Post-traumatic stress disorder

Post-traumatic stress disorder
Specialty	Psychiatry, clinical psychology

Posttraumatic stress disorder (PTSD) is a severe anxiety disorder that can develop after exposure to any event which results in psychological trauma. This event may involve the threat of death to oneself or to someone else, or to one's own or someone else's physical, sexual, or psychological integrity, overwhelming the individual's psychological defenses.

PTSD is a less frequent and more enduring consequence of psychological trauma than the more frequently seen acute stress response. PTSD has also been recognized in the past as railway spine, stress syndrome, shell shock, battle fatigue, traumatic war neurosis, or post-traumatic stress syndrome.

Diagnostic symptoms include re-experiencing the original trauma(s) through flashbacks or nightmares; avoidance of stimuli associated with the trauma; and increased arousal, such as difficulty falling or staying asleep, anger, and hypervigilance. Formal diagnostic criteria (both DSM-IV and ICD-9) require that the symptoms last more than one month and cause significant impairment in social, occupational, or other important areas of functioning.

Signs and symptoms

PTSD can cause many symptoms, only some of which have diagnostic value. These symptoms are currently grouped in the DSM-IV into three categories.

Re-experiencing

• Flashbacks—reliving the trauma over and over, including physical symptoms like a racing heart or sweating
• Bad dreams
• Frightening thoughts.

Re-experiencing symptoms may cause problems in a person’s everyday routine. They can start from the person’s own thoughts and feelings. Words, objects, or situations that are reminders of the event can also trigger re-experiencing.

Avoidance

• Staying away from places, events, or objects that are reminders of the experience
• Feeling emotionally numb
• Feeling strong guilt, depression, or worry
• Losing interest in activities that were enjoyable in the past
• Having trouble remembering the dangerous event.

Things that remind a person of the traumatic event can trigger avoidance symptoms. These symptoms may cause a person to change his or her personal routine. For example, after a bad car accident, a person who usually drives may avoid driving or riding in a car.

Hyperarousal

• Being easily startled
• Feeling tense or "on edge"
• Having difficulty sleeping, and/or having angry outbursts.

Hypervigilance symptoms are usually constant. They can make the person feel stressed and angry. These symptoms may make it hard to do daily tasks, such as sleeping, eating, or concentrating.

It is natural to have some of these symptoms after a dangerous event. Sometimes people have very serious symptoms that go away after a few weeks. This is called acute stress disorder, or ASD. When the symptoms last more than a few weeks and become an ongoing problem, they might be PTSD. Some people with PTSD show no symptoms for weeks or months.

Research-based alternative conceptualizations

Emerging factor analytic research suggests that PTSD symptoms are best described as falling into four clusters, not the three currently described in the Diagnostic and Statistical Manual of Mental Disorders. One model supported by this research divides the traditional avoidance symptoms into a cluster of numbing symptoms (such as loss of interest and feeling emotionally numb) and a cluster of behavioral avoidance symptoms (such as avoiding reminders of the trauma). An alternative model adds a fourth cluster of dysphoric symptoms; these include symptoms of emotional numbing, as well as anger, sleep disturbance, and difficulty concentrating (traditionally grouped under the hyperarousal cluster).

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Diagnosis

Diagnostic criteria in current use

The diagnostic criteria for PTSD, per the Diagnostic and Statistical Manual of Mental Disorders IV (Text Revision) (DSM-IV-TR), may be summarized as:

A. Exposure to a traumatic event

B. Persistent reexperience (e.g. flashbacks, nightmares)

C. Persistent avoidance of stimuli associated with the trauma (e.g. avoidance of experiences that they fear will trigger flashbacks and reexperiencing of symptoms fear of losing control)

D. Persistent symptoms of increased arousal (e.g. difficulty falling or staying asleep, anger and hypervigilance)

E. Duration of symptoms for more than 1 month

F. Significant impairment in social, occupational, or other important areas of functioning (e.g. problems with work and relationships.)

Notably, criterion A requires that "the person’s response involved intense fear, helplessness, or horror." The DSM-IV-TR criterion differs substantially from the previous DSM-III-R stressor criterion, which specified the traumatic event should be of a type that would cause "significant symptoms of distress in almost anyone," and that the event was "outside the range of usual human experience."

Since the introduction of DSM-IV, the number of possible events which might be used to diagnose PTSD has increased; one study suggests that the increase is around 50%. Various scales exist to measure the severity and frequency of PTSD symptoms.

Proposed changes to current DSM-IV criteria

On February 10, 2010, the American Psychiatric Association placed online for comment the draft diagnostic criteria for mental illness diagnoses which are proposed for the upcoming DSM-V. After a public comment period closes on April 20, 2010, the criteria will be field tested for two years, prior to final revisions and publication in May of 2013.

The draft PTSD diagnostic criteria contain some noteworthy changes:

• Criteria A (prior exposure to traumatic events) is more specifically stated, and evaluation of an individual's emotional response at the time (current criteria A2) is dropped.
• Several items in Criteria B (intrusion symptoms) are rewritten to add or augment certain distinctions now considered important.
• Special consideration is given to developmentally appropriate criteria for use with children and adolescents. This is especially evident in the restated Criteria B - intrusion symptoms. Development of age-specific criteria for diagnosis of PTSD is ongoing at this time.
• Criteria C (avoidance and numbing) has been split into "C" and "D":
  • Criteria C (new version) now focuses solely on avoidance of behaviors or physical or temporal reminders of the traumatic experience(s). What were formerly two symptoms are now three, due to slight changes in descriptions.
  • New Criteria D focuses on negative alterations in cognition and mood associated with the traumatic event(s), and contains two new symptoms, one expanded symptom, and four largely unchanged symptoms specified in the previous criteria.
• Criteria E (formerly "D"), which focuses on increased arousal and reactivity, contains one modestly revised, one entirely new, and four unchanged symptoms.
• Criteria F (formerly "E") still requires duration of symptoms to have been at least one month.
• Criteria G (formerly "F") stipulates symptom impact ("disturbance") in the same way as before.
• The "acute" vs "delayed" distinction is dropped; the "delayed" specifier is considered appropriate if clinical symptom onset is no sooner than 6 months after the traumatic event(s).

Finally, the inclusion in the DSM-V of a Developmental Trauma Disorder is still under discussion, at the time of the draft publication.

Prevention

In recent history, catastrophes (by human means or not) such as the Indian Ocean Tsunami Disaster may have caused PTSD in many survivors and rescue workers. Today relief workers from organizations such as the Red Cross and the Salvation Army provide counseling after major disasters as part of their standard procedures to curb severe cases of post-traumatic stress disorder.

In the United States

In part through the efforts of anti Vietnam war activists and the anti war group Vietnam Veterans Against the War and Chaim F. Shatan, who worked with them and coined the term post-Vietnam Syndrome, the condition was added to the DSM-III as posttraumatic stress disorder.

A review of the provision of compensation to veterans for PTSD by the United States Department of Veterans Affairs began in 2005 after the VA had noted a 30% increase in PTSD claims in recent years. This led to a backlash from veterans'-rights groups, and to some highly-publicized suicides by veterans who feared losing their benefits, which in some cases constituted their only income. In response, on November 10, 2005, the Secretary of Veterans Affairs announced that "the Department of Veterans Affairs (VA) will not review the files of 72,000 veterans currently receiving disability compensation for post-traumatic stress disorder..."

The diagnosis of PTSD has been a subject of some controversy due to uncertainties in objectively diagnosing PTSD in those who may have been exposed to trauma, and due to this diagnosis' association with some incidence of compensation-seeking behavior.

Many veterans of the wars in Iraq and Afghanistan returning home have faced significant physical, emotional and relational disruptions. In response the United States Marine Corps has instituted programs to assist them in re-adjusting to civilian life - especially in their relationships with spouses and loved ones - to help them communicate better and understand what the other has gone through. Similarly, Walter Reed Army Institute of Research (WRAIR) developed the Battlemind program to assist service members avoid or ameliorate PTSD and related problems. In the UK there has been some controversy that National Health Service is dumping veterans on service charities like Combat Stress.

Canadian veterans

Veterans Affairs Canada offers a new program that includes rehabilitation, financial benefits, job placement, health benefits program, disability awards and family support.

Management

Early interventions

Some benefit has been found from early access to cognitive behavioral therapy, as well as from some medications such as propranolol. Effects of all these prevention strategies is modest.

Critical incident stress management (CISM) has been used to attempt to reduce effects of a potentially traumatic incident, and to attempt to prevent a full-blown occurrence of PTSD. However, recent studies regarding CISM seem to indicate iatrogenic effects. Six studies have formally looked at the effect of CISM, four finding no benefit for preventing PTSD, and the other two studies indicating that CISM actually made things worse. Hence this is not a recommended treatment.

Psychotherapeutic interventions

Many forms of psychotherapy have been advocated for trauma-related problems such as PTSD. Basic counseling practices common to many treatment responses for PTSD include education about the condition and provision of safety and support.

The psychotherapy programs with the strongest demonstrated efficacy include cognitive behavioral programs, variants of exposure therapy, stress inoculation training (SIT), variants of cognitive therapy (CT), eye movement desensitization and reprocessing (EMDR), and many combinations of these procedures.

The British Journal of Psychiatry has recommended EMDR or trauma-specific cognitive behavioral therapy as first-line treatments for trauma victims. A meta-analytic comparison of EMDR and cognitive behavioral therapy found both protocols indistinguishable in terms of effectiveness in treating PTSD.

Cognitive behavioral therapy

Cognitive Behavioral Therapy (CBT) is a psychotherapeutic approach that aims to change the patterns of thinking and/or behavior that are responsible for a trauma victim’s negative emotions and, in doing so, change the way they feel and act. CBT has been proven to be an effective treatment for PTSD, and is currently considered the standard of care for PTSD by the Department of Defense. In CBT, individuals learn to identify thoughts that make them feel afraid or upset, and replace them with less distressing thoughts. The goal is to understand how certain thoughts about trauma cause stress and make symptoms worse.

Eye movement desensitization and reprocessing

Eye Movement Desensitization and Reprocessing (EMDR) is specifically targeted as a treatment for PTSD. Based on the evidence of controlled research, the American Psychiatric Association and the U.S. Department of Veterans Affairs and Department of Defense have placed EMDR in the highest category of effectiveness and research support in the treatment of trauma. Several international bodies have made similar recommendations.

Exposure therapy

Exposure involves assisting trauma survivors to therapeutically confront distressing trauma-related memories and reminders in order to facilitate habituation and successful emotional processing of the trauma memory. Most exposure therapy programs include both imaginal confrontation with the traumatic memories and real-life exposure to trauma reminders.

Indeed, the success of exposure-based therapies has raised the question of whether exposure is a necessary ingredient in the treatment of PTSD. Some organizations have endorsed the need for exposure.

Interpersonal psychotherapy

Other approaches, particularly involving social supports, may also be important. An open trial of interpersonal psychotherapy reported high rates of remission from PTSD symptoms without using exposure. A current, NIMH-funded trial in New York City is now comparing interpersonal psychotherapy, prolonged exposure therapy, and relaxation therapy.

Medication

Symptom prevention: potentially useful medication classes

Some medications have shown benefit in preventing PTSD or reducing its incidence, when given in close proximity to a traumatic event. These medications include:

Alpha-adrenergic agonists. Anecdotal report of success in using Clonidine ("Catapress") to reduce traumatic stress symptoms suggests that it may have benefit in preventing PTSD.

Beta blockers. Propranolol ("Inderal"), like clonidine, may be useful if there are significant symptoms of "over-arousal". These may inhibit the formation of traumatic memories by blocking adrenaline's effects on the amygdala.

Glucocorticoids. There is some evidence suggesting that administering glucocorticoids immediately after a traumatic experience may help prevent PTSD. Several studies have shown that individuals who receive high doses of hydrocortisone for treatment of septic shock, or following surgery, have a lower incidence and fewer symptoms of PTSD.

Opiates. In a retrospective analysis of combat injury field data for US troups in Iraq, it was found that those who received morphine in the early stages of their treatment had a significantly lower rate of subsequent PTSD, when compared with those who did not receive morphine at that time.

Symptom management: potentially useful medication classes

A variety of medications has shown adjunctive benefit in reducing PTSD symptoms, but "there is no clear drug treatment for PTSD". Positive symptoms (re-experiencing, hypervigilance, increased arousal) generally respond better to medication than negative symptoms (avoidance, withdrawal), and it is recommended that any drug trial last for at least 6–8 weeks. Among the anti-depressants described below, bupropion and venlafaxine have the lowest patient drop-out rates. Sertraline, fluoxetine, and nefazodone have a modestly higher drop-out rate (~15%), and the heterocyclics and paroxetine have the highest rates (~20%+). Where drop-out is caused or feared because of medication side-effects, it should be remembered that most patients do not experience such side-effects.

Alpha-adrenergic agonists. Prazosin ("Minipress"), in a small study of combat veterans, has shown substantial benefit in relieving or reducing nightmares. Clonidine ("Catapress") can be helpful with startle, hyperarousal, and general autonomic hyperexcitability.

Anti-convulsants, mood stabilizers, anti-aggression agents. Carbamazepine ("Tegretol") has likely benefit in reducing arousal symptoms involving noxious affect, as well as mood or aggression. Topiramate ("Topamax") has been effective in achieving major reductions in flashbacks and nightmares, and no reduction of effect was seen over time. Zolpidem ("Ambien") has also proven useful in treating sleep disturbances.

Lamotrigene ("Lamictil") may be useful in reducing reexperiencing symptoms, as well as avoidance and emotional numbing. Valproic acid ("Depakene") and has shown reduction of symptoms of irritability, aggression, and impulsiveness, and in reducing flashbacks. Similarly, lithium carbonate has worked to control mood and aggressions (but not anxiety) symptoms. Buspirone ("BuSpar") has an effect similar to that of lithium, with the additional benefit of working to reduce hyperarousal symptoms.

Antipsychotics. Risperidone can be used to help with dissociation, mood issues, and aggression.

Atypical anti-depressants. Nefazodone ("Serzone") can be effective with sleep disturbance symptoms, and with secondary depression, anxiety, and sexual dysfunction symptoms. Trazodone ("Desyrel") can also reduce or eliminate problems with disturbed sleep, and with anger and anxiety.

Beta blockers. Propranolol ("Inderal") has demonstrated possibilities in reducing hyperarousal symptoms, including sleep disturbances.

Benzodiazepines. These can be used with caution for short-term anxiety relief, hyperarousal, and sleep disturbance. While benzodiazepines can alleviate acute anxiety, there is no consistent evidence that they can stop the development of PTSD, or of any effectiveness in the treatment of post traumatic stress disorder.

Glucocorticoids. Additionally, post-stress high dose corticosterone administration was recently found to reduce 'PTSD-like' behaviors in a rat model of PTSD. In this study, corticosterone impaired memory performance, suggesting that it may reduce risk for PTSD by interfering with consolidation of traumatic memories. The neurodegenerative effects of the glucocorticoids, however, may prove this treatment counterproductive.

Heterocyclic / Tricyclic anti-depressants anti-depressants. Amitriptyline ("Elavil") has shown benefit for positve distress symptoms, and for avoidance, and Imipramine ("Tofranil") has shown benefit for intrusive symptoms.

Monoamine-oxidase inhibitors (MAOs). Phenelzine {"Nardil") has for some time been observed to be effective with hyperarousal and depression, and is especially effective with nightmares.

SSRIs (selective serotonin reuptake inhibitors). SSRIs are considered to be a first-line drug treatment. SSRIs for which there are data to support use include: citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline.

Miscellaneous other medications. Clinical trials evaluating methylenedioxymethamphetamine (MDMA, "Ecstasy") in conjunction with psychotherapy are being conducted in Switzerland and Israel.

Medications by symptom group affected

Medications can affect one or more of the symptoms, in one or more of the three major symptom classes involved in diagnosing PTSD, which can be summarized in the following table:

Symptom class	Symptom	Medication
Reexperiencing
	intrusive recall	amitriptyline; fluoxetine; imipramine; lamotrigine; sertraline
	intrusive reexperiencing	amitriptyline; fluoxetine; imipramine; nefazodone; sertraline (women only); topiramate;
	sleep disturbance, nightmares	benzodiazepines; carbamazepine; clonidine; nefazodone; phenelzine; prazosin; topiramate; trazodone; zolpidem
	dissociative recall	risperidone
	intense psychological distress (anger, anxiety) when exposed to reminders of traumatic event(s)	benzodiazepines; buspirone; carbamazepine; lithium (not for anxiety); nefazodone; trazodone
Avoidance
	avoidance	amitriptyline; fluoxetine; lamotrigine; nefazodone; sertraline
	feelings of detachment or estrangement from others	amitriptyline; risperidone
	restricted range of affect (numbing)	amitriptyline; lamotrigine; sertraline (women only)
Hyperarousal
	general hyperarousal	amitriptyline; nefazodone; phenelzine; sertraline (women only)
	sleep disturbance, nightmares	benzodiazepines; carbamazepine; clonidine; nefazodone; phenelzine; trazodone; zolpidem
	irritability, anger (and impulsiveness)	carbamazepine; nefazodone; valproic acid
	anger	buspirone; fluoxetine; lithium; trazodone
	aggression	risperidone
	exaggerated startle response; general autonomic hyperexcitability	benzodiazepines; buspirone; carbamazepine; clonidine; propanolol; valproic acid

Some medications can also help with symptoms which may occur secondary to PTSD.

Secondary symptom	Medication
depression	nefazodone; phenelzine
dream content distortions	nefazodone
relapse of symptoms	carbamazepine;
self-mutilation	clonidine; buprenorphine
sexual function reduction	nefazodone
sleep hours reduction	nefazodone

Medication and Self-medication issues and risks with PTSD

Alcohol and drug abuse commonly co-occurs with PTSD. Recovery from posttraumatic stress disorder or other anxiety disorders may be hindered, or the condition worsened, by medication or substance overuse, abuse, or dependence; resolving these problems can bring about a marked improvement in an individual's mental health status and anxiety levels.

Benzodiazepines are risky in several ways. They can be especially addictive when PTSD is present, and this is especially true with the fast-acting ones. Dis-inhibition upon initiation of treatment is another risk with this medication class. Finally, termination of the drug can be especially difficult. Recovery from benzodiazepine abuse or dependence tends to take a lot longer than recovery from alcohol abuse or dependence, but people can regain their previous good health. PTSD symptoms may temporarily worsen however, during alcohol withdrawal or benzodiazepine withdrawal.

Yohimbine (not considered specifically appropriate for PTSD) increases arousal by increasing release of endogenous norepinephrine, and can worsen PTSD symptoms.

Epidemiology

Disability-adjusted life year rates for post-traumatic stress disorder per 100,000 inhabitants in 2004.

  no data

  < 43.5

  43.5-45

  45-46.5

  46.5-48

  48-49.5

  49.5-51

  51-52.5

  52.5-54

  54-55.5

  55.5-57

  57-58.5

  > 58.5

There is debate over the rates of PTSD found in populations, but despite changes in diagnosis and the criteria used to define PTSD between 1997 and 2007, epidemiological rates have not changed significantly.

International PTSD rates

The United Nations' World Health Organization publishes estimates of PTSD impact for each of its member states; the latest data available are for 2004. Considering only the 25 most populated countries,ranked by overall age-standardized Disability-adjusted life year (DALY) rate, the top half of the ranked list is dominated by Asian/Pacific countries, the USA, and Egypt. Ranking the countries by the male-only or female-only rates produces much the same result, but with less meaningfulness, as the score range in the single sex rankings is much reduced (4 for women, 3 for men, as compared with 14 for the overall score range), suggesting that the differences between female and male rates, within each country, is what drives the distinctions between the countries.

Age-standardized Disability-adjusted life year (DALY) rates for PTSD, per 100,000 inhabitants, in 25 most populous countries, ranked by overall rate (2004)

Region	Country	PTSD DALY rate, overall	PTSD DALY rate, females	PTSD DALY rate, males
Asia / Pacific	Thailand	59	86	30
Asia / Pacific	Indonesia	58	86	30
Asia / Pacific	Philippines	58	86	30
Americas	USA	58	86	30
Asia / Pacific	Bangladesh	57	85	29
Africa	Egypt	56	83	30
Asia / Pacific	India	56	85	29
Asia / Pacific	Iran	56	83	30
Asia / Pacific	Pakistan	56	85	29
Asia / Pacific	Japan	55	80	31
Asia / Pacific	Myanmar	55	81	30
Europe	Turkey	55	81	30
Asia / Pacific	Viet Nam	55	80	30
Europe	France	54	80	28
Europe	Germany	54	80	28
Europe	Italy	54	80	28
Asia / Pacific	Russian Federation	54	78	30
Europe	United Kingdom	54	80	28
Africa	Nigeria	53	76	29
Africa	Dem. Republ. of Congo	52	76	28
Africa	Ethiopia	52	76	28
Africa	South Africa	52	76	28
Asia / Pacific	China	51	76	28
Americas	Mexico	46	60	30
Americas	Brazil	45	60	30

United States

The National Comorbidity Survey has estimated that the lifetime prevalence of PTSD among adult Americans is 7.8%, with women (10.4%) twice as likely as men (5%) to have PTSD at some point in their lives.

The United States Department of Veterans Affairs estimates that 830,000 Vietnam War veterans suffered symptoms of PTSD. The National Vietnam Veterans' Readjustment Study (NVVRS) found 15.2% of male and 8.5% of female Vietnam Vets to suffer from current PTSD at the time of the study. Life-Time prevalence of PTSD was 30.9 for males and 26.9 for females. In a reanalysis of the NVVRS data, along with analysis of the data from the Matsunaga Vietnam Veterans Project, Schnurr, Lunney, Sengupta, and Waelde found that, contrary to the initial analysis of the NVVRS data, a large majority of Vietnam veterans suffered from PTSD symptoms (but not the disorder itself). Four out of five reported recent symptoms when interviewed 20–25 years after Vietnam.

In other species

There have been reports of captive and wild elephants suffering from posttraumatic stress reactions, the latter from seeing members of their herd shot by hunters.

History

Earliest reports

Reports of battle-associated stress reactions appear as early as the 6th century BCE. One of the first descriptions of PTSD was made by the Greek historian Herodotus. In 490 BCE he described, during the Battle of Marathon, an Athenian soldier who suffered no injury from war but became permanently blind after witnessing the death of a fellow soldier.

In the early 1800s military medical doctors started diagnosing soldiers with "exhaustion" after the stress of battle. This "exhaustion" was characterized by mental shutdown due to individual or group trauma. As in the present time, soldiers during the 1800s were not supposed to be scared or show any fear in the midst of battle. The only treatment for this "exhaustion" was to bring the afflicted to the back for a bit then send them back into battle. During the intense and frequently repeated stress, the soldiers became fatigued as a part of their body's natural shock reaction.

One-tenth of mobilized American men were hospitalised for mental disturbances between 1942 and 1945, and after thirty-five days of uninterrupted combat, 98% of them manifested psychiatric disturbances in varying degrees.

Although PTSD-like symptoms have also been recognized in combat veterans of many military conflicts since, the modern understanding of PTSD dates from the 1970s, largely as a result of the problems that were still being experienced by US military veterans of the war in Vietnam.

Terminology

The term post-traumatic stress disorder or PTSD was coined in the mid 1970s. Early in 1978, the term was used in a working group finding presented to the Committee of Reactive Disorders. The term was formally recognized in 1980. (In the authoritative DSM-IV, the spelling "posttraumatic stress disorder" is used. Elsewhere, "posttraumatic" is often rendered as two words — "post-traumatic stress disorder" or "post traumatic stress disorder" — especially in less formal writing on the subject.)

See also

• Acute stress reaction
• Complex post-traumatic stress disorder
• Emotional dysregulation
• Media violence research
• Post-traumatic embitterment disorder
• Psychogenic amnesia
• Psychoneuroimmunology
• Survivor syndrome
• Thousand-yard stare
• Trauma model of mental disorders

External links

BEFORE adding an external link to this section, it is requested that you read a plea for thoughtfulness, on the Talk page. Thank you!

Treatment guidelines

• Australian Guidelines for the Treatment of Adults with Acute Stress Disorder and Posttraumatic Stress Disorder - downloadable from page.
• Post-traumatic stress disorder (PTSD): The management of PTSD in adults and children in primary and secondary care - downloadable from page. Guideline document from the National Institute of Health and Clinical Excellence of the Natioanal Health Service (U.K.). A summary is available.
• PTSD Treatment Guidelines - 18 individual downloadable guidelines for various treatment modalities and situations, "...developed under the auspices of the Posttraumatic Stress Disorder (PTSD) Treatment Guidelines Task Force established by the Board of Directors of the International Society for Traumatic Stress Studies (ISTSS) in 2005..."
• Treatment of Patients With Acute Stress Disorder and Posttraumatic Stress Disorder - American Psychiatric Association Practice Guideline - downloadable from page. A summary is available.

General resource sites and pages (non-governmental)

• Posttraumatic Stress Disorder (Anxiety Disorders Association of America) - brief, high-quality information.
• David Baldwin's Trauma Information Pages - award winning resource collection site, for both professionals and clinical service consumers
• Post Traumatic Stress Disorder (PTSD) - award-winning comprehensive public education leaflet, from the UK's Royal College of Psychiatrists
• Sidran Foundation - "traumatic stress education and advocacy"

Government-managed sites

• Australian Centre for Posttraumatic Mental Health - "A centre of excellence supported by the Australian Government"
• National Center for PTSD - "Advancing Science and Promoting Understanding of Traumatic Stress." While understandably focused on PTSD in military populations, the resources here go far beyond this focus.

Professional organization sites

• American Psychological Association's Division 56 - Trauma Psychology - "psychology's focal point for research, practice, and education on trauma."
• European Society for Trauma and Dissociation - offering significant information for both professionals and service consumers
• International Society for Traumatic Stress Studies - the major international professional organization devoted to studying and treating traumatic stress

Research resources

• PILOTS (Published International Literature on Traumatic Stress) database search page - the largest database of publications on PTSD.