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Post-traumatic stress disorder
Article in BMJ (online) · November 2015
DOI: 10.1136/bmj.h6161
4 authors, including:
Jonathan I Bisson
Catrin Lewis
Cardiff University
Cardiff University
Neil P Roberts
Cardiff and Vale University Health Board
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BMJ 2015;351:h6161 doi: 10.1136/bmj.h6161 (Published 26 November 2015)
Page 1 of 7
Clinical Review
Post-traumatic stress disorder
Jonathan I Bisson professor of psychiatry, Sarah Cosgrove public representative, Catrin Lewis
research psychologist, Neil P Roberts consultant clinical psychologist
Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
What is post-traumatic stress disorder
PTSD is a mental disorder that may develop after exposure to
exceptionally threatening or horrifying events. Many people
show remarkable resilience and capacity to recover following
exposure to trauma.1 PTSD can occur after a single traumatic
event or from prolonged exposure to trauma, such as sexual
abuse in childhood. Predicting who will go on to develop PTSD
is a challenge.2
Patients with PTSD are at increased risk of experiencing poor
physical health, including somatoform, cardiorespiratory,
musculoskeletal, gastrointestinal, and immunological
disorders.3 4 It is also associated with substantial psychiatric
comorbidity,5 increased risk of suicide,6 and considerable
economic burden.7 8
PTSD is a widely accepted diagnosis9 but some believe that the
term medicalises understandable responses to catastrophic events
and further disempowers those who are already disempowered.10
How common is PTSD?
About 3% of the adult population has PTSD at any one time.11
Lifetime prevalence is between 1.9%12 and 8.8%,7 but this rate
doubles in populations affected by conflict13 and reaches more
than 50% in survivors of rape.5
How does PTSD present?
Symptoms include persistent intrusive recollections, avoidance
of stimuli related to the trauma, negative alterations in cognitions
and mood, and hyperarousal (table⇓).14 15 A diagnosis can be
made in someone whose ability to function normally has been
noticeably impaired for one month according to DSM-5 criteria.
Delayed presentation (sometimes years later) is common,7
including where the effects are severe.16
How is PTSD diagnosed?
Box 1 describes the nature of the traumatic event(s) required
by DSM-5 (diagnostic and statistical manual of mental disorders,
fifth edition)14 for diagnosis and the proposed criteria by ICD-11
(international classification of diseases, 11th revision).17 Some
events such as bullying, divorce, death of a pet, and learning
about a diagnosis of cancer in a close family member are not
deemed extreme enough to precipitate PTSD. However, they
can result in almost identical symptoms and raise questions
about the validity of the definitions for traumatic events.18
DSM-5 lists the 20 symptoms required for PTSD to be
diagnosed,14 separated into four groups (table). All symptoms
must be associated with the traumatic event. In the proposed
criteria by ICD-11,17 PTSD will be diagnosed according to six
criteria (table). To reflect the heterogeneity of PTSD, ICD-11
will introduce a new complex PTSD diagnosis (table). This
requires satisfaction of the criteria for PTSD plus symptoms of
mood dysregulation, negative self concept, and persistent
difficulty in sustaining relationships and feeling close to others.
Service users may meet the diagnostic criteria in one system
but not in the other owing to the differences.19
Can PTSD be prevented?
Psychological interventions
Psychological interventions have been evaluated after traumas
concerning a single incident, such as a road traffic crash and
physical or sexual assaults. Meta-analyses show that brief,
trauma focused, cognitive behavioural interventions can reduce
the severity of symptoms when the intervention is targeted at
those with early symptoms.20 21 However, non-targeted
interventions (including psychoeducation, psychological
debriefing, individual and group counselling, cognitive
behavioural therapy (CBT) based programmes, and collaborative
care based approaches) are largely ineffective.22-25
Drug interventions
No robust evidence supports the use of drug interventions.26
Prevention after large scale traumatic events
Evidence to support routine intervention after traumatic events
involving many people (for example, terrorist attacks and natural
disasters) is lacking. However, some evidence suggests that
high levels of social support are perceived as protective.27
Consensus guidelines recommend supportive, practical, and
Correspondence to: J I Bisson [email protected]
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Page 2 of 7
What you need to know
• Individual reactions to traumatic events vary greatly and most people do not develop a mental disorder after exposure to trauma
• PTSD should be considered in any patient exposed to a major traumatic event
• Up to 3% of adults has PTSD at any one time. Lifetime prevalence rates are between 1.9% and 8.8%
• Psychological treatments, particularly trauma focused psychological therapies, can be effective
• Although the effect sizes are not as high as for psychological therapies, drug treatments can be effective
• Patients with complex PTSD should receive specialist multidisciplinary care
Sources and selection criteria
We identified Cochrane and other relevant systematic reviews and meta-analyses, and supplemented these with additional searches and
our knowledge of the subject. Wherever possible, we used evidence from recent meta-analyses of randomised trials.
Box 1 Traumatic event(s) required for diagnosis of PTSD
DSM-5 criteria[14]
Exposure to actual or threatened death, serious injury, or sexual violation, in one or more of the following ways:
Directly experiencing the traumatic event(s)
Witnessing traumatic event(s) in others
Learning that the traumatic event(s) occurred to a close family member or close friend; cases of actual or threatened death must have
been violent or unintentional
Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (for example, first responders collecting human
remains; police officers repeatedly exposed to details of child abuse); this does not apply to exposure through electronic media, television,
movies, or pictures, unless this exposure is work related
Proposed ICD-11 criterion[17]
Exposure to an extremely threatening or horrific event or series of events
pragmatic input but avoidance of formal clinical interventions
unless indicated.28-30
Can PTSD be treated?
Psychological therapy
Clinical guidelines recommend trauma focused psychological
therapies based on evidence from systematic reviews and
meta-analyses.31-33 Individual trauma focused CBT and eye
movement desensitisation and reprocessing (EMDR) (box 2)
have been found to be equally effective.34
Group trauma focused CBT is also effective, but fewer studies
have focused on this method.35 Non-trauma focused
CBT—including components such as grounding techniques to
manage flashbacks (for example, focusing on the here and now
by describing items in a room), relaxation training (for example,
controlled breathing and progressive muscle relaxation), positive
thinking and self talk (for example, repeating positive phrases
such as “I can deal with this”)—has been found to be superior
to waiting list control groups and has shown similar efficacy to
trauma focused CBT and EMDR immediately after treatment,
but this is not maintained at follow-up.34 Non-trauma focused
CBT offers a valid alternative to trauma focused therapy if the
latter is poorly tolerated, contraindicated, or unavailable. It is
unclear whether specific therapies are more or less effective for
particular subgroups or trauma types.36 37
Research on interventions for more complex presentations of
PTSD is limited.38 Evidence suggests that phased approaches
may be beneficial for more complex presentations of PTSD.39
Phase based approaches target problems such as affect
dysregulation, dissociation, and somatic symptoms to promote
adaptive coping, a sense of safety, and stabilisation before
undertaking any trauma focused intervention.
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Self help programmes
Guided self help interventions for depression and anxiety
disorders are being used as an alternative to face to face therapy
as these interventions offer enhanced access to cost effective
treatment.40 Some evidence suggests that internet based guided
self help therapies effectively alleviate the symptoms of
traumatic stress, but randomised controlled trials (RCTs) have
historically been limited to subsyndromal populations.41 42 More
recent evidence supports the efficacy of guided self help for
people meeting diagnostic criteria for PTSD,43-45 but no head to
head trials have compared guided self help with trauma focused
psychological therapy administered by a therapist.
Drug treatment
The National Institute for Health and Care Excellence and World
Health Organization recommend drug treatment second to
trauma focused therapy.33 46 The effect sizes for drug treatments
compared with placebo are inferior to those reported for
psychological treatments with a trauma focus over waiting list
or treatment as usual controls.33 47 Effect sizes with drug
treatment are similar to those observed from use of
antidepressants for depression compared with placebo.48 A recent
systematic review and meta-analysis found statistically
significant evidence (when at least two RCTs were available)
of reduction in severity of PTSD symptoms for four drugs
(fluoxetine, paroxetine, sertraline, and venlafaxine) versus
placebo.47 In single RCTs, amitriptyline, GR205171 (a
neurokinin-1 antagonist), mirtazapine, and phenelzine have
shown superiority over placebo in reducing the symptoms of
In an RCT the α 1 adrenoceptor antagonist prazosin was found
to reduce nightmares in veterans with PTSD,49 and a further
RCT in veterans showed reduction in overall symptom severity.50
This suggests a possible role for α 1 adrenoceptor blockers in
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BMJ 2015;351:h6161 doi: 10.1136/bmj.h6161 (Published 26 November 2015)
Page 3 of 7
Box 2 Trauma focused exposure therapy, CBT and EMDR
Exposure therapy
• Therapists help patients to confront their traumatic memories through written or verbal narrative, detailed recounting of the traumatic
experience, and repeated exposure to trauma related situations that were being avoided or evoked fear but are now safe (for example,
driving a car where the road traffic incident occurred or walking in the busy park where an assault occurred)
Cognitive therapy
• Focuses on identifying and modifying misinterpretations that led patients to overestimate the current threat (for example, patients who
think assault is almost inevitable if they leave the house)
• Focuses on modifying beliefs and how patients interpret their behaviour during the trauma, including problems with guilt and shame
• Standardised, trauma focused procedure. Involves the use of bilateral physical stimulation (eye movements, taps, or tones), hypothesised
to stimulate the patient’s information processing to help integrate the targeted event as an adaptive contextualised memory
PTSD, although further research is needed. Olanzapine, in
contrast with another antipsychotic, risperidone, has been shown
to accentuate the effects of antidepressants when resistance to
treatment is encountered.51 52
Combination therapy
Evidence to support the use of pharmacotherapy combined with
psychological therapy over either treatment method separately
is insufficient.53
How should PTSD and comorbidity be
PTSD is associated with depression, anxiety disorders, and drug
and alcohol use disorders. Little evidence exists for the
effectiveness of psychological interventions for PTSD with
comorbid substance use disorders. Some evidence suggests that
trauma focused CBT can be effective with concomitant
interventions to stabilise drug or alcohol use, but treatment
effects are not as large as for PTSD in the absence of drug or
alcohol misuse.54
What is the prognosis in PTSD?
Few longitudinal follow-up studies have been done of PTSD,
but for many patients PTSD is severe and enduring.5 There is,
however, good evidence that patients may benefit from treatment
even when the symptoms have been present for many years.34
Are there emerging options to prevent
and treat PTSD?
Several experimental studies provide hope that better or
alternative ways to prevent and treat PTSD are on the way.
Simple visuospatial tasks such as playing a computer game
shortly after a traumatic experience reduce re-experiencing.55
For established PTSD, interest in using drugs to augment
psychological therapy is increasing. The results of a recent RCT
of the psychedelic 3,4-methylenedioxymethylamphetamine with
psychotherapy for treatment resistant PTSD have been
promising.56 57 These approaches remain in their infancy, and
further well designed clinical studies are required to determine
if they will live up to their early promise.
Contributors: JB, CL, and NR planned, conducted reviews, and drafted
the article. SC drafted the patient’s perspective box and commented on
and amended the initial draft. All authors reviewed and agreed the final
draft. JB is the guarantor.
Competing interests: We have read and understood the BMJ policy on
declaration of interests and declare the following: JB, CL, and NR have
For personal use only: See rights and reprints http://www.bmj.com/permissions
undertaken systematic reviews, meta-analyses, randomised controlled
trials, and other research in the specialty of traumatic stress, some of
which is referred to in the manuscript. JB, CL, and NR are members of
a research team that developed a web based guided self help
programme to treat PTSD. The programme is likely to be marketed in
the future. Royalties will be payable to Cardiff University, with a
proportion of these being shared with the research team in line with
Cardiff University’s rules.
Provenance and peer review: Commissioned; externally peer reviewed.
Bonanno GA. Loss, trauma, and human resilience: have we underestimated the human
capacity to thrive after extremely aversive events? Am Psychol 2004;59:20-8.
Karstoft K, Galatzer-Levy IR, Statnikov A, Li Z, Shalev AY. Bridging a translational gap:
using machine learning to improve the prediction of PTSD. BMC Psychiatry 2015;15:30.
Schnurr PP, Green BL, Kaltman, S. Trauma exposure and physical health. In: Friedman
MJ, Keane TM, Resick PA, eds. Handbook of PTSD: science and practice. Guilford Press,
Gupta MA. Review of somatic symptoms in post-traumatic stress disorder. Int Rev
Psychiatry 2013;25:86-99.
Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder
in the national comorbidity survey. Arch Gen Psychiatry 1995;52:1048-60.
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their consequences. RAND, 2009.
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American Psychiatric Association. Diagnostic and statistical manual of mental disorders,
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Brewin CR, Fuchkan N, Huntley Z, et al. Outreach and screening following the 2005
London bombings: usage and outcomes. Psychol Med 2010:40;2049-57.
Maercker A, Brewin CR, Bryant RA, et al. Proposals for mental disorders specifically
associated with stress in the International Classification of Diseases-11. Lancet
White J, Pearce J, Morrison S, Dunstan F, Bisson JI, Fone DL. Risk of post traumatic
stress disorder following traumatic events in a community sample. Epidemiol Psychiatr
Sci 2015;24:249-57.
Bisson JI. What happened to harmonisation of the PTSD diagnosis? The divergence of
ICD11 and DSM5. Epidemiol Psychiatr Sci 2013;22:205-7.
Kleim S, Kroger C. Prevention of chronic PTSD with early cognitive behavioral therapy.
A meta-analysis using mixed-effects modeling. Behav Res Ther 2013;51:753-61.
Roberts NP, Kitchiner NJ, Kenardy J, Bisson JI. Early psychological interventions to treat
acute traumatic stress symptoms. Cochrane Database Syst Rev 2010;3:CD007944.
Bastos MH, Furuta M, Small R, McKenzie-McHarg K, Bick D. Debriefing interventions for
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Gartlehner G, Forneris CA, Brownley KA, et al. Interventions for the prevention of
Posttraumatic Stress Disorder (PTSD) in adults After exposure to psychological trauma.
Comparative Effectiveness Review No 109. AHRQ Publication No 13-EHC062-EF. Agency
for Healthcare Research and Quality, Apr 2013. www.effectivehealthcare.ahrq.gov/reports/
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BMJ 2015;351:h6161 doi: 10.1136/bmj.h6161 (Published 26 November 2015)
Page 4 of 7
How were patients involved in this clinical review?
Sarah Cosgrove is a former patient with PTSD and a representative of the public in Cardiff University’s Traumatic Stress Research Group.
Sarah is a coauthor of the paper and provides an account of her experiences in the patient’s perspective box.
A patient’s perspective
I was diagnosed with PTSD in November 2013 in the aftermath of a violent assault. From the time of the attack to the case coming to court,
I had support from police and victim services enabling me to face my assailant in court with courage and conviction.
But in the weeks after the judicial process had concluded, I started to unravel. Naturally a glass half full sort of person, I slid into a state of
great anxiety, frightened to be alone, scared to be in a group, reluctant to go out, and terrified of staying at home. I knew something was
very wrong. I had gone from being confident and outgoing, to not being able to sleep, being tearful, and experiencing episodes of unparalleled
low mood. My GP immediately diagnosed PTSD. Being able to put a label on what I was going through was so helpful—it meant that there
was something wrong.
Fortunately, I was offered the chance to participate in a trial of a guided self help programme for sufferers of PTSD. This enabled me to both
confront my experience and desensitise it, and within a few months I felt stronger than I had ever been. The programme has given me a
coping strategy to employ whenever I get negative thoughts or flashbacks. It may have saved my life; at the very least it got me back to the
person I used to be.
Tips for non-specialists
A traumatic event can precipitate conditions other than PTSD, such as depression, phobic anxiety, and substance use disorders
PTSD is associated with comorbidity
Sensitive questioning is required to elicit symptoms of PTSD as patients may avoid volunteering their traumatic experience(s)
Patients with PTSD may present in primary care with physical symptoms that are difficult to explain
Trauma focused psychological therapy is the treatment of choice for PTSD, although drugs and other forms of psychological treatment
can help
Patient choice and availability of psychological therapy will influence the treatment given
When to suspect PTSD
• When patients present with mental or physical symptoms that cannot be fully explained after a traumatic event
• When patients present with characteristic symptoms of PTSD—re-experiencing, avoidance, and hyperarousal
• When patients disclose a history of involvement in a traumatic event
• When patients present with mental or physical symptoms that are difficult to explain in the absence of a disclosed traumatic event
Additional educational resources
Information for healthcare professionals
Websites providing information on the assessment and treatment of PTSD:
International Society for Traumatic Stress Studies (www.istss.org)
US Department of Veterans Affairs, National Centre for PTSD (www.ptsd.va.gov)
Information for patients
Websites providing information on symptoms of PTSD and treatment options:
NHS Choices PTSD (www.nhs.uk/Conditions/Post-traumatic-stress-disorder/Pages/Introduction.aspx)
Royal College of Psychiatrists (www.rcpsych.ac.uk/expertadvice/problemsdisorders/posttraumaticstressdisorder.aspx)
International Society for Traumatic Stress Studies (www.istss.org)
National Centre for Mental Health (http://ncmh.info/conditions/post-traumatic-stress-disorder-ptsd/)
US Department of Veterans Affairs, National Centre for PTSD (www.ptsd.va.gov/public/pages/fslist-self-help-cope.asp)—provides
information on the symptoms of PTSD, self help, and treatment options
Roberts NP, Kitchiner NJ, Kenardy J, Bisson JI. Multiple session early psychological
interventions for the prevention of post-traumatic stress disorder. Cochrane Database
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Posttraumatic Stress Disorder and Acute Stress Disorder: a systematic review and
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disorder in trauma-exposed adults. J Consult Clin Psychol 2000;68:748–66.
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support in emergency settings. IASC, 2007.
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mental health needs after disasters. OP94. Royal College of Psychiatrists, 2014.
American Psychiatric Association. Practice guidelines for the treatment of patients with
acute stress disorder and posttraumatic stress disorder. APA, 2004.
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Australian Centre for Posttraumatic Mental Health. Australian guidelines for the treatment
of adults with acute stress disorder and posttraumatic stress disorder. ACPMH, 2007.
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the management of PTSD in adults and children in primary and secondary care—national
cost impact report. National Institute for Health and Clinical Excellence, 2005.
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post-traumatic stress disorder (PTSD) in adults (Review). Cochrane Database Syst Rev
Barrera TLM. A meta-analytic review of exposure in group cognitive behavioral therapy
for posttraumatic stress disorder. Clin Psychol Rev 2013;33:24-32.
Health Technology Assessment database. Comparative effectiveness of psychological
treatments and pharmacological treatments for adults with posttraumatic stress disorder.
2011. www.effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/
Jonas D, Cusack K, Forneris C, et al. Psychological and pharmacological treatments for
adults with posttraumatic stress disorder (PTSD). AHRQ Comparative Effectiveness
Review 2013, Report No: 13-EHC011-EF.
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Courtois CA, Ford JD. Treating complex traumatic stress disorders: an evidenced-based
guide. Guilford Press, 2009.
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Table 1| Symptoms required for diagnosis of PTSD
DSM-5 criteria14
Proposed ICD-11 criteria17
Intrusion symptoms
Recurrent, involuntary and intrusive distressing memories
Recurrent distressing dreams (content and/or affect related)
Dissociative reaction (acting or feeling as if event is recurring)
Vivid intrusive memories, flashbacks, or nightmares, typically
accompanied by strong and overwhelming emotions such as fear or
horror, and strong physical sensations
Intense or prolonged psychological distress to cues
Noticeable physiological reactions to cues
Avoidance or efforts to avoid distressing thoughts or feelings about or closely associated Avoidance of thoughts and memories of the event or events
with the trauma
Avoidance of activities, situations, or people reminiscent of the event
Avoidance or efforts to avoid external reminders (people, places, conversations, activities, or events
objects, situations)
Negative alterations in cognitions and mood
Inability to remember an important aspect (typically due to dissociative amnesia)
Not applicable
Persistent and exaggerated negative beliefs or expectations about oneself, others, or the
world (for example, “I am bad,” “No one can be trusted,” “The world is completely
Persistent, distorted cognitions about the cause or consequences that lead to self blame
or the blame of others
Persistent negative emotional state (for example, fear, horror, anger, guilt, shame)
Noticeably diminished interest or participation in important activities
Feelings of detachment or estrangement from others
Persistent inability to experience positive emotions (for example, happiness, satisfaction,
Alterations in arousal and reactivity
Irritable behaviour and angry outbursts (with little or no provocation)
Reckless or self destructive behaviour
Persistent perceptions of heightened current threat—for example, as
indicated by hypervigilance or an enhanced startle reaction to stimuli
such as unexpected noises
Exaggerated startle response
Problems with concentration
Sleep disturbance
Additional criteria for complex PTSD
Not applicable
Severe and pervasive problems in affect regulation
Persistent beliefs about oneself as diminished, defeated, or worthless,
accompanied by deep and pervasive feelings of shame, guilt, or failure
related to the stressor
Persistent difficulties in sustaining relationships and in feeling close to
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Page 7 of 7
Examples of the many different trajectories of PTSD symptoms after exposure to trauma
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