Posttraumatic Stress Disorder Overview, Part 1

An Overview to PTSD

Printable Version 

Overview

The Integrative Health approach can be built around the Circle of Health, which emphasizes the importance of personalized, values-based care that draws in mindful awareness and eight areas of self-care: Physical Activity, Surroundings, Personal Development, Nutrition, Recharge, Family, Friends and Coworkers, Spirit & Soul, and Mind and Emotions. Conventional therapies, prevention, complementary and integrative health (CIH) approaches, and community also have important roles. The narrative below describes how Integrative Health can support people with different types of posttraumatic stress disorder (PTSD).

Depending on individual needs, an Integrative Health approach to PTSD may vary greatly from person to person. A person’s health plan may incorporate a variety of self-care, conventional care, and complementary health approaches, as described below. Mind-body approaches (including an array of specific psychotherapies developed for PTSD), healthy nutrition, and an array of other approaches can support people with this challenging health problem.

Note: This overview is different from others, in that it features three different patients as examples. Key details from their Personal Health Inventories (PHIs) are offered, but there are not separate documents with their PHIs or health plans. A significant amount of the research in this area has been related to veterans and active-duty military personnel; special thanks to VA for all the contributions they have made with their Whole Health approaches to care of people with PTSD.

Meet the Patients—Todd, Erica, and Melissa

Todd is a 28-year-old veteran of Operation Iraqi Freedom (OIF). He “saw a lot go down” during his time in Iraq, but he felt like he was doing fairly well when he completed his tour and returned to the United States in 2009. Six months after his return, however, he developed a number of troubling symptoms:

  • He began to have flashbacks, focused on when his teammate, Hal, lost his leg in an explosion.
  • He finds himself wanting to avoid crowded areas or places where there is a lot of noise. He tells you, “I can’t set foot in a mall, a theater, or some other crowded place like that.”
  • He finds it is impossible to trust anyone now, and he hasn’t felt relaxed or happy in years. He gets into fights easily. He always positions himself in a room so he can see the doors and windows.
  • He is haunted by the thought that he should have been the one to lose a leg, not Hal.
  • He finds it difficult to maintain romantic relationships or friendships. His concentration is poor, and he is frustrated that he has not done well in college courses he has tried taking. He says, “Every time I try to do something new, it’s like I sabotage myself. Or I get all wired and reactive and it makes everything go wrong.”

To cope, Todd drinks, sometimes as much as a case of beer daily, but on good days, he does not drink at all. He does not own a gun or have plans for harming himself, but it has occurred to him that, as he puts it, “my life has been so hard that I am not so sure I want it anymore.” He was initially diagnosed with anxiety, until he sought out the advice of a psychiatrist who made the diagnosis of PTSD. He takes his medications as prescribed by his psychiatrist, and wants to do “anything and everything” he can to improve his quality of life.

Erica is a 34-year-old who was raped by a coworker when she was 22. She did not press charges due to various circumstances, including being threatened by her manager when she went to him for help. Erica quit her job at that time. She tells her primary care provider, “I just can’t stand to be around other people, especially men, because it all takes me back to when I was attacked.” For a year, she worked out of her home. However, she developed worsening depression and attempted suicide via an overdose of one of her sleep medications in 2012. In the wake of the suicide attempt, her worsening concentration, sleep problems, and periodic anxiety attacks, she lost her home-based job. She was evicted and has been homeless for several years. She currently lives in a women’s shelter.

Melissa is a 48-year-old oncology nurse. In her role taking care of children with cancer, she feels she has “been able to do a lot of good over the years.” However, lately, particularly after some unexpected losses related to COVID-19 infection complications, she notes, “I still feel like something is broken inside me.” Melissa continues to work, noting he has some good days and some bad days. It is increasingly difficult for her to go to work due to the fear that she will lose another patient to COVID and “lose it to the point where I can’t do my job well.” She has used up all of her sick time, and her supervisor recommended that she seek help.

Todd, Erica, and Melissa all receive their care in the same health care system, where they all registered for Mental Health resources. Each of them, when given the option, agreed to work with mental health providers (including psychiatrists) to explore their options. They also all chose to see an Integrative Health consultant to explore additional options.

Introduction

These are men whose minds the Dead have ravished.

Memory fingers in their hair of murders

Multitudinous murders they once witnessed.

Wading sloughs of flesh these helpless wander,

Treading blood from lungs that had loved laughter.

—Wilfred Owen, English poet and WWI soldier, 1893-1918

PTSD affects 7%-8% of all Americans at some point during their lifetimes, with women being affected twice as often as men (10% versus 5%).1 The National Vietnam veterans Readjustment Study estimated the lifetime prevalence of PTSD for male and female Vietnam veterans as 31% and 27% respectively.2 Prevalence for Gulf War veterans is about 12%, and for OEF/OIF veterans, it is around 14%.3,4 Studies in veterans indicate that the risk of developing PTSD increases for many people over time after they experience trauma, especially in the first three to six months after the trauma occurs.5

The etiology of PTSD is complex and arises out of a complex interaction of biological, psychosocial, and cognitive factors.6,7 Genetic studies indicate that some people with PTSD may be genetically predisposed to have more inflammatory dysregulation, and this is likely linked to why people with PTSD have a higher risk of inflammatory disorders.8

According to a 2015 review of 116 studies of veterans, the following can be said about risk factors for PTSD9:

  • It is not clear if overall risk is higher for males or females.
  • Risk is higher for younger people; it is higher for males who are under 40 years of age and females under 30.
  • Lower level of education correlates with greater risk.
  • Black/African American people have been noted to have lower risk.
  • Not being in a relationship increases risk.
  • In terms of military-specific factors, being in the Army or the Marines versus other military branches increases chances of developing PTSD. Risk is higher for enlisted personnel compared to officers. Risk also goes up based on what one does during deployment; it is higher for health care, service and supply, and combat personnel.

Childhood experiences also increase PTSD risk.10 A 2019 study including 1501 people from China found that the adjusted odds ratio for having PTSD in adulthood for people who had traumatic experiences in childhood was 1.32.11 Severity of trauma in childhood had a dose-dependent effect, PTSD was also linked more strongly to specific types of trauma at specific ages.12

Diagnosing PTSD

Historically, it was argued by some that PTSD is not an actual diagnosis; however, research indicates that there are a variety of neurological and psychobiological reactions to trauma that occur, many of which are linked to the development of PTSD.13

After it is established that a person has experienced trauma, there are four main criteria for a PTSD diagnosis outlined in the Diagnostic and Statistics Manual of Mental Disorders, 5th edition.14 The four general classes of PTSD symptoms include the following:

  1. Intrusion symptoms. These can include recurrent, involuntary, or intrusive memories or dreams. Distress may be triggered by events that have something in common with the traumatic experience(s). Flashbacks may occur.
  2. Avoidance. People with PTSD typically attempt to avoid memories, thoughts, feelings, or external reminders related to traumatic experiences.
  3. Cognitive and/or mood disturbances tied to the traumatic event(s). A person may experience impaired memory, exaggerated negative beliefs, inappropriate blame, persistent negative emotions, and other similar symptoms.
  4. Hyperarousal and reactivity. This can manifest as irritable behavior, recklessness, hypervigilance, exaggerated startle responses, and sleep problems, among other symptoms.

Symptoms within each category must be present for more than a month for PTSD to be diagnosed. Otherwise, the diagnosis of Acute Stress Disorder is made instead. For more information about diagnosis (useful to both patients and clinicians), refer to the National Center for PTSD (NCPTSD) website.15 You also can connect with the PTSD Consultation program by emailing PTSDconsult@va.gov.

Etiology

An estimated 60% of men and 51% of women in the U.S. experience trauma at some point in their lives; however, only 8% of men and 20% of women develop PTSD.16 Why do some people develop PTSD and others do not? Genetics, the environment,17 and adverse childhood experiences all can have a profound impact, as can many other factors.18 The goal is to stack the odds so as to prevent PTSD from ever even developing, and to focus on healing at all levels if PTSD already has occurred.

Fight or flight, perhaps the most familiar stress response, is linked to activation of the sympathetic nervous system. Polyvagal theory may explain some aspects of the development of PTSD by focusing on the vagus nerve, which is linked with the parasympathetic nervous system. This theory, proposed by Stephen Porges, holds that behavior can be affected differently depending on which part of the vagus nerve is activated. When the ventral vagus is activated, a person feels safe and tends to build connections with others. Conversely, when a person (or other animal) feels that their survival is threatened, the dorsal vagus can be activated. Dorsal vagal activation is associated with withdrawing, even shutting down altogether. This is linked to the avoidance and withdrawal symptoms so commonly observed in PTSD.

Recent research indicates that people with PTSD have significant increases in levels of inflammatory markers, such as interleukins 1β and 6, tumor necrosis factor-α, and C-reactive protein. It is thought that inflammation is not only an effect of having PTSD, but also a causative factor.19 Neuroinflammation, anxiety, and chronic stress may all contribute to PTSD development.20

Comorbidities

PTSD is associated with poorer functioning, lower quality of life, and earlier onset of a number of physical and mental health problems.21 It is vital to account for these during personal health planning, since they strongly influence overall patient outcomes.22 PTSD never exists in a vacuum. Just as an integrative approach using the Circle of Health can help account for each individual’s unique array of PTSD symptoms, it also can help organize the plan with respect to a person’s multiple comorbid conditions.

People with PTSD have more somatic symptoms, health care visits, and work absenteeism than average.23 Of particular concern, as noted in a 2013 systematic review of 16 studies, Veterans with PTSD are much more likely to be suicidal.24 In fact, the United States National Comorbidity Study found people with PTSD are six times more likely to attempt suicide than their peers.25 The reasons for this are complex, as noted in a recent factsheet published by the National Center for PTSD. Risk increases if someone has more distressing trauma memories, poorer impulse control, or a tendency toward a higher level of anger than average. A 2017 study suggested that targeting depression and internal hostility might be particularly beneficial for PTSD patients. There is a link between suicide and combat guilt, and the risk is greater in combat trauma survivors who were wounded more than once or hospitalized as a result of their injuries.

Suicide risk is significantly higher in people with PTSD for many reasons. Clinicians should ensure the following numbers are easily accessed by all patients and their family/friends:

National Suicide Prevention Lifeline: 1-800-273-8255

Fortunately, a landmark 2013 review by Gradus and colleagues indicated that the reverse is also true; successful treatment of PTSD significantly lowers suicide risk.26,27 Researchers are actively exploring which suicide prevention measures are most effective for people with PTSD.28

Specific comorbidities related to PTSD include the following29:

  • Sleep disorders. Sleep problems, including insomnia and nightmares, are reported by 70%-87% of people with PTSD and have a significant impact on quality of life and overall outcome.30
  • Anxiety. What first may seem to be anxiety could actually be part of the hyperarousal symptom cluster that defines PTSD.23
  • Depression. Depression is four to seven times more likely in people with PTSD, particularly in women.31
  • Personality disorders. Examples include borderline, bipolar, and narcissistic personality.32
  • Substance use disorders. Alcohol and other substance use disorders are problematic for many people with PTSD.22
  • Pain disorders. These include chronic pain, fibromyalgia, chronic musculoskeletal disorders, and osteoarthritis.33
  • Metabolic syndrome. People with PTSD have higher rates of obesity, hypertension, dyslipidemia, diabetes, and vascular disease.34 This is thought to be in part due to higher cortisol levels that predispose to inflammation. PTSD may be considered an independent heart disease risk factor (pooled hazard ratio was 1.55 with 95% CI of 1.34-1.79).35
  • Impaired immunity. This is associated with increased infections, gastric ulcers (H. pylori infection), and risk of HIV positivity.32
  • Autoimmune disorders. These include thyroid disease and rheumatoid arthritis, among others.32
  • Grief. Grief and traumatic stress are closely connected. Veterans with PTSD who have unresolved loss from trauma may be limited in their ability to grieve more recent losses, and this can result in challenging emotions or behaviors. They may experience depression, low self-esteem, isolation, and an increase in nightmares.36 A study of 114 Vietnam-era combat Veterans admitted to a PTSD inpatient rehabilitation unit identified that 70% scored higher (i.e., worse) on standardized measures of grief symptoms related to friends lost in combat 30 years previous than did spouses who were bereaved in the past six months.37 The investigators ultimately concluded that treating the symptoms of unresolved grief may be as important as treating fear-related symptoms of PTSD. More information on this topic is available in the Grief overview.
  • Traumatic brain injury (TBI). PTSD and TBI share a number of characteristics, including sleep disruption and cognitive impairment.38

Fortunately, many problems that co-occur with PTSD often resolve or show improvement when PTSD is successfully treated. For additional information on PTSD and comorbidities, along with a helpful list of resources related to various comorbid conditions, refer to the National Center for PTSD website.39

The symptoms of PTSD seldom exist in isolation. Always keep comorbidities in mind when working with people with PTSD. Pain, substance use disorders, affective disorders, autoimmune issues, and sleep problems are among the many comorbidities that may be present. Each of these, when present, can make the risk of suicide even greater.

Patient-Driven Care

The three patient narratives at the beginning of this overview offer a snapshot of the varied ways PTSD can present.40 A traumatic event can involve an actual or perceived threat to life, personal safety and security, or physical integrity.14 It can be directly experienced, witnessed in person, or heard about (in cases of family members or close friends). As in the case of Melissa, PTSD can also arise after someone witnesses traumatic events being experienced by others.

Combat trauma, as experienced by Todd, is perhaps the most familiar traumatic precursor to PTSD for most clinicians, but PTSD has different causes— and effects—for each person who suffers with it. Unfortunately, Erica’s situation of PTSD due to sexual trauma (MST) is not uncommon. One in six civilian women experience sexual assault, and for military women the frequency climbs to an estimated one in three.41 Forty percent of homeless women veterans report a history of sexual trauma in the military.42 MST is the main causal factor of PTSD in women, in contrast to combat experience being the strongest predictor in men.43,44 Male veterans (1.1%, versus 21% of women) also experience military sexual trauma.45 Risk of suicide markedly increases (hazard ratios of 1.7 and 2.3 for men and women respectively) with a history of MST.45

Education

For some time, the Veterans Administration/Department of Defense Practice Guideline for the Management of PTSD and Acute Stress Disorder46 emphasized patient education as part of the treatment for all patients with PTSD and their family members, but the latest version has scaled back with this given a paucity of research support. Nevertheless, clinicians can consider offering the following (and these steps are very much in keeping with patient centered and patient-driven care):

  1. Describe to anyone with PTSD the range of available and effective therapeutic options, emphasizing that PTSD is a highly treatable disorder.
  2. Inform the patient about evidence-based psychotherapy and/or evidence-based pharmacotherapy as first-line treatments, allowing patient and clinician preferences to drive the selection of therapies. Psychotherapies should be offered by practitioners with adequate training in the preferred treatment methods. These are described more in the conventional approaches section below.
  3. Support them with self-care. There are a number of excellent educational products developed by the National Center for PTSD for veterans and their family members, and these can be useful in the non-veteran population as well. These include “Understand PTSD” and “Understanding PTSD Treatment,” as well as a broad range of smartphone apps and online products. Clinicians can recommend smartphone apps and online tools that allow Veterans to self-monitor symptoms. These include the following:

Collaborative Treatment Planning

A collaborative care approach to therapy, including care management, can be considered; however, supportive evidence for this -specifically for PTSD - is currently lacking. Given that the average dropout rate in trials of exposure-based and cognitive interventions for PTSD is 20%-25%, and given that it is often difficult to convince those with PTSD to seek any form of treatment,47 it is vital that clinicians carefully match individual patients with the therapies and practitioners most appropriate for them. This can be accomplished through a collaborative process between people with PTSD and their health care teams that includes the following steps:

  1. Identify realistic, stepwise functional goals including a list of key activities/domains.
  2. Choose specific treatment goals and patient centered indicators of progress that include self-care strategies across the Personal Health Inventory (PHI) domains. Treatment preferences and self-care strategies should be specific, promote recovery, and be strength-based.
  3. Problem-solve around barriers to getting care, such as transportation and availability to attend daytime appointments.

Tailored Follow-Up

As part of ongoing care, it is important for clinicians and patients to:

  • Monitor patient centered progress indicators.
  • Adjust the treatment plan accordingly over time based on monitoring.
  • Re-evaluate and renegotiate treatment focus and components.
  • Provide support surrounding barriers and challenges.

A 2019 article noted a number of new directions being taken for PTSD care, including non–trauma-focused interventions, new medications, personalized medicine, family-based therapies, and enhanced focus on physical health (again, in support of working with PTSD comorbidities).7

What we know about integrative health care has come to us thanks to the efforts, experiences, and collective wisdom of people from many cultures and backgrounds. We wish to acknowledge all the healers, researchers, patients, and peoples who have informed the content of this tool.

Author(s)

“Posttraumatic Stress Disorder (PTSD)” was adapted for the Osher Center for Integrative Health at the University of Wisconsin-Madison from the original written and updated by J. Adam Rindfleisch, MPhil, MD (2016, updated 2019).

This overview was made possible through a collaborative effort between the University of Wisconsin Integrative Health Program, VA Office of Patient Centered Care and Cultural Transformation, and Pacific Institute for Research and Evaluation.

Originally created: 2016, Updated: 2019

References

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Keywords:
PTSD, Overview 
Doc ID:
150663
Owned by:
Sara A. in Osher Center for Integrative Health
Created:
2025-05-12
Updated:
2026-03-18
Sites:
Osher Center for Integrative Health
Clean URL:
https://kb.wisc.edu/osher/ptsd-overview-part-1