Posttraumatic stress disorder (PTSD)

If something that happened to you is still with you — in your sleep, in how on edge you feel, in the places and people you've started to avoid — you may be dealing with PTSD. PTSD can develop after experiences that were frightening or violent, it can surface years later, and there are well-studied treatments for it.

This page explains what PTSD is, what treatment involves, and what to ask a therapist. The trauma page covers the broader experience of being badly hurt by something, including when it doesn't lead to a diagnosis.

What causes it

PTSD follows experiences where someone's life or safety was in danger: combat, assault, sexual violence, a serious accident, a disaster, a violent crime. It can follow something that happened to you, something you saw happen to someone else, or learning that someone close to you died suddenly or violently. People whose work keeps putting them in front of other people's worst moments — paramedics, police, nurses, people who investigate abuse — can develop it from that exposure over time.

If what you went through doesn't look like that list, it can still have done real damage. The trauma page is written for that situation too.

What it can feel like

It comes back. Memories that arrive when you don't want them. Nightmares. Moments where some part of you is back there. A strong reaction — pounding heart, panic, nausea — to a sound, a smell, a place, a tone of voice.

You steer around it. Avoiding the people, places, conversations, and situations that bring it up, and working hard not to think or feel anything about it. Avoidance is easy to mistake for coping, because in the short term it works.

Your outlook changes. Gaps in what you remember. Fixed beliefs that feel like facts — I can't trust anyone, I should have stopped it, nowhere is safe. Guilt, shame, fear, or anger that has become the background of your days. Losing interest in things, feeling cut off from people you love, and finding it hard to feel much that's good.

You stay on guard. Irritability, a short fuse, startling easily, scanning rooms for danger, trouble concentrating, trouble sleeping. Some people take risks or do things that hurt them.

Not everyone has all of these, and two people with PTSD can look very different.

When it shows up

In the first weeks after something terrifying, strong reactions are common, and for many people they ease. If they don't ease, or they're getting worse, that's a good reason to talk to someone; a clinician can tell you whether what you're experiencing is a short-term stress reaction or PTSD.

It doesn't always start right away. Some people are fine, or seem fine, for months or years. A new loss, a birth, an anniversary, a news story, or a stretch of life calm enough to stop holding everything together can be what brings it up — and it's common not to connect what you're feeling to something that happened long ago.

Some people with PTSD also feel detached from their own body, as if watching themselves from outside, or find the world unreal or dreamlike. That's called dissociation, and it's worth mentioning to a therapist because it may affect how treatment is paced.

You may also see the term complex PTSD. It's used for PTSD that comes with lasting difficulty managing emotions, feeling worthwhile, and staying close to people, usually after trauma that went on for a long time or was hard to escape.

Treatment

PTSD has been studied extensively, and the major treatment guidelines agree on trauma-focused therapy — treatment that works directly with the memory and what it has come to mean, rather than around it. Four approaches are in wide use:

Cognitive processing therapy (CPT) usually runs about twelve sessions and focuses on the beliefs the experience left behind — about blame, safety, trust, power, and worth. You examine those beliefs against what actually happened. The standard current protocol doesn't require writing an account of the event; a version that adds one exists.

EMDR has you hold the memory in mind in short sets while attending to bilateral stimulation, usually side-to-side eye movements or alternating taps. It doesn't require a detailed spoken account of what happened.

Prolonged exposure (PE) involves recounting the memory in detail, repeatedly, in session — usually recorded so you can listen between sessions — and gradually returning to situations you've avoided that are objectively safe. The work is learning that the memory can be held and the reminders approached without the outcome the avoidance was built to prevent, and that the distress along the way is survivable. It typically runs eight to fifteen sessions.

Written exposure therapy (WET) is five sessions. Each one is spent writing about the experience for half an hour under specific instructions, with little or no homework between sessions.

These approaches ask very different things of you, especially in how much they require you to put what happened into words. Asking a therapist which one they use, and why it fits you, is a reasonable first question.

In trials, many people who finish one of these treatments no longer have PTSD. Many also stop partway, for a range of reasons. The work is demanding and distress can rise for a stretch, but getting worse isn't a required step toward getting better. If it feels unmanageable, tell the therapist instead of pushing through alone.

When the danger isn't over — you still live with the person who hurt you, for example — safety planning is part of treatment from the start. Trauma processing may still be possible; when to begin depends on your circumstances.

Medication can help, alone or alongside therapy. Sertraline and paroxetine are the two drugs approved by the FDA for PTSD, and other antidepressants are used as well. VA/DoD guidelines recommend against benzodiazepines for PTSD. Medication decisions belong with a psychiatrist or other prescriber.

What to look for in a therapist

Ask which named approach they use and where they trained in it. CPT, PE, and EMDR each have formal training followed by consultation on real cases, and a therapist who has completed that can tell you so specifically. For EMDR, the difference between basic training and certification is covered on the EMDR page.

Ask how they track progress. Many clinicians delivering these treatments use a standard symptom questionnaire — the PCL-5 is the common one — at regular intervals, so that you and they can see whether the treatment is working rather than guessing.

Ask what happens if you start to dissociate in session or the work becomes more than you can manage that week. You want a concrete answer about adjusting pace, not a promise that it won't happen.