# Posttraumatic Stress Disorder (PTSD)



## David Baxter PhD (Dec 12, 2007)

Posttraumatic Stress Disorder (PTSD)
by Roxanne Dryden-Edwards, MD

Posttraumatic stress disorder (PTSD) is an emotional illness that develops as a result of a terribly frightening, life-threatening, or otherwise highly unsafe experience. PTSD sufferers re-experience the traumatic event or events in some way, tend to avoid places, people, or other things that remind them of the event (avoidance), and are exquisitely sensitive to normal life experiences (hyperarousal). Although this condition has likely existed since human beings have endured trauma, PTSD has only been recognized as a formal diagnosis since 1980. However, it was called by different names as early as the American Civil War, when combat veterans were referred to as suffering from "soldier's heart." In World War I, symptoms that were generally consistent with PTSD were referred to as "combat fatigue." Soldiers who developed such symptoms in World War II were said to be suffering from "gross stress reaction," and many who fought in Vietnam who had symptoms of what is now called PTSD were assessed as having "post-Vietnam syndrome." PTSD has also been called "battle fatigue" and "shell shock." Complex posttraumatic stress disorder (C-PTSD) usually results from prolonged exposure to a traumatic event or series thereof and is characterized by long-lasting problems with many aspects of emotional and social functioning.

Approximately 7%-8% of people in the United States will likely develop PTSD in their lifetime, with the lifetime occurrence (prevalence) in combat veterans and rape victims ranging from 10% to as high as 30%. Somewhat higher rates of this disorder have been found to occur in African Americans, Hispanics, and Native Americans compared to Caucasians in the United States. Some of that difference is thought to be due to higher rates of dissociation soon before and after the traumatic event (peritraumatic); a tendency for individuals from minority ethnic groups to blame themselves, have less social support, and an increased perception of racism for those ethnic groups; as well as differences between how ethnic groups may express distress. Other important facts about PTSD include the estimate of 5 million people who suffer from PTSD at any one time in the United States and the fact that women are twice as likely to develop PTSD as men. 

Almost half of individuals who use outpatient mental-health services have been found to suffer from PTSD. As evidenced by the occurrence of stress in many individuals in the United States in the days following the 2001 terrorist attacks, not being physically present at a traumatic event does not guarantee that one cannot suffer from traumatic stress that can lead to the development of PTSD.

PTSD statistics in children and teens reveal that up to more than 40% have endured at least one traumatic event, resulting in the development of PTSD in up to 15% of girls and 6% of boys. On average, 3%-6% of high school students in the United States and as many as 30%-60% of children who have survived specific disasters have PTSD. Up to 100% of children who have seen a parent killed or endured sexual assault or abuse tend to develop PTSD, and more than one-third of youths who are exposed to community violence will suffer from the disorder.

*What are the effects of PTSD?*
Untreated PTSD can have devastating, far-reaching consequences for sufferers' functioning and relationships, their families, and for society. Women who were sexually abused at earlier ages are more likely to develop complex PTSD and borderline personality disorder. Babies that are born to mothers that suffer from this illness during pregnancy are more likely to experience a change in at least one chemical in their body that makes it more likely (predisposes) the baby to develop PTSD later in life. Individuals who suffer from this illness are at risk of having more medical problems, as well as trouble reproducing. Emotionally, PTSD sufferers may struggle more to achieve as good an outcome from mental-health treatment as that of people with other emotional problems. In children and teens, PTSD can have significantly negative effects on their social and emotional development, as well as on their ability to learn.

*What causes PTSD?*
Virtually any event that is life-threatening or that severely compromises the emotional well-being of an individual may cause PTSD. Such events often include either experiencing or witnessing a severe accident or physical injury, receiving a life-threatening medical diagnosis, being the victim of kidnapping or torture, exposure to combat or to a natural disaster, other disaster (for example, plane crash) or terrorist attack, being the victim of rape, mugging, robbery or assault; enduring physical, sexual, emotional or other forms of abuse, as well as involvement in civil conflict.

*What are the risk factors and protective factors for PTSD?*
Issues that tend to put people at higher risk for developing PTSD include increased duration of a traumatic event, higher severity of the trauma experienced, having an emotional condition prior to the event, or having little social support in the form of family or friends. In addition to those risk factors, children and adolescents, females, and people with learning disabilities or violence in the home have a greater risk of developing PTSD  after a traumatic event.

While disaster-preparedness training is generally seen as a good idea in terms of improving the immediate physical safety and logistical issues involved with a traumatic event, such training may also provide important protective factors against developing PTSD. That is as evidenced by the fact that those with more professional-level training and experience (for example, police, firefighters, mental-health professionals, paramedics, and other medical professionals) tend to develop PTSD less often when coping with disaster than those without the benefit of such training or experience.

Some medications have been found to help prevent the development of PTSD. Some medicines that treat depression, decrease the heart rate, or increase the action of other body chemicals are thought to be effective tools in the prevention of PTSD when given in the days immediately after an individual experiences a traumatic event. 

*What are the signs and symptoms of PTSD?*
The three groups of symptoms that are required to assign the diagnosis of PTSD are 


recurrent re-experiencing of the trauma (for example, troublesome memories, flashbacks that are usually caused by reminders of the traumatic events, recurring nightmares about the trauma and/or dissociative reliving of the trauma), 
avoidance to the point of having a phobia of places, people, and experiences that remind the sufferer of the trauma and a general numbing of emotional responsiveness, and 
chronic physical signs of hyperarousal, including sleep problems, trouble concentrating, irritability, anger, poor concentration, blackouts or difficulty remembering things, increased tendency and reaction to being startled, and hypervigilance to threat.
The emotional numbing of PTSD may present as a lack of interest in activities that used to be enjoyed (anhedonia), emotional deadness, distancing oneself from people, and/or a sense of a foreshortened future (for example, not being able to think about the future or make future plans, not believing one will live much longer). At least one re-experiencing symptom, three avoidance/numbing symptoms, and two hyperarousal symptoms must be present for at least one month and must cause significant distress or functional impairment in order for the diagnosis of PTSD to be assigned. PTSD is considered of chronic duration if it persists for three months or more. 

A similar disorder in terms of symptom repertoire is acute stress disorder. The major differences between the two disorders are that acute stress disorder symptoms persist from two days to four weeks, and a fewer number of traumatic symptoms are required to make the diagnosis as compared to PTSD. 

In children, re-experiencing the trauma may occur through repeated play that has trauma-related themes instead of through memories, and distressing dreams may have general content rather than of the traumatic event itself. As in adults, at least one re-experiencing symptom, three avoidance/numbing symptoms, and two hyperarousal symptoms must be present for at least one month and must cause significant distress or functional impairment in order for the diagnosis of PTSD to be assigned. When symptoms have been present for less than one month, a diagnosis of acute stress disorder (ASD) can be made. 

Symptoms of PTSD that tend to be associated with C-PTSD include: problems regulating feelings, which can result in suicidal thoughts, explosive anger, or passive aggressive behaviors; a tendency to forget the trauma or feel detached from one's life (dissociation) or body (depersonalization); persistent feelings of helplessness, shame, guilt or being completely different from others; feeling the perpetrator of trauma is all-powerful and preoccupation with either revenge against or allegiance with the perpetrator; and severe change in those things that give the sufferer meaning, like a loss of spiritual faith or an ongoing sense of helplessness, hopelessness, or despair. 

*How is PTSD assessed?*
For individuals who may be wondering if they should seek evaluation for PTSD by their medical or mental-health professional, self-tests may be useful. The National Institute of Mental Health and offers a self-test for PTSD. The assessment of PTSD can be difficult for practitioners to make since sufferers often come to the professional's office complaining of symptoms other than anxiety associated with a traumatic experience. Those symptoms tend to include body symptoms (somatization), depression, or substance abuse. Individuals with PTSD may present with a history of making suicide attempts. In addition to depression and substance abuse disorders, the diagnosis of PTSD often co-occurs (is comorbid with) bipolar disorder (manic depression), eating disorders, and other anxiety disorders like obsessive compulsive disorder, panic disorder, and generalized anxiety disorder. 

Most practitioners who examine a child or teenager for PTSD will interview both the parent and the child, usually separately, in order to allow for each party to speak freely. Interviewing the child in addition to the adults in their life is quite important given that while the child or adolescent's parent or guardian may have a unique perspective, there are naturally things the young person may be feeling that the adult is not aware of. Another challenge for diagnosing PTSD in children, particularly in younger children, is that they may express their symptoms differently from adults. For example, they may go backward or regress in their development, become accident-prone, engage in risky behaviors, become clingy, or suffer from more physical complaints as compared to adults with PTSD. Traumatized younger children may also have trouble sitting still, focusing, or managing their impulses and therefore be mistaken as suffering from attention deficit hyperactivity disorder (ADHD). 

Sometimes, professionals will use a structured psychiatric interview for children in its entirety or just the portion that assesses PTSD in order to test for PTSD. Examples of such tools include the Diagnostic Interview for Children and Adolescents?Revised (DICA-R), the Diagnostic Interview Schedule for Children?Version IV (DISC-IV), and the Schedule for Affective Disorders and Schizophrenia for School Age Children (K-SADS). There are also some PTSD-specific structured interviews, like the Clinician-Administered PTSD Scale?Child and Adolescent Version, the Child PTSD Checklist, and the Child PTSD Symptom Scale. For the assessment of the severity of PTSD symptoms in children, structured interviews like the Child Posttraumatic Stress Reaction Index, the Child and Adolescent Trauma Survey, and the Trauma Symptom Checklist for Children are sometimes used. The Child Trauma Screening Questionnaire has been found by some professionals to be useful in predicting which children who endure a traumatic event will go on to develop PTSD. 

*How is PTSD treated?*
Treatments for PTSD usually include psychological and medical treatments. Providing information about the illness, helping the individual manage the trauma by talking about it directly, teaching the person ways to manage symptoms of PTSD, and exploration and modification of inaccurate ways of thinking about the trauma are the usual techniques used in psychotherapy for this illness. Education of PTSD sufferers usually involves teaching individuals about what PTSD is, that it is caused by extraordinary stress rather than weakness, how it is treated, and what to expect in treatment. This education thereby increases the likelihood that inaccurate ideas the person may have about the illness are dispelled, and any shame they may feel about having it is minimized. This may be particularly important in populations like military personnel that may feel particularly stigmatized by the idea of seeing a mental-health professional and therefore avoid doing so. 

Teaching people with PTSD practical approaches to coping with what can be very intense and disturbing symptoms has been found to be another useful way to treat the illness. Specifically, helping sufferers learn how to manage their anger and anxiety, improve their communication skills, and use relaxation techniques can help individuals with PTSD gain a sense of mastery over their emotional and physical symptoms. Cognitive therapy can help people with PTSD recognize and adjust trauma-related thoughts and beliefs by educating sufferers about the relationships between thoughts and feelings, exploring common negative thoughts held by traumatized individuals, developing alternative interpretations, and by practicing new ways of looking at things. This treatment also involves practicing learned techniques in real-life situations. 

Eye-movement desensitization and reprocessing (EMDR) is a form of cognitive therapy in which the practitioner guides the person with PTSD in talking about the trauma suffered and the negative feelings associated with the events, while focusing on the professional's rapidly moving finger. While some research indicates this treatment may be effective, it is unclear if this is any more effective than cognitive therapy that is done without the use of rapid eye movement. 

Families of PTSD individuals, as well as the sufferer, may benefit from family counseling, couples' counseling, parenting classes, and conflict resolution education. Family members may also be able to provide relevant history about their loved one (for example, about emotions and behaviors, drug abuse, sleeping habits, and socialization) that people with the illness are unable or unwilling to share. 

Directly addressing the sleep problems that can be part of PTSD has been found to not only help alleviate those problems but to thereby help decrease the symptoms of PTSD in general. Specifically, rehearsing adaptive ways of coping with nightmares (imagery rehearsal therapy), training in relaxation techniques, positive self-talk, and screening for other sleep problems have been found to be particularly helpful in decreasing the sleep problems associated with PTSD. 

Medications that are usually used to help PTSD sufferers include serotonergic antidepressants (SSRIs) like fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), and medicines that help decrease the physical symptoms associated with illness, like clonidine (Catapres), guaneficine (Tenex), and propranolol. Individuals with PTSD are much less likely to experience a relapse of their illness if antidepressant treatment is continued for at least a year. SSRIs are the first group of medications that have achieved approval by the U.S. Food and Drug Administration (FDA) for the treatment of PTSD. These medicines have been found to help PTSD sufferers modify information that is taken in from the environment (stimuli) and to decrease fear. Research also shows that this group of medicines tends to decrease anxiety, depression, and panic. SSRIs may also help reduce aggression, impulsivity, and suicidal thoughts that can be associated with this disorder.

Other less directly effective but nevertheless potentially helpful medications for managing PTSD include mood stabilizers like lamotrigine (Lamictal), tiagabine (Gabitril), divalproex sodium (Depakote), as well as mood stabilizers that are also antipsychotics, like risperidone (Risperdal), olanzapine (Zyprexa), and quetiapine (Seroquel). Antipsychotic medicines seem to be most useful in the treatment of PTSD in those who suffer from agitation, dissociation, hypervigilance, intense suspiciousness (paranoia), or brief breaks in being in touch with reality (brief psychotic reactions). 

Benzodiazepines (tranquilizers) have unfortunately been associated with a number of problems, including withdrawal symptoms and the risk of overdose and have not been found to be significantly effective for helping individuals with PTSD. 

*How can people cope with PTSD?*
Some ways that are often suggested for PTSD patients to cope with this illness include learning more about the disorder as well as talking to friends, family, professionals, and PTSD survivors for support. Joining a support group may be helpful. Other tips include reducing stress by using relaxation techniques (for example, breathing exercises, positive imagery), actively participating in treatment as recommended by professionals, increasing positive lifestyle practices (for example, exercise, healthy eating, distracting oneself through keeping a healthy work schedule if employed, volunteering whether employed or not) and minimizing negative lifestyle practices like substance abuse, social isolation, working to excess, and self-destructive or suicidal behaviors. 

*The future*
As the use of the Internet continues to expand, so will internet psychiatry. This is particularly true given that it may be quite useful in specifically providing access to psychotherapy for individuals with PTSD. Other areas that researchers are targeting to improve recovery for PTSD sufferers include expanding research on EMDR, studying how PTSD can be more specifically treated in various ethnic groups, and discovering how to best prevent people from developing the illness.


----------



## David Baxter PhD (Dec 12, 2007)

*PTSD At A Glance*

Posttraumatic stress disorder (PTSD) is an emotional illness that was first formally diagnosed in soldiers and war veterans and is caused by terribly frightening, life-threatening, or otherwise highly unsafe experiences. 
PTSD symptom types include re-experiencing the trauma, avoidance, and hyperarousal. 
PTSD has a lifetime prevalence of seven up to 30%, with about 5 million people suffering from the illness in any one year. Girls, women, and ethnic minorities tend to develop PTSD more than boys, men, and Caucasians. 
Complex posttraumatic stress disorder (C-PTSD) usually results from prolonged exposure to traumatic event(s) and is characterized by long-lasting problems that affect many aspects of emotional and social functioning. 
Symptoms of C-PTSD include problems regulating feelings, dissociation or depersonalization; persistent depressive feelings, seeing the perpetrator of trauma as all-powerful, preoccupation with the perpetrator, and a severe change in what gives the sufferer meaning. 
Untreated PTSD can have devastating, far-reaching consequences for sufferers' medical and emotional functioning and relationships, their families, and for society. Children with PTSD can experience significantly negative effects on their social and emotional development, as well as their ability to learn. 
Although almost any event that is life-threatening or that severely compromises the emotional well-being of an individual may cause PTSD, such events usually include experiencing or witnessing a severe accident or physical injury, getting a frightening medical diagnosis, being the victim of a crime or torture, exposure to combat, disaster or terrorist attack, enduring any form of abuse, or involvement in civil conflict. 
Issues that tend to put people at higher risk for developing PTSD include female gender, minority ethnicity, increased duration or severity of, as well as exposure to, the trauma experienced, having an emotional condition prior to the event, and having little social support. Risk factors for children and adolescents also include having any learning disability or experiencing violence in the home. 
Disaster preparedness training may be a protective factor for PTSD. 
Medicines that treat depression (for example, serotonergic antidepressants or SSRIs), decrease the heart rate (for example, propranolol) or increase the action of other body chemicals (for example, hydrocortisol) are thought to be effective tools in the prevention of PTSD when given in the days immediately after an individual experiences a traumatic event. 
Individuals who wonder if they may be suffering form PTSD may benefit from taking a self-test as they consider meeting with a practitioner. Professionals may used a clinical interview in either adults, children, or adolescents, or one of a number of structured tests with children or adolescents to assess for the presence of this illness. 
Diagnosing PTSD can present a challenge for professionals since sufferers often come for evaluation of something that seems to be unrelated to that illness at first. Those symptoms tend to be physical complaints, depression, or substance abuse. Also, PTSD often co-occurs with manic depression, eating disorders, or other anxiety disorders. 
Challenges for assessment of PTSD in children and adolescents include adult caretakers' tendency to be unaware of the extent of the young person's symptoms and the tendency for children and teens to express symptoms of the illness in ways that are quite different from adults. 
Treatments for PTSD usually include psychological and medical treatments. Education about the illness, helping the individual talk about the trauma directly, exploration and modification of inaccurate ways of thinking about it, and teaching the person ways to manage symptoms and are the usual techniques used in psychotherapy. Family and couples' counseling, parenting classes, and education about conflict resolution are other useful psychotherapeutic interventions. 
Directly addressing the sleep problems that are associated with PTSD has been found to help alleviate those problems, thereby decreasing the symptoms of PTSD in general. 
Medications that are usually used to help PTSD sufferers include serotonergic antidepressants (SSRIs) and medicines that help decrease the physical symptoms associated with illness. Other potentially helpful medications for managing PTSD include mood stabilizers and antipsychotics. Tranquilizers have been associated with withdrawal symptoms and other problems and have not been found to be significantly effective for helping individuals with PTSD. 
Some ways that are often suggested for PTSD patients to cope with this illness include learning more about the illness, talking to others for support, using relaxation techniques, participating in treatment, increasing positive lifestyle practices, and minimizing negative lifestyle practices.
*Where can people get help?*

Air Force Palace HART
Phone: 1-800-774-1361
Email: severelyinjured@militaryonesource.com

American Love and Appreciation Fund (for veterans)
1-305-673-2856

Army Wounded Warrior Program
Phone: 1-800-237-1336 or 1-800-833-6622

DHSD Deployment Helpline
Phone: 1-800-497-6261

Marine for Life
Phone: 1-866-645-8762
Email: injuredsupport@M4L.usmc.mil

Military One Source
Phone: 1-800-342-9647
Military OneSource

Military Severely Injured Center
Phone: 1-800-774-1361
Email: severelyinjured@militaryonesource.com

National Coalition Against Sexual Assault
Phone: 1-717-728-9764 

National Alliance for Mentally Ill
Phone: 1-800-950-6264 

National Mental Health Association
Phone: 1-800-969-6642 

Navy Safe Harbor
Phone: 1-800-774-1361
Email: severelyinjured@militaryonesource.com

Operation Comfort (for veterans and their families)
Phone: 1-866-632-7868 (1-866-NEAR TO U)

PTSD Information Hotline
Phone: 1-802-296-6300 

PTSD Sanctuary
Phone: 1-800-THERAPIST 

Rape, Abuse and Incest National Network
Phone: 1-800-656-HOPE
Rape, Abuse & Incest National Network


----------



## David Baxter PhD (Dec 12, 2007)

*References:*

Andreasen, N. C. Acute and delayed posttraumatic stress disorders: a history and some issues. American Journal of Psychiatry 161:1321-1323, August 2004.
American Academy of Child and Adolescent Psychiatry. Child and adolescent mental health statistics Resources for Families, 2007.
American Psychiatric Association. Diagnostic Criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition, Treatment Revision, Washington, D.C., 2000.
Beals, J., Novins, D. K., Whitesell, N. R., Spicer, P., Mitchell, C. M., Manson, S. M. American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project Team. Prevalence of mental disorders and utilization of mental health Services in two American Indian reservation populations: mental health disparities in a national context. American Journal of Psychiatry 162: 1723-1732, September 2005.
Bryant, R. A., Harvey, A. G. Gender differences in the relationship between acute stress disorder and posttraumatic stress disorder following motor vehicle accidents. Australian and New Zealand Journal of Psychiatry 37(2): 226-229, April 2003.
Cahill, S. P. Counterpoint: evaluating EMDR in treating PTSD. Psychiatric Times 17(7), July 2000.
Davidson, J. R. T. Effective Management Strategies for Posttraumatic Stress Disorder. Focus 1: 239-243, 2003.
Davidson, J. R. T, Stein, D. J., Shalev, A. Y., Yehuda, R. Posttraumatic stress disorder: acquisition, recognition, course and treatment. Journal of Neuropsychiatry 16: 135-147, May 2004.
Davidson, J. R. T. Surviving disaster: what comes after the trauma? The British Journal of Psychiatry 181: 366-368, 2002.
Department of Mental Health and Developmental Disabilities. Initiatives promoting mental health, 2007.
Ferenc, M., Brown, E. B., Zhang, H., Koke, S. C., Prakash, A. Fluoxetine v. placebo in prevention of relapse in post-traumatic stress disorder. The British Journal of Psychiatry 181: 315-320, 2002.
Friedman, M. J. Acknowledging the psychiatric cost of war New England Journal of Medicine 351(1): 75-77, 7/1/04.
Friedman, M. J. Posttraumatic stress disorder among military returnees from Afghanistan and Iraq American Journal Psychiatry 163: 586-593, April 2006.
Holtzheimer, P. E., Russo, J., Zatzick, D., Bundy, C., Roy-Byrne, P. P. The impact of comorbid posttraumatic stress disorder on short-term clinical outcome in hospitalized patients with depression. American Journal of Psychiatry 162: 970-976, May 2005.
Kaminer, D., Seedat, S., Stein, D. J. Post-traumatic stress disorder in children. World Psychiatry 4(2): 121-125, June 2005.
Keane, T. M., Marshall, A. D., Taft, C. T. Posttraumatic stress disorder: etiology, epidemiology and treatment outcome. Annual Review of Clinical Psychology 2: 161-197, April 2006.
Kenardy, J. A., Spence, S. H., Macleod, A. C. Screening for posttraumatic stress disorder in children after accidental injury. Pediatrics 118: 1002-1009. 2006. 
Knaevelsrud, C., Maercker, A. Internet-based treatment for PTSD reduces distress and facilitates the development of a strong therapeutic alliance: a randomized controlled clinical trial. BioMed Central Psychiatry 7: 13, 4/19/07.
Lamarche, L. J., De Koninck, J. Sleep disturbance in adults with posttraumatic stress disorder: a review. Journal of Clinical Psychiatry 68(8): 1257-1270. August 2007.
Loo, C. M. PTSD among ethnic minority veterans. National Center for PTSD, 2007. 
MayoClinic.com. Post traumatic stress disorder (PTSD). April 12, 2007.
Meiser-Stedman, R., Smith, P., Glucksman, W. Y., Dalgleish, T. parent and child agreement for acute stress disorder, post-traumatic stress disorder and other psychopathology in a prospective study of children and adolescents exposed to single-event trauma. Journal of Abnormal Child Psychology 35(2): 191-201. April 2007.
Mental Health News. Prevalence and Correlates of Post Traumatic Stress Disorder and Chronic Severe Pain in Psychiatric Outpatients. June 1, 2007.
McLean, L. M., Gallop, R. Implications of childhood sexual abuse for adult borderline personality disorder and complex posttraumatic stress disorder. American Journal of Psychiatry 160: 369-371, April 2003.
NARSAD. Post-traumatic stress disorder can damage children's brain development. http://www.narsad.org, 11/20/07.
NIMH. Post traumatic stress disorder: a real illness. NIMH  Home, 11/19/07.
Perilla, J. L., Norris, F. H., Lavizzo. Ethnicity, culture and disaster response: identifying and explaining ethnic differences in PTSD six months after hurricane Andrew. Journal of Social and Clinical Psychology 21(1): 20-45, March 2002.
Perrin, M. A., DiGrande, L., Wheeler, K., Thorpe, L., Farfel, M., Brackbill, R. Differences in PTSD prevalence and associated risk factors among World Trade Center disaster rescue and recovery workers. American Journal of Psychiatry 164(9): 1385-1394, September 2007.
Pole, N., Best, S. R., Metzer, T., Marmar, C. R. Why are Hispanics at greater risk for PTSD? Cultural, Diversity and Ethnic Minority Psychology 11(2): 144-161, 2005. 
Reeves, R. R. Diagnosis and management of posttraumatic stress disorder in returning veterans. Journal of the American Osteopathic Association 107(5): 181-189, May 2007.
Ruchkin, V., Schwab-Stone, M., Jones, S., Cicchetti, D. V., Koposov, R., Vermeiren. R. Is posttraumatic stress in youth a culture-bound phenomenon? A comparison of symptom trends in selected U.S. and Russian communities. American Journal of Psychiatry 162: 538-544, March 2005.
Ruzek, J. Coping with PTSD and recommended lifestyle changes for PTSD patients. National Center for Post Traumatic Stress Disorder, 5/22/07.
Schuster, M. A., Stein, B. D., Jaycox, L. H., Collins, R. L., Marshall, G. N., Elliott, M. N., Zhou, A. J., Kanouse, D. E., Morrison, J. L., Berry, S. H. A national survey of stress reactions after the September 11, 2001 terrorist attacks. New England Journal of Medicine 345(20): 1507-1512, 11/15/01.
Schoenfeld, F. B., Marmar, C. R., Neylan, T. C. Current concepts in pharmacotherapy for post traumatic stress disorder. Psychiatric Services 55: 519-531 May 2004.
Seng, J. S., Graham-Bermann, S. A., Clark, M. K., McCarthy, A. M., Ronis, D. L. Posttraumatic stress disorder and physical comorbidity among female children and adolescents: results form service-use data. Pediatrics 116(6): 767-776, December 2005.
Udwin, O., Boyle, S., Yule, W., Bolton, D., O'Ryan, D. Risk factors for long-term psychological effects of a disaster experienced in adolescence: predictors of post traumatic stress disorder. The Journal of Child Psychology and Psychiatry and Allied Disciplines 41: 969-979, 2000.
Wikipedia. Combat stress reaction. Wikipedia.com, 11/13/07.
Wikipedia. Complex post traumatic stress disorder. Wikipedia.com, 11/1/07. 
Wu, P., Duarte, C. S., Mandell, D. J., Fan, B., Liu, X., Fuller, C. J., Musa, G., Cohen, M., Cohen, P., Hoven, C. W. Exposure to the World Trade Center attack and the use of cigarettes and alcohol among New York City public high-school students. American Journal of Public Health 96(5): 804-807, 2006.
Yehunda, R., Engel, S. M., Brand, S. R., Seckl, J., Marcus, S. M., Berkowitz, G. S. Transgenerational effects of post traumatic stress disorder in babies of mothers exposed to the World Trade Center attacks during pregnancy. The Journal of Clinical Endocrinology and Metabolism 90(7): 4115-4118, 2005.


----------

