Post-traumatic stress disorder (PTSD) is often associated with war veterans. These days, assuming symptoms of PTSD in soldiers returning from combat tours is almost stereotypical. In fact, in the 2012 American Psychological Association (APA) annual meeting, some argue to change PTSD to post-traumatic stress “injury” to be more accommodating to soldiers, and to resolve the issue of unreported PTSD-related symptoms within military ranks (American Psychiatric Association, 2013). Military officials explained that many soldiers do not report their symptoms because of the fear of being viewed as weak (American Psychiatric Association, 2013). However, the incidence of PTSD can be as common among civilians as it is for those in the military. Barlow and Durand (2013) reported recent studies showing that those who are “raped, held captive, tortured, or kidnapped, or badly assaulted” are more at risk for developing PTSD than those who experienced military combat. While the reports conveying “zero” conditional risk of PTSD from exposure to military combat seem to need clarification, PTSD remains to be a debilitating condition for those who have the proclivity to develop the disorder. This paper will discuss the diagnostic criteria, etiology, effective treatment, and outcome research pertaining to PTSD.
PTSD: A trauma and stressor-related disorder PTSD now belongs in the group of trauma and stressor-related disorders as published in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013). Other disorders included in this group are: reactive attachment disorder, disinhibited social engagement disorder, acute stress disorder, and adjustment disorders. Previously, these disorders were classified under anxiety disorders, dissociative disorders, obsessive-compulsive and related disorders (American Psychiatric Association, 2013). The authors of the new DSM recognize that the salient characteristic—significant emotional distress following a traumatic event—of the clinical conditions mentioned above fits better with the classification of trauma and stressor-related disorders (Barlow and Durand, 2013). In anxiety disorders and obsessive-compulsive disorders, symptoms are often associated with persistent irrational thoughts involving fear of an object or an event that can occur but the probability of it actually producing the usually exaggerated feared outcome is slim to none. In PTSD, the symptoms ensuing onset of the disorder can also be anxiety and fear-based but they are more closely associated with emotional distress caused by an actual exposure to or real occurrence of a traumatic or stressful experience such as assault, accidents or receiving fire in combat (American Psychiatric Association, 2013). The same holds true for reactive attachment disorder, disinhibited social engagement disorder, acute stress disorder, and adjustment disorders. In reactive attachment disorder and disinhibited social engagement disorder, the emotional distress is caused by “inappropriate attachment behaviors” while the traumatic experience is identified as “social neglect” during early childhood (American Psychiatric Association, 2013). In reactive attachment disorder, the child often refuses to seek comfort from an adult or parent figure when in distress, whereas in disinhibited social engagement disorder, it is the other way around—the child tends to overly seek attention and comfort not just from caregivers but even from strangers (American Psychiatric Association, 2013). Adjustment disorders also has the same distinctive feature: the incidence of an “identifiable stressor” that causes undue stress (American Psychiatric Association, 2013). Acute stress disorder has a very similar diagnostic criteria as PTSD except that is a shorter reaction to stress. In acute stress disorder, the symptoms “must occur within one month of the traumatic experience and resolve within that one-month period” (American Psychiatric Association, 2013).

Diagnostic Criteria for PTSD
The new DSM 5 identifies “exposure to actual or threatened death, serious injury, or sexual violence” via firsthand experience, observing or seeing others go through the traumatic experience, hearing about a traumatic incident that significantly affected a family or a friend, and direct repetitive exposure or re-experiencing of the traumatic event or details of it (American Psychiatric Association, 2013). Anyone of these situations can trigger the onset of PTSD and the symptoms can be very debilitating even life-threatening not just to the individuals with the disorder but to those around them. Emotional responses such as “intense fear, hopelessness, and horror” are no longer included in the diagnostic features of PTSD in the DSM-5. In the new DSM, behavioral reaction directly related to the traumatic experience are found to be of better use for identifying the onset of PTSD (American Psychiatric Association, 2013). The DSM-5 requires the identified symptoms to be classified under four new diagnostic categories: “re-experiencing, avoidance, negative cognitions and mood, and arousal” (American Psychiatric Association, 2013). Re-experiencing may include invasive memories, flashbacks, nightmares, and physical reactions to auditory, visual, or olfactory cues. Avoidance may involve engaging in activities or behaviors that suppress memories, thoughts or feelings, or avoidance of concrete reminders (i.e., people, places, objects) of the traumatic experience. Negative cognitions and mood pertain more to negative internalizing behaviors such as self-blaming or putting the blame on others, anhedonic symptoms, and feelings of disaffection towards others. Changes in arousal, on the other hand, are more about externalizing behaviors such as “angry outbursts, hypervigilance, exaggerated startle response and sleep disturbance” (American Psychiatric Association, 2013).
The DSM-5 discusses that these syndromes vary from person to person. Some individuals may only exhibit one of the syndromes while others may present with a combination of two or more of these patterns (American Psychiatric Association, 2013). There are two specifiers for PTSD listed in the DSM-5: with dissociative symptoms and with delayed expression. Dissociative symptoms involve depersonalization or “persistent or recurrent experiences of feeling detached from one’s mental processes or body,” and derealization or “persistent or recurrent experiences of unreality of surroundings” (American Psychiatric Association, 2013). The DSM-5 also identifies three groups of risk factors for PTSD: pretraumatic, peritraumatic, and posttraumatic (American Psychiatric Association, 2013). Pretraumatic factors include genetic factors such as “being a female and younger” at the time of the traumatic incident; temperamental factors such as excessive externalizing behaviors and history of psychological disorder (i.e., depression, panic disorder); and environmental factors such as poverty, minority status and poor education. Peritraumatic factors pertain to environmental factors such as the gravity of the traumatic event and how life-threatening it was. The DSM-5 also talks about posttraumatic factors through the lens of temperamental factors such as maladaptive coping techniques and environmental factors such emotional, physical, and financial difficulties as a result of trauma (American Psychiatric Association, 2013).
Comorbidity
Depression is perhaps one of the most commonly associated disorders with PTSD. Keller et al. (2014) reported that Major Depression typically co-occurs with PTSD and the combination of the two disorders tend to exhibit more serious symptoms than PTSD or Major Depression alone. Because the co-occurrence of depression among PTSD patients are fairly common, Keller and her colleagues (2014) warn clinicians to pay close attention to how treatment affects symptom improvement particularly fluctuations in depressive symptoms. Tracking depressive symptoms via depression inventories such as the Beck Depression Inventory, in addition to monitoring PTSD symptoms, can help experts in identifying patterns of improvement and in providing them a better picture of the efficacy of treatment. For military personnel, the DSM-5 reports that Traumatic Brain Injury (TBI) is highly comorbid with PTSD (48%) (American Psychiatric Association, 2013). In a study of 213 soldiers who served during Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), Morrissette and her colleagues (2011) reported that 46% of the participants tested positive for TBI and out of that 46%, about 85% reported symptoms that overlap with PTSD (and depression). Substance abuse is another common comorbid disorder with PTSD. The DSM-5 reports that this is more prevalent among males than females. In a study involving only female participants, Najavits and Walsh (2012) reported that the use of substance is a common coping mechanism that helped the participants deal with their PTSD symptoms. This is an example of what the DSM-5 calls a posttraumatic factor. In this case, poor coping strategies are the main culprit for maintenance of the disorder. Alcohol and drug abuse is also prevalent among the military community. Miller et al. (2013) reported that “PTSD severity is highly correlated with substance abuse severity” and that PTSD is usually a prelude to substance abuse disorder among soldiers. Similar to results of the study by Najavits and Walsh, Miller et al. (2013) also found that a majority of veterans returning from deployment use substances especially alcohol to help cope with the emotional turmoil following combat tours.
ETIOLOGY
Assuming exposure to traumatic experience as the culprit to the onset of PTSD is too simplistic. As with other disorders, PTSD can also be complex and a multidisciplinary approach might be the best course of action in understanding the etiology of the disorder. Looking at different contributors and examining what maintains and exacerbates the symptoms are also crucial in designing an effective treatment plan. We are all too familiar with veterans being at risk for developing PTSD. Barlow and Durand (2013) reported that in a study of prisoners of war (POW) in Vietnam, about 67% was diagnosed with PTSD. However, they also pointed out the other 33% that did not develop the disorder. How do you explain the difference between the 67% of POWs that had PTSD and the other 33% that did not show symptoms? What made the 67% susceptible to the disorder? Barlow and Durand (2013) uses the diathesis-stress model to explain the development of PTSD and the consensus remains that some people tend to be more “predisposed” than others when it comes to developing the disorder. Genetics is believed to play a role when it comes to biological proclivity. Barlow and Durand (2013) mentioned that a family history of anxiety is a plausible contributor to biological susceptibility to PTSD.
Today, with the advantage of modern technology, clinicians and experts are given an edge in understanding PTSD in a neurobiological level. Sun et al. (2013) reported another biological consideration for the development of PTSD. In a study involving 11 participants who have traffic accident-induced PTSD, Sun et al. (2013) found that white matter changes in these victims may account for susceptibility to the disorder. Barlow and Durand (2013) also mentioned damage to the hippocampus, which can result in learning and memory deficits, as a plausible explanation that can account for the autonomic arousal in PTSD patients.
In a behavioral level, Resick and her colleagues (2007) discuss learning theory as an explanation for the development of PTSD. They point out that classical conditioning is the reason behind the emotional dysphoria and fear experienced by trauma victims, and operant conditioning is what accounts for the avoidance that helps maintain the symptoms of PTSD (Resick et al., 2007).
A strong social factor that is found to be a strong predictor of PTSD is “family instability” (Barlow and Durand, 2013). They explain that those who grew up in unstable homes have a tendency to view the world as an unsafe place which makes them highly at risk for PTSD following exposure to trauma (Barlow and Durand, 2013). Conversely, strong social resources such as stable familial ties is a protective factor against PTSD. Barlow and Durand (2013) discuss that strong social bonds can account for the reduction in cortisol levels and hypothalamic-pituitary-adrenocortical (HPA) axis activity during stressful situations. Strong social bonds also provide a sense of security that people with unstable relationships do not have. Another social factor found to be a safety valve against development of PTSD is religiosity. In a study involving veterans in PTSD residential units, Tran and her colleagues (2012) found that strong religious ties account for low incidence of PTSD symptoms among war veterans. More specifically, Tran et al. (2012) found that “a more negative concept of God was associated with higher severity of PTSD and depressive symptoms, whereas a more positive concept of God was associated with lower severity of depressive symptoms and was not significantly associated with PTSD symptoms.” Witnessing death, especially one caused by intentional acts, is not a natural experience to go through. Taking lives is another story. Soldiers in combat are exposed to these “unnatural” experiences for prolonged periods of time. The sense of security is non-existent and the threat is always there. For those who have strong religious motivation, perhaps the sense of security comes from the belief in a higher power. This is one explanation that may account for lower PTSD symptoms among “religious” veterans.
In a social-cognitive level, Resick et al. (2007) explain how information processing and belief systems play a big role in the development and maintenance of PTSD. They report studies showing that strong beliefs about “predictability and controllability” of traumatic experiences have a significant impact on the severity of symptoms (Resick et al., 2007). In a more cognitive level, Resick and her colleagues (2007), also discuss the role of irrational thoughts in the maintenance of the disorder. They report that “people with PTSD are unable to see the event as time-limited.” The inability to dissociate from the traumatic event can also be explained by the tendency to re-live the experience (i.e., having flashbacks) which can sometimes be involuntary. This, combined with maladaptive thinking, only exacerbate the symptoms of PTSD. As previously mentioned, exposure to traumatic events is the most salient feature in PTSD patients. However, in a study by Edmondson et al. (2013), serious cardiovascular conditions such as stroke and transient ischemic attacks (TIA) can predispose individuals to PTSD. They report that “1 in 4 stroke or TIA survivors develop significant PTSD symptoms. This discovery is crucial because for the most part, PTSD is currently viewed as a disorder triggered by an “external” traumatic event as opposed to a medical condition.
TREATMENT
As with any other disorder, the first step in treatment is assessment for severity (and other comorbid disorders). When it comes to treatment of PTSD, the National Center for PTSD within the U.S. Department of Veterans Affairs takes the lead for both military and civilian victims of trauma. When it comes to assessment, the Clinician Administered PTSD Scale (CAPS) is the “gold standard” for assessment and diagnosis (National Center for PTSD, 2014). The CAPS is a “structured interview” which can be used to make a current or lifetime diagnosis of PTSD (National Center for PTSD, 2014). It can also be used as a measure of improvement. An exhaustive list of other measures for both adults and children can be found at the National Center for PTSD website (http://www.ptsd.va.gov/PTSD/professional/assessment/all_measures.asp). Cognitive behavior therapy (CBT) is considered one of the most effective treatment for PTSD. More specifically, trauma-focused CBT is suggested to be the “first line of treatment for PTSD” (Ehlers et al., 2013). In a study of 330 PTSD patients who received trauma-focused CBT as the primary form of treatment, about 78% experienced significant improvement (Ehlers et al., 2013). CBT also has a proven track record for treatment of depression. As previously discussed, depression is commonly comorbid with PTSD and CBT is originally designed to target depressive symptoms. Monitoring for depressive symptoms, as previously discussed, is crucial in treating PTSD. Exposure, and in this case, imaginal exposure, remains to be the “gold standard” as far as behavioral techniques for treatment of PTSD. In the military, computerized-based treatments and use of simulators (closest they can get to in vivo) are becoming increasingly popular. Computer-based treatments are especially attractive to soldiers who are more hesitant to seek help for fear of being stigmatized (Samuelson et al., 2013). However, web-based treatment still require more research when it comes to efficacy and currently, there are no published research addressing the effectiveness of computerized treatment for PTSD. Barlow and Durand (2013) discuss story-telling as one of most common techniques for managing PTSD. This is where the patient simply provides a narrative and talks about the specific details of the traumatic event. Narration, like exposure, also has proven therapeutic value as it helps patients “make sense of an event and gain insight” (Peri and Gofman, 2014). Narration, whether verbal or written, also provides a healthy outlet for managing distress associated with traumatic experiences. Narrative reconstruction, which combines “exposure and cognitive restructuring” is a relatively new, yet promising, technique which aims to target the memory disturbances as a result of trauma (Peri and Gofman, 2014). In narrative reconstruction, the story-telling piece of the technique is much more organized and focused than regular narration. While trauma-focused and exposure-based CBT show the most reliable treatment for PTSD, Rafaeli and Markowitz (2011) proposed that Interpersonal Therapy (IPT) might be an effective alternative for those who do not respond well to CBT. The interpersonal focus of IPT, especially the focus on resolving interpersonal disputes and role transition problems that can trigger or maintain PTSD symptoms, also targets strengthening social bonds which, as previously discussed, is a major protective factor against PTSD. Role transitions are salient among military personnel especially those coming back from deployment. Often times, soldiers have a hard time integrating to a non-combat lifestyle which can result in interpersonal problems that can ultimately trigger PTSD symptoms. IPT combined with CBT can be very effective for military families.