Diagnosis and Treatment of Trauma and Stressor-Related Disorders
Most people had experienced some type of trauma in their life, either when they were children or adults. While some trauma may be unnoticed and have no impact on a person’s mental health, experiencing violence or a threat of death can cause severe impairments. As a result of this severe trauma, an individual cannot function appropriately, socialize, or work. Despite a common belief that post-traumatic stress disorder (PTSD) impacts only war veterans, approximately 3.5% of the people in the United States are diagnosed with it each year (APA, 2020). There is no difference in the number of affected individuals when comparing the populations by gender and ethnicity. Hence, any exposure to traumatic events can cause PTSD, regardless of the person’s characteristics. The only relevant factor is exposure to serious risk: a natural disaster, death, rape, or other trauma.
The specific problem that this research focuses on is the PTSD-related issues that are not widely discussed—the prevalence of PTSD in populations other than veterans, the impact on physical health, and the lack of pharmaceutical developments in this field. For example, EMDR allows mitigating PTSD symptoms after 18 to 20 sessions. CBT addresses coping behaviors and will enable individuals to deal with stressors more effectively. On the other hand, medications for PTSD are typically the ones used to treat mood disorders, and not much research or trials have been done in recent years to develop a robust pharmacological aid.
A significant problem with PTSD research and treatment is the need to recognize that different populations exposed to stress in their daily lives, such as refugees or healthcare workers, can develop PTSD. This research shows that there are two ways of treating PTSD: medication and psychotherapy. The best PTSD treatment for the general population is EMDR or CBT because multiple studies show improvements in a patient’s well-being.
Background Information on PTSD
Trauma and stress-related disorders are a broad category of mental health diagnoses.
Trauma is defined as “actual or threatened death, serious injury, or sexual violence” (Shapiro, 1989, p. 271). Hence, any experience that a patient perceives as dangerous can cause trauma and subsequent mental health issues. Despite the negative experience, a person has and the problems this may cause, trauma is a universal issue (Braquehais & Sher, 2010). Hence, most people have experiences of events that caused them to develop trauma, but the severity of its consequences and the impact on a person’s quality of life may be different. Some people are exposed to extreme violence, for example, the military or hospital employees, which increases their risk of developing PTSD (Braquehais & Sher, 2010). Examples of trauma during childhood include negligence, abuse, and later life, witnessing death can lead to PTSD.
PTSD is a part of stress disorders since it occurs after a person encounters an event that causes them to feel extreme stress or even horror. PTSD, as defined by Bisson (2017), is witnessing or experiencing harm or a threat of death by the individual or others. In essence, when a patient sees a natural cataclysm or becomes a victim of a crime, which are some examples of PTSD causes, they may develop this condition. Bisson (2017) voices a concern that a natural response and emotions an individual has after a natural disaster or another traumatic event is being labeled as a severe mental health illness. However, the recognition in the DSM-5 manual and the distinction made between Acute Acute Post Traumatic Disorder suggest that scholars and practitioners recognize the differences and potential issues of mislabeling responses to trauma.
This disorder has been recognized by official sources since the publication of the 3rd edition of the DSM manual, although the descriptions of patient cases existed before. In editions of the DSM prior to firth, this disorder was classified as an anxiety disorder. At the same time, currently, it is in the category of Trauma- and Stressor-Related Disorders (“DSM-5 criteria for PTSD,” n.d.). Notably, the DSM-5 distinguishes between persistent PTSD symptoms and its acute stage. The latter occurs within the first few months of being exposed to a traumatic incident and, if addressed, does not progress into PTSD (“DSM-5 criteria for PTSD,” n.d.).
Moreover, the DSM-5 criteria for PTSD diagnosis are applicable for adults, while preschoolers or children are diagnosed with pediatric PTSD. This subtype incorporates only three criteria: arousal, reexperiencing, and avoidance (“DSM-5 criteria for PTSD,” n.d.). Under DSM-5, adults with PTSD experience criterions A, B, C, D, E, F, G, and H, which include a specification of stressors, durations, and symptoms (“DSM-5 criteria for PTSD,” n.d.). Notably, symptoms similar to PTSD induced by drug use or medication are exclusion criteria for this diagnosis.
The overdiagnosing of PTSD has become an issue in the United States. Bisson (2017) notes that many researchers and practitioners are now concerned with the number of reported PTSD cases. However, the majority of population-focused studies examined in this report, for instance, by Creech and Misca (2017), Hurley (2018), Lehavot et al. (2018), and Sherman et al. (2016), focus on the military. The military has a resource dedicated to PTSD treatment, the National Center for PTSD which is a part of the U.S. Department of Veterans Affairs. Much less attention is devoted to others who are also exposed to trauma: healthcare workers who work in critical care units or refugees.
The official diagnosis criteria require the symptoms to be present for at least one month (Bisson, 2017; “DSM-5 criteria for PTSD,” n.d.). Main symptoms include the experience of distress and inability to participate in social or other areas of life. Hence, PTSD symptoms directly influence a person’s ability to function—work, communicate with friends and family and do daily chores. Some people may experience the symptoms of PTSD for several weeks, after which these disappear. Approximately 10% to 20% of people with PTSD experience symptoms that are not alleviated, and they need professional help (Watkins et al., 2018, p. 1).
Another sign of PTSD is reexperiencing the traumatic events and states of reactivity and arousal (“DSM-5 criteria for PTSD,” n.d.). In essence, this state significantly decreases the person’s quality of life because experiencing severe PTSD symptoms does not allow them to engage in normal daily activities. Moreover, these symptoms affect a person’s social relationships and can affect their family relationships, especially if a person with PTSD is a parent. This social implication will be reviewed in the next section.
Key Patterns in PTSD Research
With the examined research, there are several key themes and patterns that help one understand the trends in PTSD studies. Firstly, the researchers try to determine the populations who are at the most risk of having PTSD due to their work or exposure to dangers. Moreover, these studies help determine that there is no association between gender or age and the likelihood of having PTSD. Examples of articles focusing on PTSD danger for populations are Braquehais and Sher (2010), Luftman et al. (2017), Lehavot et al. (2018), Henkelmann et al. (2020), Helzer et al. (1978), Duckers et al. (2018), and Creech and Misca (2017). PTS is a condition that can affect anyone, but there are specific populations that are at a higher risk—the military, healthcare workers, and refugees.
Research into PTSD Populations
War veterans are a specific category of people with PTSD since their work is directly linked to the fear and serious distress that can cause this condition. According to Braquehais and Sher (2010), “fear-stress response appeared as a reaction to inter-group male-to-male and intra-group killings after the rising of population densities in the Neolithic period” (p. 1). Notably, Watkins et al. (2018) report that when comparing the military and non-military populations, the percentage of PTSD cases approximately ranges from 4% to 8% in both cases. Hence, the Neuroevolutionary Time-depth Principle is one explanation for why, in some occupations, trauma often leads to PTSD in veterans. However, the prevalence of PTSD within this population is similar to the non-military population.
PTSD impacts not only people who have this condition but also their families. Creech and Misca (2017) state that research on PTSD is strongly linked to the military because war often results in trauma. The hypothesis is that apart from the impact on the veterans themselves, there is an interpersonal aspect to PTSD. Mainly, it affects the parent-child relationship. Creech and Misca (2017) argue that the prevalence of PTSD in the military veteran population is approximately 28% (p. 10).
The C-BIT model suggests that mental illness can affect the functioning of the family and the study by Creech and Misca (2017) reveals that parents with PTSD are more inclined to report having a complicated relationship with their children. There are other studies that test the hypothesis that PTSD affects intrafamily relationships. For example, Sherman et al. (2016) state that three clusters of PTSD affect the parenting process, such as “including avoidance, alterations in arousal and reactivity, and negative alterations of cognitions and mood” (p. 15). Hence, PTSD affects not just the person who has this condition but their families as well and can have a negative impact on parent-child interactions.
Among the populations that are exposed to trauma, one should mention the medical personnel, especially professionals who are first-responders and emergency care employees. Luftman et al. (2017) found that people who care for the injured, for instance, those working at emergency units, are at a high risk of developing PTSD. This is an example of how witnessing a highly stressful event can lead to similar psychological consequences as being directly involved in it. Luftman et al. (2017) used the Primary Care PTSD Screen, where individuals who answered positively on three or more questions were diagnosed with PTSD.
The findings show that 33% of care providers tested positively for PTSD, with no significant variance of gender, age, or characteristics (Luftman et al., 2017, p. 293). Moreover, pre-hospital providers had a higher prevalence of cases, and only 55% were educated about the issue (Luftman et al., 2017, p. 293). These results should alarm the healthcare providers and policymakers because the prevalence of PTSD among medical professionals is high.
This condition is traditionally viewed as something common among military veterans and not the general population. Yet, the previous paragraph shows that the medical staff is at risk as well and does not have the knowledge of the risk.
However, populations of refugees is another category of people at high risk of developing PTSD. Henkelmann et al. (2020) argue that the number of refugees in 2020 has increased to its highest since WWII, and these people often suffer from anxiety, depression, or PTSD. The prevalence of PTSD upon a review of self-reported data is from 29% to 37% (Henkelmann et al., 2020, p. 1). The reason for such high prevalence is constant exposure to stress since these people are subjected to violence in their home state and have to look for shelter in other countries. Based on these findings, one can argue that there are distinct categories among the population, where the PTSD prevalence is much higher compared to other populations.
As with the families of veterans, PTSD affects the family life of other populations, including refugee parents and their children. The issue of children dealing with PTSD either themselves or in their families is serious since, among the population of refugees, children, and adolescents account for the largest percentage (Bryant et al., 2018). The study of the Australian refugee caregivers shows that their experience of trauma and difficulties with migration result in harsher parenting practices (Bryant et al., 2018). This parenting approach directly impacts children refugees who are unable to receive adequate care within their families. Among other problems that children in these families face there are misconduct, hyperactivity, problems with peers, and emotional difficulties, all of which are connected to their caregivers’ PTSD (Bryant et al., 2018).
The implication of this study, similar to the study on parenting behavior of veterans with PTSD, is a need to dedicate attention to the families and their experiences. Children, in particular, suffer because of their dependence on the parents and require additional support if a family member has PTSD. Again, with the population of veterans, this problem is addressed by the National Center for PTSD, while little attention is dedicated to the refugee families.
Physical Effect of PTSD
PTSD is linked to several biologically significant changes in the person’s body and brain. Pan et al. (2018) explore the catecholamines levels in association with PTSD and argue that people with PTSD have higher levels of norepinephrine when compared to controls with no difference in dopamine and epinephrine levels. Previous neurobiology studies have shown that these hormones are linked with the different states of a person with PTSD experiences. Moreover, Pan et al. (2018) note that one of the hypotheses explaining why PTSD occurs is the disbalance of dopamine levels. Although more research is necessary to confirm this hypothesis, there is a clear impact on the person’s brain and body functioning when they have PTSD.
The consequences of PTSD are present not only within a person’s mental health. Many patients experience PTSD symptoms chronically, which may impair their physical health as well (Ryder et al. 2018). Some studies have shown that PTSD, similarly to other stress-related disorders, can affect one’s physical health as well. Ryder, et al. (2018) state that patients with PTSD have high rates of “cardiovascular, metabolic, and musculoskeletal disorders” (p. 116). Previous studies have shown a connection between the sympathetic nervous system and simultaneous instances of inflammation. More studies should explore diverse populations, especially minorities, to determine the cause and effect relationship between PTSD and physical health.
The co-occurrence of PTSD and cardiovascular problems creates a significant health burden for these patients. In a study by Nichter et al. (2019), the veterans diagnosed with PTSD are at risk of developing the comorbid cardiovascular illness. Moreover, with PTSD and comorbidity, the health burden is much greater when compared to PTSD alone. Nichter et al. (2019) provide one explanation for this, which is impaired physical functioning of PTSD veterans when compared to non-PTSD or veterans with a major depressive disorder. In addition, Nichter et al. (2019) report that veterans with PTSD have a higher prevalence of “migraine, fibromyalgia, and rheumatoid arthritis” (p. 109744). This points out to a potential link between experiencing PTSD symptoms and developing physical health problems.
Due to the prevalence of physical health problems among the PTSD-affected populations, the comorbid physical symptoms should be examined as well. Post-traumatic stress symptomatology (PTSS) is a set of physical health symptoms and chronic conditions that are linked to PTSD (Ryder et al. 2018). Different longitudinal studies focus on varied diseases, but there is a link between PTSD and physical health. Moreover, chronic PTSD leads to “reductions in volumes of the hippocampus and anterior cingulate cortex and enlarged amygdala volumes,” as reported by studies that use neuroimaging (Ryder et al. 2018, p. 116). These issues can cause problems with memory, executive functioning, and attention.
Among the metabolic problems, gaining excess weight or developing obesity is one issue that PTSD patients often have. Stefanovics et al. (2020) report that 5.8% percent of military veterans have both PTSD and obesity. These co-occurring conditions increase the health burden of these individuals and also the risk of suicide. Another study suggesting a connection between PTSD and obesity is by Brewerton (2017), who reports that food addiction is a proxy that makes the disorder’s symptoms and symptoms of some other mental health conditions more severe. This leads to greater mortality and morbidity since the two conditions create a greater health burden for an individual. The implication of this research by Brewerton (2017) is that PTSD patients should also be evaluated for comorbid food addiction disorders to ensure that the treatment is effective.
Due to the complexity of PTSD and the fact that it impacts the physical structures of the brain, the treatment of this condition may be complicated. Van Etten and Taylor (1998) focus specifically on exploring the existing methods for treating PTSD, with the main treatment methods being drug therapy and psychotherapy. For medications, the commonly used ones are “TCAs, carbamazepine, MAOIs, SSRIs, and BDZs” (Van Etten & Taylor, 1998, p. 126).
The pshycotheratupic approach targets behavior and alternative measures such as hypnotherapy or relation therapy. Van Etten and Taylor (1998) report that the most effective treatments with clinically significant outcomes were SSRIs and carbamazepine as a part of drug therapy. However, psychotherapy has shown better results when compared to medication and had a lower dropout rate (Van Etten & Taylor, 1998). Both behavioral therapy and Eye‐Movement Desensitization and Reprocessing have shown great results in treating PTSD. Thus, therapy is more effective when treating PTSD, but one should understand the time frame required for achieving the therapeutic effect.
There are some issues with the use of drugs for PTSD treatment. For example, Krystal et al. (2017) argue that there is a critical lack of advancements in the treatment of PTSD using medication. The APA (2017) reports that “sertraline, paroxetine, fluoxetine, and venlafaxine” are the recommended treatment options for patients with PTSD (para. 2). The response of patients to the specific drugs and dosage differs. Hence, a professional has to monitor the process of selecting an appropriate medication. The three drugs are serotonin reuptake inhibitors, which are commonly used for mood disorders. This may point out one issue voiced by Krystal et al. (2017), there are no drugs designed to treat PTSD and address the mechanisms triggered by this state in particular. Other medications, such as topiramate, an antiepileptic drug, are also used to address PTSD symptoms. However, there are significant side effects to this drug reported by patients, such as cognitive dulling.
Different types of therapy can be applied for effective PTSD treatment. A more recent study by Watkins et al. (2018) contains recommendations for PTSD treatment that include “Prolonged Exposure (PE), Cognitive Processing Therapy (CPT) and trauma-focused Cognitive Behavioral Therapy (CBT)” (p. 1). These therapies are trauma-oriented, which helps relieve the symptoms of individual experiences. The basis of these therapies is in addressing the thoughts and emotions an individual has regarding a traumatic event.
Notably, cognitive-behavioral therapy (CBT), which is a recent development in the field of psychotherapy, has been applied to PTSD patients as well. Shou et al. (2017) report that CBT increases amygdala connectivity with the frontoparietal network. Intrinsic functional connectivity is connectivity between distributed regions of the brain with fluctuations in activity over time (Shou et al., 2017). Studies on CBT’s application for PTSD are fairly recent when compared to the examination of other methods. Simon et al. (2019) examine the internet-based CBT titled “i-CBT” and argue that this is an adequate alternative for offline CBT sessions. The only difference these authors report is the dropout rate, which was higher for the population attention in CBT sessions when compared to non-i-CBT.
The CBT method for the treatment of PTSD allows the patients to change their behavior and to think patterns, allowing them to cope with their trauma. Simon et a. (2019) state that among the methods that CBT practitioners use, there are “psychoeducation, cognitive and exposure work, stress/relaxation management, and homework” (p. 10). Evidence from previous studies shows that CBT is effective for changing the maladaptive behavior of individuals, which can affect the way people address stress. Since i-CBT therapy shows promising results and can be either therapist-guided or non-guided, it is advised as a potential remedy for PTSD, especially due to its lower costs when compared to traditional therapy sessions.
Interestingly, CBT affects the structures of the patient’s brain, suggesting that this therapy does not merely address issues on the surface but has an impact on the overall functioning of the individual. Santarnecchi et al. (2019) report changes in brain connectivity after correctly delivered CBT for the patients who experienced a natural disaster, with “connectivity between the bilateral superior medial frontal gyrus and right temporal pole, and a (ii) decrease in connectivity between left cuneus and left temporal pole” (p. 11). For example, Acosta et al. (2017) report that correctly delivered CBT reduces heavy drinking in the population of veterans.
Moreover, in this study, the authors focused on a web delivery of CBT instead of face-to-face sessions. The results show that CBT is effective in improving the patients’ coping mechanisms. However, this study did not find a statistically significant improvement in PTSD symptoms. Considering that previously discussed studies report the positive effect of CBT and i-CBT, one can assume that the particular model of delivery or the fact that the veterans in the study by Acosta et al. (2017) had comorbid substance abuse issues affected the results. However, the contradicting effect of this study shows that more evidence is necessary to create an adequate CBT program for PTSD treatment delivered via the Internet.
Eye movement decentralization is the therapy where saccadic eye movements are used to treat traumatic disorders. The study by Shapiro (1989) shows that this approach is effective for PTSD treatment. The patient is asked to recall the traumatic memory, and during the process, they should elicit large-magnitude and rhythmic saccadic eye movements. As Shapiro (1989), the results include “
- a lasting reduction of anxiety,
- changes in the cognitive assessment of the memory, and
- cessation of flashbacks, intrusive thoughts, and sleep disturbance” (p. 212).
Moreover, this and other studies show that the therapy is effective after one session. Considering the detrimental impact of PTSD on a person’s daily life, eye movement decentralization is a promising way of treating this disorder.
EMDR has shown a great potential for treating PTSD, along with CBT. The basis of this method is based on the theory of Shapiro, who introduced a therapy method based on the alternation of the patient’s eye movements. Under this approach, a patient is asked to recall the event that caused them to have PTSD (Shapiro, 1989). Here, the eye movements of these individuals differ from the natural ones. The therapist asks the patients to move their eyes. The hypothesis of this therapy is that when an individual recalls stress and they are distracted by other events, the process is less traumatic (Shapiro, 1989).
The evidence that EMDR is effective is provided by Valiente-Gómez et al. (2017) in their systematic review of the literature and found that this approach is effective for treating PTSD with comorbid psychiatric disorders. EMDR can help improve the psychotic symptoms in patients. Hurley (2018) reports that in comparison with two methods of EMDR-one provided twice a day and the second with one session per week. The results show that both forms of therapy are effective, with no significant difference in outcomes after a 1-year outcome. Hurley (2018) cites the WHO’s description of EMDR and the differences with CBT, which is the following: “EMDR aims to reduce subjective distress and strengthen adaptive beliefs related to the traumatic event. Unlike CBT with a trauma focus, EMDR does not involve
- detailed descriptions of the event,
- direct challenging of beliefs,
- extended exposure, or
- homework” (p. 11).
Hence, at least for the veteran population, which was the focus of this study, EMDR therapy is a very effective method for PTSD treatment, which can be offered to patients through sessions once per week for the duration of 18-20 sessions.
EMDR can be offered to patients as one of the effective methods for treating PTSD. de Bont et al. (2016) suggest that EMDR is effective for PTSD that is accompanied by psychosis, depression, and impaired social functioning. In their study, psychiatric patients were treated with EMDR and prolonged exposure (PE). PE, in particular, is a method taken from CBT, where patients learn how to tolerate traumatic memories gradually. Both PE and EMDR have shown good results in reducing the psychotic symptoms in patients in this study (de Bont et al., 2016). The main outcome is the lessening of paranoid thoughts in most patients and the reduction of patients with acute symptoms of schizophrenia.
There are other, less traditional approaches to treating PTSD that have some research suggesting their efficiency. Among other promising treatment options, one should review the implications of cannabis and 3,4-methylenedioxymethamphetamine (MDMA). Feduccia et al. (2018) state that these substances are undergoing approval for further studies under the Food and Drug Administration’s guidance. However, some early research does suggest the positive impact of cannabis on relieving the symptoms of PTSD, mainly because it affects the functioning of the amygdala. This part of the brain is deemed responsible for the emotions associated with fear, and therefore, cannabis has some impact on relieving these segments of PTSD. Generally, PTSD treatments may include variations of psychotherapy or the use of pharmacological agents.
All in all, avoiding stress is impossible, and some stressors can cause severe damage to a person’s well-being and mental health, resulting in PTSD. PTSD is characterized by a prolonged duration of symptoms, periods of reactivity, and recollections of the traumatic events, which often leads to avoidance. As shown by some studies, PTSD affects not only the traumatized people but their families because, in self-reported studies, parents with PTSD argue that their condition affects their relationship with children.
Due to the fact that many studies and treatment programs are dedicated to helping veterans with PTSD and the best approaches to treatment, the population that lacks attention is refugees and immigrants. More attention should be dedicated to these individuals because they suffer from many stressors and may struggle to reintegrate into society in their new place of residence. The research findings suggest that medication is not the most effective way of treating PTSD. Instead, psychotherapy should be recommended as an effective remedy, for example, CBT or CPT, or EMDR. Other approaches, such as eye decentralization, also help reduce PTSD symptoms.
The studies in this paper suggest that the most effective ways of treating PTSD are EMDR and CBT. These two approaches are based on different theories. For instance, CBT allows challenging a patient’s beliefs and helps them develop adequate coping mechanisms. EMDR is based on bilateral stimulation using different eye movements. Regardless of the type of therapy, the studies that focus on using medications point out the limitations of this method. PE, a technique from CBT that teaches individuals to tolerate events that cause them trauma is also useful for treating PTSD. Notably, this review did not locate a study that would provide a clear answer to what method of treating PTSD is the most effective, with studies suggesting that practitioners can use several approaches.
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