Review
Posttraumatic stress disorder: A state-of-the-science review

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Abstract

This article reviews the state-of-the-art research in posttraumatic stress disorder (PTSD) from several perspectives: (1) Sex differences: PTSD is more frequent among women, who tend to have different types of precipitating traumas and higher rates of comorbid panic disorder and agoraphobia than do men. (2) Risk and resilience: The presence of Group C symptoms after exposure to a disaster or act of terrorism may predict the development of PTSD as well as comorbid diagnoses. (3) Impact of trauma in early life: Persistent increases in CRF concentration are associated with early life trauma and PTSD, and may be reversed with paroxetine treatment. (4) Imaging studies: Intriguing findings in treated and untreated depressed patients may serve as a paradigm of failed brain adaptation to chronic emotional stress and anxiety disorders. (5) Neural circuits and memory: Hippocampal volume appears to be selectively decreased and hippocampal function impaired among PTSD patients. (6) Cognitive behavioral approaches: Prolonged exposure therapy, a readily disseminated treatment modality, is effective in modifying the negative cognitions that are frequent among PTSD patients. In the future, it would be useful to assess the validity of the PTSD construct, elucidate genetic and experiential contributing factors (and their complex interrelationships), clarify the mechanisms of action for different treatments used in PTSD, discover ways to predict which treatments (or treatment combinations) will be successful for a given individual, develop an operational definition of remission in PTSD, and explore ways to disseminate effective evidence-based treatments for this condition.

Introduction

It has long been known that people sometimes develop maladaptive symptoms after exposure to extreme stress. Jacob Mendez Da Costa, an eminent Philadelphia physician, described an eponymous condition resembling posttraumatic stress disorder (PTSD) among veterans of the American Civil War (Vaisrub, 1975). The relatively high prevalence of this condition among veterans of the Vietnam War (Card, 1987, Long et al., 1996, Beals et al., 2002) was one important impetus for the burgeoning of PTSD research over the last several decades. The diagnosis of PTSD was first included in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980; (APA, 1980), since then, considerable research effort has been directed towards the etiology, phenomenology, clinical and neurobiological characteristics, and treatment of PTSD and related and common comorbid disorders.

In this article, we review the state of the art in PTSD from six different perspectives: (1) sex differences in trauma and PTSD; (2) risk and resilience factors in the mass traumas of disasters and terrorism; (3) the impact of early life trauma and its relationship to psychiatric sequelae including PTSD; (4) imaging studies of depression which can serve as a paradigm of failed adaptation to chronic emotional stress; (5) alterations in neural circuits and memory in PTSD; and (6) cognitive therapy approaches to the treatment of PTSD. We conclude with suggestions for key directions in future PTSD research.

Section snippets

Sex, trauma, and PTSD: what are the differences?

While much of the early research on PTSD involved men with combat-related disorders, population studies have revealed that PTSD is more prevalent in women. In the National Comorbidity Survey, Kessler et al. (1995) found an overall lifetime prevalence of PTSD of 7.8%, but women were over twice as likely as men to have suffered from the condition (10.4% vs 5.0%; p < 0.05). Community surveys consistently reveal elevated rates of PTSD among women [e.g., a Swedish study by Frans et al. (2005)]. Why

Risk and resilience factors after disasters and terrorism

Resilience has been addressed since ancient times by authors as diverse as Confucius (“Our greatest glory is not in never falling, but in rising every time we fall”) and Nietzsche (“That which does not kill us can only make us stronger”). Merriam-Webster’s Collegiate Dictionary (M-W Collegiate Dictionary, 1993) defines resilience as: (1) the capability of a strained body to recover its size and shape after deformation and (2) an ability to recover from or adjust easily to misfortune or change.

Early life trauma and PTSD

Until the last decade, the hypothesis that early life trauma is associated with an increased risk of adult mood and anxiety disorders was supported largely by anecdotal reports inspired by psychoanalytic concepts of early critical periods of development. Research on the biology of depression and some anxiety disorders has commonly been plagued by the confounding factor of early life stress—the hypercortisolemia and structural brain changes attributed solely to the disorder is likely due, at

What can imaging studies of depression teach us about failed adaptation to chronic emotional stress and anxiety disorders?

Research on functional brain imaging in depression (and on the biology of depression in general) has “matured” much more than similar research in PTSD. Not only can we learn a great deal from the depression literature that is relevant to PTSD, but it is now well established that these syndromes are frequently comorbid, and that certain antidepressants, the SSRIs in particular, are effective for both conditions.

Depression may be conceptualized as an end-product of failed adaptation to chronic

Neural circuits, memory, and PTSD

The neural circuitry implicated in PTSD probably involves complex interactions between the thalamus (a gateway for sensory inputs), the hippocampus (which is involved in short-term memory and probably fear of the context of an event), the amygdala (which is involved in conditioned fear responses), the posterior cingulate, parietal and motor cortex (which are involved in visuospatial processing and assessment of threat), and the medial prefrontal cortex, including the anterior cingulate,

Cognitive behavioral approaches to the treatment of PTSD: what works?

Like re-experiencing, hyperarousal and avoidance symptoms, negative cognitions are ubiquitous immediately after an individual suffers a trauma (Foa and Jaycox, 1999). Usually, however, subsequent everyday life experiences gradually correct these negative cognitions, and the traumatized individual has the opportunity to regain a sense of competence and safety in the world. In contrast, those who make extensive use of avoidance and numbing will also avoid the very experiences that could have

Future directions for research

What are the key priorities for future research in the PTSD field? In the area of neurobiology, future studies are required to determine brain mechanisms underlying the successful response to treatment. Studies are also needed to examine changes in brain receptor and neurotransmitter systems in greater detail in PTSD. In the areas of phenomenology and etiology, it is important to assess the validation of the PTSD and acute stress disorder constructs and their distinction from other disorders,

Disclosure statement

Author Financial Disclosures for this article can be obtained from the U.S. Journal Office

Acknowledgments

The authors thank GlaxoSmithKline for providing an unrestricted educational grant in support of the development of this article, and CTC Communications Corporation for providing editorial support.

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