder), and [[personality:​borderline|borderline personality disorder]]. 
 +    * Individuals with comorbid borderline personality disorder and PTSD have a greater risk for suicide than individuals with either diagnosis alone. 
 +  * Close to half of individuals seeking substance use disorder treatment also meet criteria for current PTSD, and individuals with co-occurring disorders tend to have poorer treatment outcomes compared with those without such comorbidity. 
 +  * Substance use disorder and conduct disorder is more common among males with PTSD than females 
 +  * Recent data from veterans in the Afghanistan and Iraq wars, have found that PTSD and mild traumatic brain injuries had a cooccurrence of 48%. 
 +  * In children with PTSD, oppositional defiant disorder and separation anxiety disorder are the predominant comorbidities. 
 + 
 +== Risk Factors == 
 +  * Epidemiological research on PTSD has shown consistently that //​pre-existing psychopathology//​ is a strong predictor of PTSD following a trauma exposure. Thus, these comorbid conditions should also be treated concurrently with PTSD. Pre-trauma risk factors for developing PTSD include: 
 +    * A history of childhood emotional problems, prior mental disorders such as panic disorder, depressive disorder, or obsessive compulsive disorder, and a family history of psychiatric disorders. 
 +    * Environmental risk factors include lower socioeconomic status, lower education and intelligence,​ childhood adversity, and cultural characteristics 
 +    * Female gender and certain genotypes may also increase one's risk for PTSD 
 +  * Peritrauma factors (risk factors at the time of the trauma) include severity of the trauma, degree of perceived threat to life, personal injury, degree of interpersonal violence, and for military personnel, whether or not they were a perpetrator or witness to a killing of an enemy. 
 +  * Temperamental traits such as inappropriate coping strategies and negative appraisals are risk factors. 
 +  * Individuals with the support of social networks such as family stability is an important protective factor. 
 + 
 +== Cultural == 
 +<alert icon="​fa fa-arrow-circle-right fa-lg fa-fw" type="​success">​ 
 +See also article: **[[anxiety:​z-other-specified-anxiety|]]** 
 +</​alert>​ 
 +  * PTSD can be expressed differently in various cultural contexts (similar to panic attacks and [[anxiety:​panic|panic disorder]]).[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)] Thus, having an understanding of the cultural concepts of disease and mental disorders is important when assessing symptoms in a cultural context.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)] 
 +    * In Hispanic individuals,​ //ataque de nervios// ("​attack of nerves"​) is a cultural syndrome used frequently to describe symptoms of intense emotional upset including acute anxiety, anger, or grief, screaming and shouting uncontrollably,​ attacks of crying, trembling, feeling of heat in the chest rising into the head, and verbal and physical aggression.[([[https://​pubmed.ncbi.nlm.nih.gov/​8184996/​|Liebowitz,​ M. R., Salmán, E., Jusino, C. M., Garfinkel, R., Street, L., Cárdenas, D. L., ... & Davies, S. (1994). Ataque de nervios and panic disorder. The American journal of psychiatry.]])] Some individuals may even report dissociative episodes. 
 +    * In Cambodians, "//​Khyâl//​ attacks"​ (//khyâl cap//) or "wind attacks"​ include palpitations,​ shortness of breath, dizziness, and cold extremities. Individuals also have other symptoms of anxiety and autonomic arousal such as neck soreness and tinnitus.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)] 
 +===== DSM-5 Diagnostic Criteria ===== 
 +<​callout>​ 
 +**Note**: The following criteria below apply to adults, adolescents,​ and children older than ''​6''​ years. For children ''​6''​ years and younger, refer to specific alternative criteria. 
 +</​callout>​
  
-===== Diagnostic Criteria ===== 
 == Criterion A (Exposure) == == Criterion A (Exposure) ==
 **Exposure to actual or threatened death, serious injury, or sexual violence** in at least ''​1''​ of the following ways: **Exposure to actual or threatened death, serious injury, or sexual violence** in at least ''​1''​ of the following ways:
-<WRAP group> 
-<WRAP half column> 
   - Directly experiencing the traumatic event(s).   - Directly experiencing the traumatic event(s).
   - Witnessing, in person, the event(s) as it occurred to others.   - Witnessing, in person, the event(s) as it occurred to others.
   - Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.   - Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
   - Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g. - first responders collecting human remains or police officers repeatedly exposed to details of child abuse).   - Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g. - first responders collecting human remains or police officers repeatedly exposed to details of child abuse).
-</​WRAP>​ 
-<WRAP half column> 
-<callout type="​info"​ icon="​true">​Note:​ Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.</​callout>​ 
-</​WRAP>​ 
-</​WRAP>​ 
  
 +<​callout>​
 +**Note**: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.
 +</​callout>​
  
- 
-<WRAP group> 
-<WRAP half column> 
 == Criterion B (Intrusion Symptoms) == == Criterion B (Intrusion Symptoms) ==
 **Presence of at least ''​1''​ of the following intrusion symptoms associated with the traumatic event(s)**, beginning after the traumatic event(s) occurred: **Presence of at least ''​1''​ of the following intrusion symptoms associated with the traumatic event(s)**, beginning after the traumatic event(s) occurred:
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   - **Marked physiological reactions to internal or external cues** that symbolize or resemble an aspect of the traumatic event(s).   - **Marked physiological reactions to internal or external cues** that symbolize or resemble an aspect of the traumatic event(s).
  
-</​WRAP>​ 
- 
-<WRAP half column> 
 == Criterion C (Avoidance) == == Criterion C (Avoidance) ==
 **Persistent avoidance of stimuli** associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by ''​1''​ or all of the following: **Persistent avoidance of stimuli** associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by ''​1''​ or all of the following:
   - Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).   - Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
   - Avoidance of or efforts to avoid external reminders (people, places, conversations,​ activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).   - Avoidance of or efforts to avoid external reminders (people, places, conversations,​ activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
-</​WRAP>​ 
-</​WRAP>​ 
  
- 
- 
-<WRAP group> 
-<WRAP half column> 
 == Criterion D (Negative Cognition and Mood) == == Criterion D (Negative Cognition and Mood) ==
 **Negative alterations in cognitions and mood** associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by at least ''​2''​ of the following: **Negative alterations in cognitions and mood** associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by at least ''​2''​ of the following:
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   - **Feelings of detachment** or estrangement from others.   - **Feelings of detachment** or estrangement from others.
   - **Persistent inability to experience positive emotions** (e.g., inability to experience happiness, satisfaction,​ or loving feelings).   - **Persistent inability to experience positive emotions** (e.g., inability to experience happiness, satisfaction,​ or loving feelings).
-</​WRAP>​ 
  
-<WRAP half column> 
 == Criterion E (Changes in Arousal) == == Criterion E (Changes in Arousal) ==
 **Marked alterations in arousal and reactivity** associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by at least ''​2''​ of the following: **Marked alterations in arousal and reactivity** associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by at least ''​2''​ of the following:
- 
   - **Irritable behavior and angry outbursts** (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.   - **Irritable behavior and angry outbursts** (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.
   - **Reckless or self-destructive** behavior   - **Reckless or self-destructive** behavior
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   - **Problems with concentration**   - **Problems with concentration**
   - **Sleep disturbance** (e.g., difficulty falling or staying asleep or restless sleep).   - **Sleep disturbance** (e.g., difficulty falling or staying asleep or restless sleep).
-</​WRAP>​ 
-</​WRAP>​ 
  
- 
-<WRAP group> 
-<WRAP third column> 
 == Criterion F == == Criterion F ==
 Duration (Criteria B, C, D, and E) is more than ''​1''​ month. Duration (Criteria B, C, D, and E) is more than ''​1''​ month.
-</​WRAP>​ 
  
-<WRAP third column> 
 == Criterion G == == Criterion G ==
 The disturbance causes clinically significant distress or impairment in social, occupational,​ or other important areas of functioning. The disturbance causes clinically significant distress or impairment in social, occupational,​ or other important areas of functioning.
-</​WRAP>​ 
  
-<WRAP third column> 
 == Criterion H == == Criterion H ==
-The disturbance is not attributable to the physiological effects of a substance (e.g.medication, alcohol) or another medical condition. +The disturbance is not attributable to the physiological effects of a substance (e.g. medication, alcohol) or another medical condition.
-</​WRAP>​ +
-</​WRAP>​ +
- +
- +
- +
- +
-== Specifiers == +
-<​accordion collapsed="​true">​ +
-<panel icon="​fa fa-search-plus"​ size="​xs"​ title="​Specifiers">​ +
-**Specify if:** +
-Specify whether: +
-  * **With dissociative symptoms**: The individual’s symptoms meet the criteria for post traumatic stress disorder, and the individual experiences persistent or recurrent symp toms of either of the following:​ +
-  * **1. Depersonalization:​** Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly). +
-  * **2. Derealization:​** Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted). Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g., blackouts) or another medical condition (e.g., complex partial seizures). +
-  * **With delayed expression**:​ If the full diagnostic criteria are not met until at least 6 months after the event (although the onset and expression of some symptoms may be immediate). +
-</​panel>​ +
-</​accordion>​ +
-</​WRAP>​ +
-</​WRAP>​+
  
 <callout icon="​fa fa-lightbulb-o"​ type="​success"​ title="​Mnemonic">​ <callout icon="​fa fa-lightbulb-o"​ type="​success"​ title="​Mnemonic">​
 The clinical presentation of PTSD can be remembered by the mnemonic **''​TRAUMA''​**[(https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC1071434/​)] The clinical presentation of PTSD can be remembered by the mnemonic **''​TRAUMA''​**[(https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC1071434/​)]
-<​HTML><​br><​br></​HTML>​ 
   * ''​**T**''​ - **Traumatic event** (experienced,​ witnessed, or was confronted, and the person experienced intense helplessness,​ fear, and horror)   * ''​**T**''​ - **Traumatic event** (experienced,​ witnessed, or was confronted, and the person experienced intense helplessness,​ fear, and horror)
   * ''​**R**''​ - **Re-experiencing** (intrusive thoughts, nightmares, flashbacks, or traumatic memories/​images)   * ''​**R**''​ - **Re-experiencing** (intrusive thoughts, nightmares, flashbacks, or traumatic memories/​images)
   * ''​**A**''​ - **Avoidance** (emotional numbing, detachment from others, flattening of affect, loss of interest, lack of motivation, and persistent avoidance of things associated with the traumatic experience)   * ''​**A**''​ - **Avoidance** (emotional numbing, detachment from others, flattening of affect, loss of interest, lack of motivation, and persistent avoidance of things associated with the traumatic experience)
-  * ''​**U**''​ - **Unable to function** (symptoms ​are distressing and cause significant impairment in social, occupational,​ and interpersonal life)+  * ''​**U**''​ - **Unable to function** (symptoms ​cause negative mood, distress, or cause significant impairment in social, occupational,​ and interpersonal life)
   * ''​**M**''​ - **1 month of symptoms** (at least)   * ''​**M**''​ - **1 month of symptoms** (at least)
   * ''​**A**''​ - **Arousal increased** (insomnia, poor concentration,​ irritable, angry, startle reflex, hypervigilance)   * ''​**A**''​ - **Arousal increased** (insomnia, poor concentration,​ irritable, angry, startle reflex, hypervigilance)
 </​callout>​ </​callout>​
  
-===== Pathophysiology ​===== +==== Specifiers ​==== 
-The amygdala, hippocampus, and prefrontal cortex are all involved in the stress responseTraumatic stress can be associated with lasting changes ​in these brain areasIndividuals with PTSD have smaller hippocampal and anterior cingulate volumesincreased amygdala functionand decreased medial prefrontal/​anterior cingulate functionPatients with PTSD also show increased cortisol and norepinephrine responses ​to stress.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181836/​|Bremner,​ J. D. (2006). Traumatic stresseffects on the brain. Dialogues in clinical neuroscience,​ 8(4), 445.]])]+<WRAP group> 
 +<WRAP half column>​ 
 +<panel icon="fa fa-search-plus"​ size="​xs"​ title="​Specifiers">​ 
 +**Specify whether:​** 
 +  * **With dissociative symptoms**: ​The individual’s symptoms meet the criteria for PTSD, and the individual experiences persistent or recurrent symptoms of either of the following:​ 
 +    - **Depersonalization:​** Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental processes or body (e.g. - feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly). 
 +    - **Derealization:​** Persistent or recurrent experiences of unreality of surroundings (e.g. - the world around the individual is experienced as unrealdreamlikedistant, or distorted) 
 +<​callout>​ 
 +**Note**: To use this subtype, the dissociative symptoms must not be attributable ​to the physiological effects of a substance (e.g. - blackouts) or another medical condition ​(e.g. - [[neurology:approach-seizures|complex partial seizures]]). 
 +</callout>​ 
 +</panel> 
 +</WRAP> 
 +<WRAP half column>​ 
 +<panel icon="​fa fa-search-plus"​ size="​xs"​ title="​Specifiers">​ 
 +**Specify if:** 
 +  * **With delayed expression**:​ If the full diagnostic criteria are not met until at least ''​6''​ months after the event (although the onset and expression of some symptoms may be immediate). 
 +</​panel>​ 
 +</​WRAP>​ 
 +</​WRAP>​
  
-Brain imaging studies ​have shown alterations ​in a circuit including medial prefrontal cortex ​(including anterior cingulate), hippocampus, ​and amygdala ​in PTSD.+==== Signs and Symptoms ==== 
 +  * Following severe and repeated traumatic events, an individual may experience difficulty with regulation of emotion or keeping interpersonal relationships. Dissociative symptoms may also develop. 
 +  * Individuals may be engaged in high-risk activities such as dangerous driving, excessive substance use, or self-injurious behaviours.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)] 
 +  * The presentation of PTSD can vary greatly. 
 +    * In some individuals,​ the predominant presentation is marked by fear-based re-experiencing of trauma, and behavioural symptoms. 
 +    * For other individuals,​ dysphoria and negative thoughts may be the predominant symptoms. 
 +    * Finally, others may have dissociative symptoms as the predominant presentation.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)] 
 +==== Diagnostic Pearls ==== 
 +  * PTSD is unique among the psychiatric diagnoses ​in that it requires ​specific external event as part of the diagnostic criteria. Incorrect application of the trauma exposure criterion ​(Criterion Aby clinicians and researchers has led to misdiagnosis and erroneously high prevalence rates of PTSD.[([[https://​pubmed.ncbi.nlm.nih.gov/​27724836/​|NorthC. S. (2016). Disaster mental health epidemiology:​ methodological review ​and interpretation of research findings. Psychiatry, 79(2), 130-146.]])] 
 +  * It is important to recognize that for the majority of individuals,​ exposure to trauma does **not** result ​in PTSD. The symptoms from PTSD must be linked temporally and conceptually to the traumatic exposure to qualify as PTSD symptom.
  
-===== Differential ​Diagnosis ​=====+<​imgcaption image1|>​ 
 +{{ :​trauma-and-stressors:​ptsd_algorithm.png?​direct&​900 |PTSD Diagnosis ​Algorithm (Adapted from: Downs, D. L. (2018). PTSD: A systematic approach to diagnosis and treatment. Current Psychiatry, 17(4), 35.}} 
 +</​imgcaption>​
  
-===== Investigations ​=====+===== Diagnostic Criteria (6 Years and Younger) ​===== 
 +== Criterion A == 
 +In children 6 years and younger, exposure to actual or threatened death, serious injury, or sexual violence in ''​1''​ (or more) of the following ways: 
 +  - Directly experiencing the traumatic event(s). 
 +  - Witnessing, in person, the event(s) as it occurred to others, especially primary caregivers. 
 +  - Learning that the traumatic event(s) occurred to a parent or caregiving figure.
  
-===== Treatment ===== +<​callout>​ 
-The following treatment recommendations are based on the 2014 Canadian Clinical Practice Guidelines for anxiety, posttraumatic stress and obsessive-compulsive disorders:[([[https://​bmcpsychiatry.biomedcentral.com/​track/​pdf/​10.1186/​1471-244X-14-S1-S1?​site=bmcpsychiatry.biomedcentral.com|Katzman MABleau PBlier Pet al. Canadian clinical practice guidelines for the management of anxietyposttraumatic stress and obsessive-compulsive disordersBMC Psychiatry. 2014;​14(Suppl 1):S1.]])]+**Note**For Criterion A2witnessing does not include events that are witnessed only in electronic mediatelevisionmoviesor pictures. 
 +</​callout>​
  
-==== Medication ==== +== Criterion B == 
-Treatment should start with one of the first-line optionseither an SSRI or an SNRIIf there is poor response ​or tolerability, ​the patient should be switched ​to another firstor second-line agentAlternatively,​ a second-line agent can be added (patients with PTSD may make few gains during treatment, and it is important to preserve even small gains). Augmentation ​with secondor third-line agents can be important early in treatmentPatients who do not respond ​to multiple courses ​of therapy are considered to have treatment-refractory illnessIn such patients it is important ​to reassess ​the diagnosis and consider comorbid medical and psychiatric conditions that may be affecting response to therapy.+Presence of 1 (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: 
 +  ​Recurrentinvoluntary,​ and intrusive distressing memories of the traumatic event(s). 
 +  - Recurrent distressing dreams in which the content and/or affect of the dream are related ​to the traumatic event(s). 
 +  ​Dissociative reactions (e.g. - flashbacks) in which the child feels or acts as if the traumatic event(swere recurring(Such reactions may occur on a continuum, ​with the most extreme expression being a complete loss of awareness of present surroundings.) Such trauma-specific reenactment may occur in play. 
 +  - Intense or prolonged psychological distress at exposure ​to internal or external cues that symbolize or resemble an aspect ​of the traumatic event(s). 
 +  - Marked physiological reactions ​to reminders of the traumatic event(s).
  
-<panel type="​info"​ title="​Pharmacotherapy for Posttraumatic Stress Disorder"​ no-body="​true"​ footer="​*Adjunctive therapy is used in patients who have had an inadequate response to adequate antidepressant therapy, and can be considered for patients with treatment-resistant PTSD."+<callout>​ 
-^ 1st line            | Fluoxetineparoxetinesertralinevenlafaxine XR                                                                                                                                                                                               | +**Note**: For Criterion B1spontaneous and intrusive memories may not necessarily appear distressing ​and may be expressed as play reenactmentFor Criterion B2, it may not be possible to ascertain that the frightening content is related to the traumatic event. 
-^ 2nd line            | Fluvoxaminemirtazapinephenelzine ​                                                                                                                                                                                                            | +</​callout
-^ 3rd line            | Amitriptyline,​ aripiprazolebupropion SRbuspirone, carbamazepine,​ desipramine,​ duloxetine, escitalopram,​ imipramine,​\\ lamotrigine,​ memantine, moclobemide,​ quetiapine, reboxetine, risperidone,​ tianeptine, topiramate, trazodone ​           | + 
-^ Adjunctive therapy*  ​| __Second-line__: eszopiclone,​ olanzapine, risperidone\\ __Third-line__: aripiprazoleclonidinegabapentinlevetiracetampregabalinquetiapinereboxetinetiagabine\\ __Not recommended__bupropion SR, guanfacine, topiramate, zolpidem ​ | +== Criterion C == 
-^ Not recommended ​    | Alprazolamcitalopramclonazepamdesipramine,​ divalproex, olanzapine, tiagabine ​                                                                                                                                                              +''​1''​ (or more) of the following symptomsrepresenting either persistent avoidance of stimuli associated with the traumatic event(s) or negative alterations in cognitions and mood associated with the traumatic event(s)must be presentbeginning after the event(s) or worsening after the event(s): 
-</panel>+ 
 +**Persistent Avoidance of Stimuli** 
 +  - Avoidance of or efforts to avoid activitiesplacesor physical reminders that arouse recollections of the traumatic event(s). 
 +  - Avoidance of or efforts to avoid peopleconversationsor interpersonal situations that arouse recollections of the traumatic event(s). 
 + 
 +**Negative Alterations in Cognitions** 
 +  ​- ​Substantially increased frequency of negative emotional states (e.g. fearguiltsadnessshameconfusion). 
 +  - Markedly diminished interest or participation in significant activitiesincluding constriction of play. 
 +  - Socially withdrawn behavior. 
 +  - Persistent reduction in expression of positive emotions. 
 + 
 +== Criterion D == 
 +Alterations in arousal and reactivity associated with the traumatic event(s)beginning or worsening after the traumatic event(s) occurredas evidenced by ''​2''​ (or more) of the following: 
 + 
 +  - Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects (including extreme temper tantrums). 
 +  - Hypervigilance. 
 +  - Exaggerated startle response. 
 +  - Problems with concentration. 
 +  - Sleep disturbance (e.g. - difficulty falling or staying asleep or restless sleep). 
 + 
 +== Criterion E == 
 +The duration of the disturbance is more than ''​1''​ month 
 + 
 +== Criterion F == 
 +The disturbance causes clinically significant distress or impairment in relationships with parentssiblingspeersor other caregivers or with school behavior. 
 + 
 +== Criterion G == 
 +The disturbance is not attributable to the physiological effects of a substance (e.g. - medication or alcohol) or another medical condition. 
 +===== Screening and Rating Scales ===== 
 +<alert type="​info"​ icon="​fa fa-book fa-lg fa-fw">​ 
 +See also: **[[https://​www.ptsd.va.gov/​professional/​assessment/​list_measures.asp|U.S. Department of Veterans Affairs: National Center for PTSD, List of All Measures]]** 
 +</alert>
  
-<​panel ​type="​info" ​title="​Pharmacotherapy for PTSD-associated nightmares" no-body="​true">​ +<panel title="​PTSD ​Scales" no-body="​true"​
-1st line            ​Prazosin ​                                                                                                                                                                                            +<​mobiletable 1
-2nd line            ​Naltrexonefluphenazine ​                                                                                                                                                                                              |+Name                                                  ^ Rater      ^ Description ​                                                                                                                                                                                                                                    ^ Download ​                                                                             ^ 
 +^ Clinician-Administered PTSD Scale for DSM-5 (CAPS-5)  ​Clinician ​ | The CAPS is a 30-item structured interview that is the gold standard in PTSD assessment. It can be used to make a current (past month) diagnosis of PTSD, lifetime diagnosis of PTSD, and assess severity of PTSD symptoms over the past week.  | [[https://​www.ptsd.va.gov/​professional/​assessment/​adult-int/​caps.asp|Link]] ​          
 +PTSD Checklist for DSM-5 (PCL-5) ​                     ​Patient ​   | The PCL-5 is a 20-item self-report measure that assesses the 20 DSM-5 symptoms of PTSD. The PCL-5 can monitor symptom change during and after treatmentscreening individuals for PTSD, help make a provisional PTSD diagnosis. ​               ​[[https://​www.ptsd.va.gov/​professional/​assessment/​adult-sr/​ptsd-checklist.asp|Link]] ​ | 
 +</​mobiletable>​
 </​panel>​ </​panel>​
 +===== Pathophysiology =====
 +  * The amygdala, hippocampus,​ and prefrontal cortex are all involved in the stress response. Traumatic stress can be associated with lasting changes in these brain areas. Individuals with PTSD have smaller hippocampal and anterior cingulate volumes, increased amygdala function, and decreased medial prefrontal/​anterior cingulate function. Patients with PTSD also show increased cortisol and norepinephrine responses to stress.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3181836/​|Bremner,​ J. D. (2006). Traumatic stress: effects on the brain. Dialogues in clinical neuroscience,​ 8(4), 445.]])]
 +  * Brain imaging studies have shown alterations in a circuit including medial prefrontal cortex (including anterior cingulate), hippocampus,​ and amygdala in PTSD.
 +
 +===== Differential Diagnosis =====
 +<WRAP group>
 +<WRAP half column>
 +  * **[[trauma-and-stressors:​adjustment|Adjustment disorder]]**
 +    * In adjustment disorder, the stressor can be of any severity or type and not just a traumatic event as defined by the PTSD criterion. Adjustment disorder should be diagnosed when there is a trauma, but the individual does not meet all other PTSD criteria.
 +  * **[[trauma-and-stressors:​acute|Acute stress disorder]]**
 +    * In acute stress disorder, there is a restriction of the duration of symptoms being between 3 days to 1 month following exposure to the traumatic event.
 +  * **[[anxiety:​home|Anxiety disorders]]**
 +    * The arousal and dissociative symptoms of panic disorder, and the avoidance, irritability,​ and anxiety of generalized anxiety disorder are not linked to a specific traumatic event. The symptoms of separation anxiety disorder are clearly related to separation from home or family, rather than to a specific traumatic event.
 +  * **[[ocd:​1-ocd|Obsessive-compulsive disorder]]**
 +    * In OCD, there are also recurrent intrusive thoughts, but these meet the definition of an obsession. Importantly,​ the intrusive thoughts are not related to an experienced traumatic event. Compulsions are also usually present in OCD, while this is absent in PTSD.
 +  * **[[mood:​1-depression:​home|Major depressive disorder]]**
 +    * Major depression does not include any intrusion (Criterion B) or avoidance (Criterion C) symptoms.
 +  * **[[:​personality|Personality disorders]]**
 +    * Interpersonal difficulties that develop after a trauma would suggest PTSD, rather than a personality disorder, which is more long-standing. A detailed psychiatric history can help elicit this difference.
 +</​WRAP>​
 +<WRAP half column>
 +  * **[[dissociative-disorders:​home|Dissociative disorders]]**
 +    * In dissociative amnesia, dissociative identity disorder, and depersonalization-derealization disorder, an experienced trauma with temporal association is not needed. If PTSD criteria are met, the "with dissociative symptoms subtype"​ of PTSD should be considered.
 +  * **[[somatic:​dsm-5:​conversion|Conversion disorder (functional neurological symptom disorder)]]**
 +    * New onset of somatic symptoms within the context of a traumatic event would suggest PTSD over conversion disorder.
 +  * **[[psychosis:​home|Psychotic disorders]] and others**
 +    * Flashbacks in PTSD must be distinguished from illusions, hallucinations,​ and other perceptual disturbances that may occur psychotic disorders, or psychotic symptoms in mood disorders. Other disorders include [[cl:​1-delirium|delirium]],​ substance/​medication-induced disorders, and psychotic disorders due to another medical condition.
 +  * **[[cl:​tbi|Traumatic brain injury]]**
 +    * When a brain injury occurs in the context of a traumatic event (e.g. - traumatic accident, bomb blast, acceleration/​deceleration trauma), PTSD can develop. Thus, traumatic brain injury (TBI)-related neurocognitive symptoms and PTSD are not mutually exclusive diagnoses and may occur concurrently. Differentiating between the two may be challenging. One difference is that while reexperiencing and avoidance are seen in PTSD, executive dyusfunction,​ disorientation and confusion are more specific to TBI.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)]
 +</​WRAP>​
 +</​WRAP>​
 +===== Investigations =====
 +  * As clinically indicated.
 +===== Treatment =====
 +
 +==== Prevention and Early Intervention ====
 +<WRAP group>
 +<WRAP half column>
 +
 +  * Meta-analyses currently do not support the widespread use of individual psychological debriefing in reducing the intensity of PTSD symptoms.
 +  * The evidence for group debriefings is unclear at this time, and is still commonly done in first-responder settings (police, fire, ambulance).
 +  * Multisession trauma-focused cognitive behavioural therapy can be helpful for individuals with PTSD or acute stress disorder.[([[https://​pubmed.ncbi.nlm.nih.gov/​25081580/​|Katzman,​ M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., & Van Ameringen, M. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC psychiatry, 14(1), 1-83.]])]
 +    * Thus, screening for and treating appropriate individuals is recommended over debriefing all trauma victims.
 +  * The data on use of pharmacotherapy to prevent PTSD symptoms at the time of trauma is limited.[([[https://​pubmed.ncbi.nlm.nih.gov/​25081580/​|Katzman,​ M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., & Van Ameringen, M. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC psychiatry, 14(1), 1-83.]])]
 +</​WRAP>​
 +<WRAP half column>
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 +
 +==== Acupuncture ====
 +  * Verum acupuncture has been shown to be effective in reducing PTSD symptoms and enhancing fear extinction in combat veterans.[([[https://​pubmed.ncbi.nlm.nih.gov/​38381417/​|Hollifield,​ M., Hsiao, A. F., Smith, T., Calloway, T., Jovanovic, T., Smith, B., ... & Cocozza, K. (2024). Acupuncture for combat-related posttraumatic stress disorder: a randomized clinical trial. JAMA psychiatry.]])]
 ==== Psychotherapy ==== ==== Psychotherapy ====
-Trauma-Focused ​CBT (TF-CBT), ​Prolonged Exposure ​(PE) therapy, and Cognitive Processing Therapy ​(CPT) has significant efficacy.+<WRAP group> 
 +<WRAP half column>​ 
 +  * Both pharmacotherapy and psychotherapy are effective for the treatment of PTSD. 
 +    * Research has not conclusively shown either treatment modality to be superior than the other.[([[https://​pubmed.ncbi.nlm.nih.gov/​25081580/​|Katzman,​ M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., & Van Ameringen, M. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC psychiatry, 14(1), 1-83.]])] 
 +  * [[psychotherapy:​cbt|Cognitive behavioural therapy]] is a first-line treatment for PTSD.[([[https://​pubmed.ncbi.nlm.nih.gov/​25081580/​|Katzman,​ M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., & Van Ameringen, M. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC psychiatry, 14(1), 1-83.]])] 
 +  * [[psychotherapy:​cpt|Cognitive processing therapy (CPT)]], trauma-focused ​CBT (TF-CBT), ​and prolonged exposure ​(PE) therapy ​are also effective treatments.[([[https://​pubmed.ncbi.nlm.nih.gov/​25081580/​|KatzmanM. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., & Van Ameringen, M. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress ​and obsessive-compulsive disorders. BMC psychiatry, 14(1), 1-83.]])] 
 +  * [[https://​www.ptsd.va.gov/​professional/​treat/​txessentials/​written_exposure_therapy.asp|Written exposure therapy (WET)]] ​has also recently been investigated and shown to be non-inferior to CBT and prolonged exposure therapy. 
 +    * WET is a brief focused therapy that involves individuals writing about their trauma experiences and paying particular attention to their thoughts and emotions that occurred at the time of the event, without a need for //in vivo// exposure 
 +  * [[psychotherapy:​emdr-eye-movement-desensitization|Eye movement desensitization and reprocessing therapy (EMDR)]] has also emerged as a trauma-focused therapy with effectiveness. 
 +  * Following treatment with psychotherapy,​ benefits can be maintained between 1 to 10 years. 
 +  * In children, art therapy, play therapy, and family therapy (without the perpetrators of the trauma) can also be helpful.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC6374007/​|Van Westrhenen, N., Fritz, E., Vermeer, A., Boelen, P., & Kleber, R. (2019). Creative arts in psychotherapy for traumatized children in South Africa: An evaluation study. PloS one, 14(2), e0210857.]])] 
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 +</​WRAP>​ 
 +</​WRAP>​ 
 + 
 + 
 +==== Pharmacotherapy ==== 
 +  * Treatment should start with either a [[meds:​antidepressants:​ssri:​home|selective serotonin reuptake inhibitor]] or a s[[meds:​antidepressants:​snri:​home|erotonin norepinephrine reuptake inhibitor]]. 
 +    * If there is poor response or tolerability,​ the patient should be switched to another first- or second-line agent.  
 +    * Alternatively,​ a second-line agent can be added (patients with PTSD may make few gains during treatment, and it is important to preserve even small gains). 
 +  * Patients who do not respond to multiple courses of therapy are considered to have treatment-refractory symptoms. 
 +    * In these patients, it is important to reassess the diagnosis and consider other comorbid medical and psychiatric conditions that may be affecting response to therapy. 
 +  * Some studies are looking into the role of propranolol reduction of chronic PTSD symptoms, but remains under investigation.[([[https://​pubmed.ncbi.nlm.nih.gov/​29325446/​|Brunet,​ A., Saumier, D., Liu, A., Streiner, D. L., Tremblay, J., & Pitman, R. K. (2018). Reduction of PTSD symptoms with pre-reactivation propranolol therapy: a randomized controlled trial. American Journal of Psychiatry, 175(5), 427-433.]])] 
 +  * **For PTSD-associated nightmares**:​ 
 +    * [[meds:​alpha-1-antagonist-blocker:​prazosin|Prazosin]] can reduce trauma nightmares and improve sleep quality. However, one recent randomized control trial actually found no difference between prazosin and placebo in military veterans with PTSD-associated nightmares.[([[https://​pubmed.ncbi.nlm.nih.gov/​29414272/​|Raskind,​ M. A., Peskind, E. R., Chow, B., Harris, C., Davis-Karim,​ A., Holmes, H. A., ... & Huang, G. D. (2018). Trial of prazosin for post-traumatic stress disorder in military veterans. New England Journal of Medicine, 378(6), 507-517.]])][([[https://​pubmed.ncbi.nlm.nih.gov/​29414268/​|Ressler,​ K. J. (2018). Alpha-adrenergic receptors in PTSD—failure or time for precision medicine?​.]])] 
 +    * [[meds:​opioids:​naltrexone|Naltrexone]] may also reduce flashbacks 
 + 
 +<panel type="​info"​ title="​Pharmacotherapy for Posttraumatic Stress Disorder"​ subtitle="​Katzman,​ M. A. et al. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC psychiatry, 14(S1), S1." no-body="​true"​ footer="​† = If there is a co-morbid substance use disorder, sertraline is recommended as the medication of choice, * = Adjunctive therapy is used in patients who have had an inadequate response to adequate antidepressant therapy, and can be considered for patients with treatment-resistant PTSD.">​ 
 +^ 1st line             | **Monotherapy**:​ [[meds:​antidepressants:​ssri:​fluoxetine|fluoxetine]],​ [[meds:​antidepressants:​ssri:​paroxetine|paroxetine]],​ [[meds:​antidepressants:​ssri:​sertraline|sertraline]]†,​ [[meds:​antidepressants:​snri:​venlafaxine|venlafaxine XR]]                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    | 
 +^ 2nd line             | **Monotherapy**:​ [[meds:​antidepressants:​ssri:​fluvoxamine|fluvoxamine]],​ [[meds:​antidepressants:​nassa:​mirtazapine|mirtazapine]],​ [[meds:​antidepressants:​maoi:​phenelzine|phenelzine]] ​                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         | 
 +^ 3rd line             | **Monotherapy**:​ [[meds:​antidepressants:​tca:​amitriptyline|amitriptyline]],​ [[meds:​antipsychotics:​second-gen-atypical:​3-aripiprazole|aripiprazole]],​ [[meds:​antidepressants:​ndri:​bupropion|bupropion SR]], [[meds:​non-benzo-anxiolytics:​buspirone|buspirone]],​ [[meds:​mood-stabilizers-anticonvulsants:​carbamazepine|carbamazepine]],​ [[meds:​antidepressants:​tca:​desipramine|desipramine]],​ [[meds:​antidepressants:​snri:​duloxetine|duloxetine]],​ [[meds:​antidepressants:​ssri:​escitalopram|escitalopram]],​ [[meds:​antidepressants:​tca:​imipramine|imipramine]],​ [[meds:​mood-stabilizers-anticonvulsants:​lamotrigine|lamotrigine]],​ [[meds:​dementia:​memantine|memantine]],​ [[meds:​antidepressants:​maoi:​moclobemide|moclobemide]],​ [[meds:​antipsychotics:​second-gen-atypical:​6-quetiapine|quetiapine]],​ reboxetine, [[meds:​antipsychotics:​second-gen-atypical:​1-risperidone|risperidone]],​ tianeptine, [[meds:​alcohol:​topiramate|topiramate]],​ [[meds:​antidepressants:​sari:​trazodone|trazodone]] ​ | 
 +^ Adjunctive therapy* ​ | **Second-line**:​ [[meds:​hypnotics:​eszopiclone|eszopiclone]],​ [[meds:​antipsychotics:​second-gen-atypical:​3-olanzapine|olanzapine]],​ [[meds:​antipsychotics:​second-gen-atypical:​1-risperidone|risperidone]]\\ **Third-line**:​ [[meds:​antipsychotics:​second-gen-atypical:​3-aripiprazole|aripiprazole]],​ [[meds:​alpha-2-adrenergic-agonist:​clonidine|clonidine]],​ [[meds:​mood-stabilizers-anticonvulsants:​gabapentin|gabapentin]],​ [[meds:​mood-stabilizers-anticonvulsants:​levetiracetam|levetiracetam]],​ [[meds:​mood-stabilizers-anticonvulsants:​pregabalin|pregabalin]],​ [[meds:​antipsychotics:​second-gen-atypical:​6-quetiapine|quetiapine]],​ reboxetine, tiagabine\\ **Not recommended**:​ [[meds:​antidepressants:​ndri:​bupropion|bupropion SR]], [[meds:​alpha-2-adrenergic-agonist:​guanfacine|guanfacine]],​ [[meds:​alcohol:​topiramate|topiramate]],​ [[meds:​hypnotics:​zolpidem|zolpidem]] ​                                                                                                        | 
 +^ Not recommended ​     | [[meds:​benzos:​3-alprazolam|Alprazolam]],​ [[meds:​antidepressants:​ssri:​citalopram|citalopram]],​ [[meds:​benzos:​2-clonazepam|clonazepam]],​ [[meds:​antidepressants:​tca:​desipramine|desipramine]],​ [[meds:​mood-stabilizers-anticonvulsants:​1-valproic-divalproex|divalproex]],​ [[meds:​antipsychotics:​second-gen-atypical:​3-olanzapine|olanzapine]] (as monotherapy),​ tiagabine ​                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    | 
 +</​panel>​ 
 + 
 + 
 +===== Guidelines ===== 
 +<alert icon="​fa fa-arrow-circle-right fa-lg fa-fw" type="​success">​ 
 +See also: **[[teaching:​clinical-practice-guidelines-cpg|]]** 
 +</​alert>​ 
 + 
 +{{page>​teaching:​clinical-practice-guidelines-cpg#​acute-and-post-traumatic-stress-disorder-ptsd&​nouser&​noheader&​nodate&​nofooter}} 
 ===== Resources ===== ===== Resources =====
 <WRAP group> <WRAP group>
 <WRAP quarter column> <WRAP quarter column>
-==== For Patients ​====+== For Patients ==
   * [[https://​www.ptsd.va.gov/​index.asp|Veteran'​s Affairs: National Center for PTSD]]   * [[https://​www.ptsd.va.gov/​index.asp|Veteran'​s Affairs: National Center for PTSD]]
   * [[https://​www.ptsd.va.gov/​public/​materials/​apps/​ptsdcoach.asp|PTSD Coach (Free App)]]   * [[https://​www.ptsd.va.gov/​public/​materials/​apps/​ptsdcoach.asp|PTSD Coach (Free App)]]
 +  * [[https://​www.amazon.com/​Seeking-Safety-Treatment-Substance-Guilford/​dp/​1572306394/​|Seeking Safety: A Treatment Manual for PTSD and Substance Abuse]]
 </​WRAP>​ </​WRAP>​
  
 <WRAP quarter column> <WRAP quarter column>
 == For Providers == == For Providers ==
-  * [[https://​www.ncbi.nlm.nih.gov/​pmc/articles/PMC3181836/|BremnerJD. (2006). Traumatic ​stress: effects on the brainDialogues in clinical neuroscience8(4), 445.]] +  ​* **[[https://​www.nature.com/articles/nrdp201557|YehudaRet al. (2015). Post-traumatic ​stress ​disorderNature Reviews Disease Primers1(1), 1-22.]]**
-  ​[[https://​www.youtube.com/​watch?​v=g4PErIZDe8A|Dr. Elise Hall : The Complexity of PTSD and HIV (CH MHS Feb 2016)]] +
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   * [[http://​www.mdedge.com/​clinicalpsychiatrynews/​article/​100053/​ptsd/​apa-dsm-5-leaves-one-third-soldiers-subthreshold-ptsd|APA:​ DSM-5 leaves one-third of soldiers with subthreshold PTSD in limbo, expert says]]   * [[http://​www.mdedge.com/​clinicalpsychiatrynews/​article/​100053/​ptsd/​apa-dsm-5-leaves-one-third-soldiers-subthreshold-ptsd|APA:​ DSM-5 leaves one-third of soldiers with subthreshold PTSD in limbo, expert says]]
   * [[https://​www.youtube.com/​watch?​v=2wE6p7j705Q|YouTube:​ How Survivors of Mass Shootings '​Grieve in a Fishbowl'​]]   * [[https://​www.youtube.com/​watch?​v=2wE6p7j705Q|YouTube:​ How Survivors of Mass Shootings '​Grieve in a Fishbowl'​]]
 +  * [[http://​nautil.us/​issue/​30/​identity/​science-is-proving-that-tragic-curses-are-real|Science Is Proving That Tragic Curses Are Real]]
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-==== Research ​==== +== Research == 
-  * [[http://nautil.us/issue/30/identity/science-is-proving-that-tragic-curses-are-real|Science Is Proving That Tragic Curses Are Real]] - Hereditary Trauma+  * [[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181836/|Bremner, J. D. (2006). Traumatic stress: effects on the brain. Dialogues in clinical neuroscience,​ 8(4), 445.]]
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