Posttraumatic Stress Disorder (PTSD)

Posttraumatic stress disorder is a psychiatric disorder that can occur in people who have experienced or witnessed a traumatic event such as a natural disaster, a serious accident, a terrorist act, war/combat, rape or other violent personal assault. PTSD affects approximately 3.5 percent of U.S. adults or 8 million American adults, and an estimated one in 11 people will be diagnosed PTSD in their lifetime. Researchers estimate that as many as 40% of children and adolescents will experience at least one traumatic event in their lifetime. Women are twice as likely as men to have PTSD. There is evidence that it may run in families.

PTSD can occur in all people, in people of any ethnicity, nationality or culture, and any age. People with PTSD have intense, disturbing thoughts and feelings related to their experience that last long after the traumatic event has ended. They may relive the event through flashbacks or nightmares; they may feel sadness, fear or anger; and they may feel detached or estranged from other people. People with PTSD may avoid situations or people that remind them of the traumatic event, and they may have strong negative reactions to something as ordinary as a loud noise or an accidental touch.

Whether a child or teen develops PTSD depends on many factors, including the severity of the trauma, how frequently it occurs, and how family members react to the event. A child or adolescent with PTSD feels that they are unable to escape the impact of the trauma. They try to avoid people or situations that remind them of the event. Sometimes they will experience memories or “flashbacks” of the event, or they may have nightmares about it that feel very real. These constant reminders make living day-to-day life a real challenge, especially for young people who might struggle to express what they’re feeling and experiencing.

A diagnosis of PTSD requires exposure to an upsetting traumatic event. However, exposure could be indirect rather than first hand. For example, PTSD could occur in an individual learning about the violent death of a close family. It can also occur as a result of repeated exposure to horrible details of trauma such as police officers exposed to details of child abuse cases. For people with PTSD the symptoms cause significant distress or problems functioning. PTSD often occurs with other related conditions, such as depression, substance use, memory problems and other physical and mental health problems. For a person to be diagnosed with PTSD, however, symptoms last for more than a month and often persist for months and sometimes years. Many individuals develop symptoms within three months of the trauma, but symptoms may appear later.

 

Symptoms

Common PTSD Symptoms in Children and Teens

  • Avoiding situations that make them recall the traumatic event

  • Experiencing nightmares or flashbacks about the trauma

  • Playing in a way that repeats or recalls the trauma

  • Acting impulsively or aggressively

  • Feeling nervous or anxious frequently

  • Experiencing emotional numbness

  • Having trouble focusing at school

 

Adult Symptoms of PTSD fall into four categories and specific symptoms can vary in severity.

 

  1. Intrusive thoughts such as repeated, involuntary memories; distressing dreams; or flashbacks of the traumatic event. Flashbacks may be so vivid that people feel they are re-living the traumatic experience or seeing it before their eyes.

  2. Avoiding reminders of the traumatic event may include avoiding people, places, activities, objects and situations that bring on distressing memories. People may try to avoid remembering or thinking about the traumatic event. They may resist talking about what happened or how they feel about it.

  3. Negative thoughts and feelings may include ongoing and distorted beliefs about oneself or others (e.g., “I am bad,” “No one can be trusted”); ongoing fear, horror, anger, guilt or shame; much less interest in activities previously enjoyed; or feeling detached or estranged from others.

  4. Arousal and reactive symptoms may include being irritable and having angry outbursts; behaving recklessly or in a self-destructive way; being easily startled; or having problems concentrating or sleeping.

 

Diagnosis criteria that apply to adults, adolescents, and children older than six include those below. 

 

Exposure to actual or threatened death, serious injury, or sexual violation:

  • directly experiencing the traumatic events 

  • witnessing, in person, the traumatic events

  • learning that the traumatic events occurred to a close family member or close friend; cases of actual or threatened death must have been violent or accidental

  • experiencing repeated or extreme exposure to aversive details of the traumatic events (Examples are first responders collecting human remains; police officers repeatedly exposed to details of child abuse). Note: This does not apply to exposure through electronic media, television, movies, or pictures, unless exposure is work-related.

 

The presence of one or more of the following:

  • spontaneous or cued recurrent, involuntary, and intrusive distressing memories of the traumatic events (Note: In children repetitive play may occur in which themes or aspects of the traumatic events are expressed.)

  • recurrent distressing dreams in which the content or affect (i.e. feeling) of the dream is related to the events (Note: In children there may be frightening dreams without recognizable content.)

  • flashbacks or other dissociative reactions in which the individual feels or acts as if the traumatic events are recurring (Note: In children 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 events

  • physiological reactions to reminders of the traumatic events

 

Two or more of the following:

  • inability to remember an important aspect of the traumatic events (not due to head injury, alcohol, or drugs)

  • persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” "The world is completely dangerous"). 

  • persistent, distorted blame of self or others about the cause or consequences of the traumatic events

  • persistent fear, horror, anger, guilt, or shame

  • markedly diminished interest or participation in significant activities

  • feelings of detachment or estrangement from others

  • persistent inability to experience positive emotions

 

Two or more of the following marked changes in arousal and reactivity:

  • irritable or aggressive behavior

  • reckless or self-destructive behavior

  • hypervigilance

  • exaggerated startle response

  • problems with concentration

  • difficulty falling or staying asleep or restless sleep

 

Causes

The cause of PTSD is unknown, but psychological, genetic, physical, and social factors are involved. PTSD changes the body's response to stress. It affects the stress hormones and chemicals that carry information between the nerves. People who have suffered childhood abuse or other previous traumatic experiences are likely to develop the disorder, sometimes months or years after the trauma. Temperamental variables such as externalizing behaviors or other anxiety issues may also increase risk. Other environmental risk factors include family dysfunction, childhood adversity, cultural variables, and family history of psychiatric illness. The greater the magnitude of the trauma, the greater the risk for PTSD—witnessing atrocities, severe personal injury, perpetrating violence. Inappropriate coping mechanisms, lack of social support, family instability, or financial stress may further worsen the outcome.

 

Resilience factors can help reduce the risk of the disorder. Some resilience factors are present before the trauma and others become important during and after a traumatic event. The resilience factors may reduce the risk of PTSD and include seeking out support from other people, such as mental health professionals, friends and family, finding a support group after a traumatic event, feeling good about one’s own actions in the face of danger, having a coping strategy, and being able to act and respond effectively despite feeling fear.

 

Treatment

Treating PTSD in Children and Teens

It’s important to remember that if your child does exhibit trauma symptoms, chances are they will decrease and disappear within a few months. This does not mean, however, that you should not consult with a mental health professional for an assessment and to discuss treatment options when symptoms occur. PTSD is treatable, so never hesitate to ask for help and see what works best. Here are some common treatment options for children with Post-traumatic stress disorder.

 

Cognitive behavioral therapy – CBT is one of the most common forms of “talk therapy,” and therapists can use a trauma-focused style of the therapy to work with children and adults. A trauma-focused CBT therapist helps a child identity and correct irrational or illogical thoughts they might have about the trauma itself or people and situations they encounter in everyday life. CBT also typically includes psychoeducation about relaxation and coping techniques for stress.

 

Play therapy – This type of therapy can work especially well for younger children who struggle to communicate their reactions to the trauma and understanding of what happened. Play therapists use art therapy, games, and other interventions to help a child process a trauma and cope resiliently with life.

 

Eye moment desensitization and reprocessing – EMDR is a technique that is increasingly in popularity among mental health professionals. The therapy incorporates guided eye movement exercises while a child recalls the traumatic event and works through cognitions and emotional responses they have about it.

 

Medication – There is no medication that “cures” PTSD, but sometimes antidepressants and anti-anxiety medication can help relieve symptoms in some children while they are also seeing a therapist.

 

PTSD symptoms frequently co-occur with other types of mental illness or lead to other issues with children and teens, including substance use, risky behaviors, and self-injury. These issues may need to be addressed in treatment as well to protect your child and help them achieve a full recovery.

 

As a parent, you want nothing but the best for your child. So watching them be “held hostage” by trauma symptoms can make you feel powerless and clueless about where you should begin. The best place to begin is by listening to your child and choosing not to ignore their symptoms and struggles. Ally yourself with friends, family, and professionals who support both you and your child. Search for resources at your child’s school, the doctor’s office, or your local community center that can get you pointed in the right direction. Help your child learn to accept trauma and recover from it.

 

Remember, PTSD is treatable, and your child can have a healthy body and mind, free of symptoms and fully in control of their own destiny.

 

Complementary Health Approaches

Recently, many health care professionals have begun to include complementary and alternative methods into treatment regimens.

 

Some methods that have been used for PTSD include:

  • Yoga

  • Aqua therapy

  • Acupuncture

  • Mindfulness and meditation strategies and practices

 

Service dogs are another option for non-traditional therapy for people experiencing PTSD. A service dog is by a person’s side 24 hours a day to help navigate daily stressors. Most animals come to the person pre-trained with a set of commands. The owner can rely upon the dog for help and as a reality grounding tool, which can help prevent a re-experience or other symptoms. These animals can also serve as a social buffer, an incentive to exercise and a de-escalation tool during times of stress.

 

Other strategies for treatment include:

  • Educating trauma survivors and their families about risks related to PTSD, how PTSD affects survivors and their loved ones, and other problems commonly associated with PTSD symptoms. Understanding that PTSD is a medically recognized disorder is essential for effective treatment.

  • Exposure to the event via imagery allows the survivor to re-experience the event in a safe, controlled environment. A professional can carefully examine reactions and beliefs in relation to that event.

  • Examining and resolving strong feelings such as shame, anger, or guilt, which are common among survivors of trauma.

  • Teaching the survivor to cope with post-traumatic memories, reminders, reactions, and feelings without avoiding them or becoming overwhelmed or emotionally numb. Trauma memories usually do not go away entirely as a result of therapy, but new coping skills can make them more manageable.

 

Related Conditions

Acute stress disorder occurs in reaction to a traumatic event, just as PTSD does, and the symptoms are similar. However, the symptoms occur between three days and one month after the event. People with acute stress disorder may relive the trauma, have flashbacks or nightmares and may feel numb or detached from themselves.  These symptoms cause major distress and cause problems in their daily lives. About half of people with acute stress disorder go on to have PTSD.

An estimated 13 to 21 percent of survivors of car accidents develop acute stress disorder and between 20 and 50 percent of survivors of assault, rape or mass shootings develop it.

Psychotherapy, including cognitive behavior therapy can help control symptoms and help prevent them from getting worse and developing into PTSD.  Medication, such as SSRI antidepressants can help ease the symptoms.

 

Adjustment disorder occurs in response to a stressful life event (or events). The emotional or behavioral symptoms a person experiences in response to the stressor are generally more severe or more intense than what would be reasonably expected for the type of event that occurred.

Symptoms can include feeling tense, sad or hopeless; withdrawing from other people; acting defiantly or showing impulsive behavior; or physical manifestations like tremors, palpitations, and headaches. The symptoms cause significant distress or problems functioning in important areas of someone’s life, for example, at work, school or in social interactions. Symptoms of adjustment disorders begin within three months of a stressful event and last no longer than six months after the stressor or its consequences have ended.

The stressor may be a single event (such as a romantic breakup), or there may be more than one event with a cumulative effect. Stressors may be recurring or continuous (such as an ongoing painful illness with increasing disability). Stressors may affect a single individual, an entire family, or a larger group or community (for example, in the case of a natural disaster).

An estimated 5% to 20% of individuals in outpatient mental health treatment have a principal diagnosis of adjustment disorder. A recent study found that more than 15% of adults with cancer had adjustment disorder. It is typically treated with psychotherapy.     

Disinhibited social engagement disorder occurs in children who have experienced severe social neglect or deprivation before the age of 2. Similar to reactive attachment disorder, it can occur when children lack the basic emotional needs for comfort, stimulation and affection, or when repeated changes in caregivers (such as frequent foster care changes) prevent them from forming stable attachments.

Disinhibited social engagement disorder involves a child engaging in overly familiar or culturally inappropriate behavior with unfamiliar adults. For example, the child may be willing to go off with an unfamiliar adult with minimal or no hesitation. These behaviors cause problems in the child’s ability to relate to adults and peers. Moving the child to a normal caregiving environment improves the symptoms. However, even after placement in a positive environment, some children continue to have symptoms through adolescence. Developmental delays, especially cognitive and language delays, may co-occur along with the disorder.

The prevalence of disinhibited social engagement disorder is unknown, but it is thought to be rare. Most severely neglected children do not develop the disorder. Treatment involves the child and family working with a therapist to strengthen their relationship.   

 

Reactive attachment disorder occurs in children who have experienced severe social neglect or deprivation during their first years of life. It can occur when children lack the basic emotional needs for comfort, stimulation and affection, or when repeated changes in caregivers (such as frequent foster care changes) prevent them from forming stable attachments.

Children with reactive attachment disorder are emotionally withdrawn from their adult caregivers. They rarely turn to caregivers for comfort, support or protection or do not respond to comforting when they are distressed. During routine interactions with caregivers, they show little positive emotion and may show unexplained fear or sadness. The problems appear before age 5. Developmental delays, especially cognitive and language delays, often occur along with the disorder.

Reactive attachment disorder is uncommon, even in severely neglected children. Treatment involves the child and family working with a therapist to strengthen their relationship.