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Published: 17 April 2024

Neuroimaging of posttraumatic stress disorder in adults and youth: progress over the last decade on three leading questions of the field

Cecilia A. Hinojosa ORCID: orcid.org/0000-0002-2577-6142 1 ,
Grace C. George 2 &
Ziv Ben-Zion ORCID: orcid.org/0000-0003-3629-5851 3 , 4 , 5

Molecular Psychiatry ( 2024 ) Cite this article

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Almost three decades have passed since the first posttraumatic stress disorder (PTSD) neuroimaging study was published. Since then, the field of clinical neuroscience has made advancements in understanding the neural correlates of PTSD to create more efficacious treatment strategies. While gold-standard psychotherapy options are available, many patients do not respond to them, prematurely drop out, or never initiate treatment. Therefore, elucidating the neurobiological mechanisms that define the disorder can help guide clinician decision-making and develop individualized mechanisms-based treatment options. To this end, this narrative review highlights progress made in the last decade in adult and youth samples on three outstanding questions in PTSD research: (1) Which neural alterations serve as predisposing (pre-exposure) risk factors for PTSD development, and which are acquired (post-exposure) alterations? (2) Which neural alterations can predict treatment outcomes and define clinical improvement? and (3) Can neuroimaging measures be used to define brain-based biotypes of PTSD? While the studies highlighted in this review have made progress in answering the three questions, the field still has much to do before implementing these findings into clinical practice. Overall, to better answer these questions, we suggest that future neuroimaging studies of PTSD should (A) utilize prospective longitudinal designs, collecting brain measures before experiencing trauma and at multiple follow-up time points post-trauma, taking advantage of multi-site collaborations/consortiums; (B) collect two scans to explore changes in brain alterations from pre-to-post treatment and compare changes in neural activation between treatment groups, including longitudinal follow up assessments; and (C) replicate brain-based biotypes of PTSD. By synthesizing recent findings, this narrative review will pave the way for personalized treatment approaches grounded in neurobiological evidence.

Distinctively different human neurobiological responses after trauma exposure and implications for posttraumatic stress disorder subtyping

Suji Lee, Sujung Yoon, … In Kyoon Lyoo

post traumatic stress disorder case study

Longitudinal volumetric evaluation of hippocampus and amygdala subregions in recent trauma survivors

Ziv Ben-Zion, Nachshon Korem, … Talma Hendler

Neurostructural associations with traumatic experiences during child- and adulthood

Sebastian Siehl, Maurizio Sicorello, … Herta Flor

Introduction

In 2013, the American Psychiatric Association revised the posttraumatic stress disorder (PTSD) criteria in the 5 th edition of its “Diagnostic Statistical Manual of Mental Disorders” (DSM-5). While the DSM-IV classified PTSD under “Anxiety Disorders,” the DSM-5 has repositioned it within a newly established category of “Trauma-and Stressor-Related Disorders.” According to the DSM-5, traumatic events are defined as exposure to actual or threatened death, serious injury, or a threat to the physical integrity of oneself or others, either directly (witnessing trauma) or indirectly (learning that trauma happened to a close relative or friend) [ 1 ]. In addition to trauma exposure (i.e., criterion A), four symptom clusters that characterize the disorder are persistent re-experiencing the trauma (i.e., criterion B), avoiding people, places, or thoughts related to the trauma (i.e., criterion C), negative thoughts and feelings that began or worsened after the trauma (i.e., criterion D); and trauma-related increased in arousal and reactivity (i.e., criterion E). Symptoms must last at least one month, not be caused by drugs or other illnesses, and cause significant functional impairment. The DSM-5 introduced a developmental subtype of PTSD specifically for children aged six years or younger, aligning closely with adult diagnostic criteria. However, it adapts criterion A for this age group, allowing for indirect exposure to trauma, such as through witnessing an event or learning about a traumatic event affecting a parent or caregiver [ 1 ].

Epidemiology and prognosis

Worldwide, up to 70% of the adult population will experience at least one traumatic event (as defined by criterion A) in their lifetime [ 2 ], and the prevalence of PTSD ranges from 2 to 9% [ 3 ]. Indeed, four post-traumatic symptom trajectories have been highlighted in literature: resiliency, recovery, chronic, and delayed onset, the most common being the resiliency trajectory [ 4 , 5 ]. Similarly, childhood trauma exposure is common, with up to two-thirds of youth reported having experienced a traumatic event and almost 5% of trauma-exposed youth meeting the criteria for PTSD [ 6 , 7 , 8 ]. It is important to note that females are more prone to developing PTSD than males [ 9 , 10 ]. This disparity is theorized to be attributed to trauma one is exposed to, with females experiencing more interpersonal violence than males [ 11 ]. However, even when controlling for trauma type, females still exhibit greater PTSD prevalence [ 11 ]. This suggests that biological factors may contribute to this disparity. Given this, more studies are introducing sex as a biological variable to explore this disparity further. For in-depth reviews, see [ 12 , 13 ].

PTSD is a debilitating disorder in many aspects across the lifespan. A PTSD diagnosis contributes to billions in annual productivity loss [ 14 ] and increased medical problems [ 15 ] and is associated with a variety of co-occurring disorders, including substance use disorders [ 16 ], depression, and anxiety [ 17 ]. For individuals diagnosed with PTSD, many treatment options are available. The most empirically supported options are trauma-focused interventions [ 18 ]. Of psychotherapy options available, up to half of the patients who complete treatment will show clinically meaningful improvement [ 19 , 20 , 21 ], and many patients prematurely drop out of treatment before receiving an adequate dose [ 22 ]. Furthermore, many patients fail to seek treatment altogether, especially in marginalized groups [ 23 ]. Given the considerable overlap between PTSD, depression, and anxiety, and because research still has not identified pharmaceutical targets specific for PTSD, sertraline and paroxetine are FDA-approved pharmacological options for PTSD, both with limited efficacy [ 24 ]. Research on using psychedelics to treat PTSD has skyrocketed and looks promising, though more research is needed to determine efficacy and validate safe implementation procedures [ 25 , 26 ]. Psychotherapeutic treatments have shown a greater benefit than pharmacological intervention alone [ 27 ]. Determining the superiority of combining psychotherapy with pharmacological treatment needs further exploration [ 28 ]. To improve the efficacy of current treatment options and to design novel, more efficacious treatment options, we must understand the neural alterations that contribute to the development of PTSD, improve with treatment, and potentially define biotypes of the disorder.

Current narrative review

Given the influx of neuroimaging data published since the first neuroimaging paper using a PTSD sample in 1995 [ 29 ], an extensive library of reviews and meta-analyses has examined this literature [ 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 ]. Our narrative review builds upon this previous literature by exploring progress made in the past decade on three major questions in the field: (1) Which neural alterations serve as predisposing (pre-exposure) risk factors for PTSD development, and which are acquired (post-exposure)? (2) Which neural alterations can predict treatment outcomes and define clinical improvement? and (3) Can neuroimaging measures be used to define brain-based biotypes of PTSD? This review will examine structural and functional magnetic resonance imaging (MRI) literature using univariate, bivariate, and network-based approaches in adult and youth PTSD populations. Following a brief overview of neural alterations in PTSD, we will address each question above by synthesizing current findings, identifying gaps, and discussing limitations. We included articles published in peer-reviewed journals and were found using in-house expertise and searches of databases including PubMed. We will conclude by highlighting the review’s limitations and suggest future directions. Tables 1 – 2 provide an overview of neuroimaging findings for questions 1 and 2 (respectively), and Figs. 1 – 2 illustrate these findings. We will begin by describing different neuroimaging techniques.

Blue dots represent decreased activation. Red triangles represent increased activation. Solid blue represents decreased volume. Solid blue lines represent decreased structural integrity. Red lines represented increased structural integrity. Functional connectivity findings are depicted with arrows, with blue lines (–) that represent decreased functional connectivity and red lines (+) that represent increased functional connectivity. dACC dorsal anterior cingulate cortex, dmPFC dorsomedial prefrontal cortex, Hippo hippocampus, mPFC medial prefrontal cortex, OFC orbitofrontal cortex, rACC rostral anterior cingulate cortex, VS ventral striatum.

A Brain measures at baseline that predict a positive treatment response. B Brain measures associated with a positive response to treatment. Blue dots represent decreased activation. Red triangles represent increased activation. Solid blue represents decreased volume. Solid red represents greater volume. Solid blue lines represent decreased structural integrity. Functional connectivity findings are depicted with arrows, with blue lines (–) equating to decreased functional connectivity and red lines (+) equating to greater functional connectivity. dACC dorsal anterior cingulate cortex, dlPFC dorsolateral prefrontal cortex, Hippo hippocampus, OFC orbitofrontal cortex, PCC posterior cingulate cortex, rACC rostral anterior cingulate cortex, vmPFC ventromedial prefrontal cortex.

Neuroimaging techniques

Structural techniques.

Structural MRI of PTSD populations typically determines alterations in the morphometry of brain regions in patients versus controls (trauma-exposed non-PTSD [TENC] or healthy controls [HC]). Morphometric measures include subcortical and cortical gray matter volumes, thickness, and white matter microstructure. There are two analysis pipelines one can follow: (1) surface-based, which identifies borders between pial and white matter surfaces, and (2) voxel-based, which labels each voxel in cortical and subcortical tissues and allows for calculating subcortical structures and total intracranial volume [ 41 ]. Thus, structural volume can be measured by contrasting volume inside the pial surface from the white surface and regions, not part of the cortex, or by measuring total cortical labeled voxels. Cortical thickness is measured by contrasting the distance between the pial and the white surface [ 41 ]. Generally, smaller volumes and lower cortical thickness are representative of poorer structural integrity. Diffusion tensor imaging is a structural tool used to measure the structural integrity of white matter tracts via the diffusivity of water molecules along the axial direction of white matter fibers. The pattern of diffusivity can be computed using scalar measures such as fractional anisotropy (FA), whereby lower FA values illustrate a reduced axonal packing density [ 42 ].

Functional techniques

Functional MRI (fMRI) can be used as an indirect proxy to measure brain activation with great spatial and limited temporal resolution. Researchers record activation during the presentation of different tasks designed to induce activation in regions responsible for given functions. There are many different approaches one can take to analyze fMRI data, which can be categorized into three general techniques. The simplest technique is univariate analyses, which examine the activation of single voxels in response to various tasks. As techniques developed with time, more researchers have also included bivariate analyses, which calculate the temporal association of two regions based on activation. This includes task-based and resting-state functional connectivity (FC), which measure spontaneous changes in brain activation during the completion or absence of a task, respectively. Finally, recent years have seen an increase in network-based approaches, which measure activation across many brain regions and networks. Network-based approaches in fMRI studies typically conceptualize the human brain as a network of interconnected functional components that operate in a coordinated dynamic fashion [ 43 ]. By employing such methods, researchers can overcome the limitations of traditional univariate and bivariate approaches by mitigating the bias of preselecting target regions a priori and allowing a more comprehensive investigation of large-scale brain organization (rather than isolated regions or simplistic circuits). In this narrative review, we will focus on the two primary tools for network-based analysis of neuroimaging data in PTSD: (1) independent component analysis (ICA), which isolates individual functional networks within the whole brain, and (2) graph theory methods, which examine properties of networks (e.g., nodes and edges of a graph) and characterize them based on their intercorrelations.

Neural alterations in PTSD

PTSD is the only DSM diagnosis with a known origin (i.e., experiencing trauma). Given the importance of traumatic memory in the development of the disorder, early neuroimaging studies sought to discover alterations in structure and function of brain regions implicated in fear learning and memory (e.g., amygdala and hippocampus) in patients with PTSD compared to controls. These discoveries have created “classical” neurocircuitry models of PTSD that emphasize an inability of cortical regions to successfully regulate subcortical regions important in initiating a fear response [ 33 ]. Research over the last decade has noted diminished structural integrity in areas associated with executive functions, including reduced cortical volumes in the anterior cingulate cortex (ACC) [ 44 , 45 ] and frontal cortical regions [ 44 , 46 ] in PTSD patients and in subcortical structures, including the amygdala and hippocampus (see [ 39 , 47 ] for recent reviews). Furthermore, PTSD patients, compared to controls, have shown reduced white matter integrity in the uncinate fasciculus (UF) [ 48 , 49 , 50 ], corpus callosum, corticospinal tract, and enhanced white matter integrity in the inferior fronto-occipital fasciculus, and inferior temporal gyrus (for review see [ 51 ]), highlighting the structural disconnect between cortical and subcortical regions. Functional studies also support classical neurocircuitry models, with greater amygdala alongside reduced activation in brain regions associated with emotional regulation (e.g., ventromedial prefrontal cortex [vmPFC], inferior, superior, medial frontal gyrus [MFG], ACC, dorsolateral PFC [dlPFC], and dorsomedial PFC [dmPFC]) during emotion-related tasks [ 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 ], extinction recall [ 63 ], and fear generalization [ 64 , 65 ]. Limitations of these classical neurocircuitry models of PTSD include the deficiency of the models to understand the biological bases of PTSD systems holistically rather than focusing on fear processes alone (see [ 35 ] for an in-depth discussion).

Network-level neural alterations in PTSD are present. Specifically, disruptions in connectivity structure or activation profiles within the salience network (SN), default mode network (DMN), and central executive network (CEN) may underlie univariate and bivariate impairments in PTSD patients. For example, hyperarousal and hyperreactivity symptoms were linked to increased activation of the amygdala and dACC, two critical nodes of the SN [ 33 , 66 , 67 ]. Further, intrusive symptoms, impaired fear extinction, and deficits in emotional regulation are associated with decreased activation of the hippocampus and vmPFC, two nodes of the DMN [ 31 , 33 , 68 ]. Decreased activation of nodes within the CEN, such as the IFG and MFG in PTSD, are present [ 32 ].

Numerous neuroimaging studies have employed ICA methodology to test alterations in large-scale networks in adults with PTSD (see reviews [ 69 , 70 , 71 , 72 , 73 , 74 ]). Overall, results are mixed and provide limited support for classical neurocircuitry models of PTSD. Within the DMN, most studies report decreased activation and connectivity at rest in PTSD patients [ 75 , 76 , 77 ], possibly associated with re-experiencing and dissociative symptoms [ 71 , 78 ]. However, one study reported higher integration of the amygdala with the DMN in PTSD patients during a threat-processing task [ 79 ]. Research typically suggests increased activation and connectivity [ 83 , 84 ] within the SN, potentially linked to hyperarousal and hypervigilance symptoms. In contrast, other findings indicate decreased SN connectivity in PTSD [ 48 , 77 ]. The CEN seems to show reduced activation and connectivity among PTSD patients [ 32 , 76 ].

In addition to alterations within each network, some recent evidence points to aberrant connectivity patterns between networks in PTSD. For example, Zhang and colleagues (2015) [ 77 ] reported decreased FC between the SN and DMN, possibly explaining previous contrasting findings regarding the connectivity of the SN in PTSD. As the SN is believed to facilitate the transition between the DMN and CEN in response to external cognitive demands [ 80 ], the reduced connectivity between the SN and DMN might suggest a compromised ability in PTSD to shift between a self-referential state and a cognitive control mode. In another study, PTSD patients showed increased excitatory influence of the executive central network (ECN, like the CEN) on the posterior DMN. Finally, Akiki et al. (2017) [ 71 ] suggested that PTSD is characterized by impaired SN, incapable of DMN-CEN modulation, and weakened top-down regulation of the SN by the CEN.

Several neuroimaging studies of PTSD used graph theory approaches in resting-state data to examine possible alternations in local and global connectivity patterns. One study found that PTSD patients exhibit a transformation from a random or regular network to a “small-world” network, compared to TENC [ 81 ]. The concept of “small-world” networks describes a network topology in which most nodes are not neighbors of one another, but still, nodes can be reached from every other by a small number of steps [ 82 ]. Furthermore, these patients show increased centrality in the DMN and SN [ 81 ] (i.e., amount of nodes with many paths passing through them). Indeed, more severe PTSD symptoms were linked to DMN alteration, including decreased FC strength [ 83 ], decreased functional integration, and increased segregation within the DMN [ 84 ]. Additionally, reduced within-network connectivity and decreased connectional density within a hippocampus-PFC network are associated with more severe re-experiencing symptoms in combat-exposed veterans [ 85 ]. These studies suggest a complex interplay of network alterations in PTSD.

In normative brain development, gray matter volume is shaped like an inverted U, whereby matter increases from birth to childhood, then around early adolescence, starts to decline until adulthood [ 86 ]. This development pattern is due to synaptic proliferation and pruning, which makes the child’s brain more efficient [ 87 ]. White matter generally increases throughout childhood and adolescence and then levels off [ 86 ]. This pattern represents increases in myelination over time to maximize neuronal transmission speed and adjust the timing and synchrony of neural spikes [ 88 ]. In total volume, including gray and white matter, young brains grow in size until late childhood/early adolescence, when they start to asymptote [ 89 ].

In pediatric samples, PTSD and TENC youth typically exhibit overall smaller amygdala [ 90 , 91 , 92 ] and hippocampal volumes [ 91 , 93 ], including smaller CA2/3 hippocampal subfields [ 90 , 94 ]. Studies report that youth with PTSD have smaller vmPFC volumes than TENC or HC youth [ 91 , 95 ]. One study found no differences in the structure of the medial PFC (mPFC) between youth with PTSD and TENC [ 96 ], indicating that more work needs to be done to disentangle how maltreatment and PTSD relate to volume. Heyn and colleagues [ 97 ] (2022) explored sex differences in volume in female and male youth. Female youth with PTSD showed increased volume and surface area in the ventrolateral PFC and frontal pole regions. In contrast, male youth showed smaller volumes of these regions that predicted more severe symptoms one year later [ 97 ]. Additionally, youth with PTSD, compared to controls, had age- and sex-related differences in the UF, inferior longitudinal fasciculus, and cingulum bundle [ 98 ]. Finally, a review found that youth with PTSD had lower FA in the corpus callosum, including the anterior and posterior midbody, the isthmus, and the splenium [ 99 ], and increased PTSD symptoms have been related to lower FA in these regions [ 100 ].

Our comprehension of the typical developmental trajectories of brain function in youth remains limited. Univariate investigations have focused mostly on associations between childhood trauma and brain activation. In the past decade, a movement towards employing consistent brain atlases and pre-processing methods has emerged, particularly for comparing studies with limited sample sizes [ 101 ]. That said, the literature reviewed here will be specific to youth with PTSD and is, therefore, sparse.

In task-based fMRI, greater activation in the amygdala and dACC in response to emotional faces and threatening images have been found in youth with PTSD versus controls [ 102 , 103 ]. Greater activation has been found in the ACC and frontal brain regions in maltreated youth than in HC during the presentation of negative stimuli [ 104 ]. Furthermore, there is an interesting pattern of decreased FC while viewing angry faces and increased FC while viewing happy faces, specifically between the dACC-dmPFC, amygdala-dmPFC, and amygdala-vlPFC [ 102 ]. Youth with PTSD showed increased PCC-vmPFC resting-state FC, which may indicate problems in self-referential tasks or memory consolidation [ 105 ]. In another resting-state study, youth with PTSD showed decreased PCC-hippocampus FC and increased PCC-insula and PCC-cerebellum FC [ 106 ].

Network-based analyses have had limited application in youth PTSD populations. This could be for numerous reasons, including low sample sizes and the novelty of computational imaging methods. The handful of studies that have used ICA and graph theory methods to identify alterations in youth with PTSD have identified a greater anticorrelation between DMN and task-positive network (TPN), indicative of difficulty switching between internal (DMN) and external (TPN) stimuli [ 105 ]. In one study of resting-state whole-brain connectivity in youth exposed to an earthquake, the PTSD group (compared to TENC) showed an increased clustering coefficient and a normalized characteristic path length and local efficiency, suggesting a shift toward regular networks [ 107 ]. Further, the authors found enhanced nodal centralities in the DMN and SN, which may be related to altered processing of negative emotions. They also found reduced centralities in the CEN, which may indicate worse goal-directed behaviors. In contrast, Xu and colleagues (2018) [ 108 ] reported a lower clustering coefficient among youth with PTSD compared to TENC. They further found increases in centralities in the attention and DMN and decreases in the salience and sensorimotor networks [ 109 ].

Question 1: which neural alterations serve as predisposing (pre-exposure) risk factors for PTSD development, and which are acquired (post-exposure)?

An important goal in the PTSD field is to uncover whether the neural alterations in PTSD discussed above are predisposing risk factors that make an individual more susceptible to developing PTSD after experiencing trauma or acquired characteristics of the disorder. Uncovering these distinctions will enable the development of preventative interventions or the creation of more efficacious treatment options that target specific targets affected by the disorder. Many methodological approaches are used to disentangle predisposed from acquired neural alterations in PTSD [ 110 ]. The most methodologically sound techniques include prospective longitudinal studies, which collect neuroimaging data from participants either before trauma exposure or in the early aftermath of trauma and follow these participants at various time points post-trauma. Examples include the Neurobehavioral Moderators of Posttraumatic Disease Trajectories (NMPTDT) [ 111 ] and the Advancing Understanding of Recovery After Trauma (AURORA) studies [ 112 ]. While prospective longitudinal study designs are optimal for answering this question, they are hard to execute as they are often time-consuming, expensive, and have inherently poor participant attrition rates (see [ 111 ]). Further, though it is the goal to recruit participants before or in the early aftermath of trauma, participants may endorse childhood trauma experienced years before study participation, confounding the data collected.

Twin-pair designs have also been used to answer this question. Usually, these studies include monozygotic twin pairs, where one twin has PTSD from combat-related trauma, while their co-twin did not experience combat trauma nor has a PTSD diagnosis. A separate monozygotic twin pair contains a cotwin who experienced combat-related trauma but did not develop PTSD, and their cotwin did not experience combat-related trauma nor develop PTSD [ 113 ]. Again, limitations exist in this design, including an inability to determine whether the findings are attributed to heredity or shared environments.

Lastly, while not optimal, cross-sectional studies that explore brain alterations in three groups, PTSD, TENC, and HC, can provide some insight into whether alterations are PTSD-specific or related to trauma exposure.

Structural neuroimaging

Few structural imaging studies have used prospective longitudinal designs in the past decade. Studies that scanned participants pre-trauma and post-trauma found reduced hippocampal volume [ 68 , 114 ], post-pre-trauma orbitofrontal cortex (OFC) volume, and pre-trauma ventral ACC were related to greater PTSD symptom severity post-trauma [ 115 ]. It is important to highlight that these studies had relatively small sample sizes ( n < 50). One large study ( n = 210) that scanned police recruits found smaller pre-trauma dentate gyrus volume was associated with greater PTSD symptom severity post-trauma and that experiencing more police-related trauma between scan assessments was related to an increase in the volume of the basal nucleus of the amygdala [ 116 ]. It should be noted that the studies reviewed consisted of resilient individuals, with many participants without a PTSD diagnosis.

Numerous recent longitudinal studies have investigated how structural neuroimaging data collected shortly after trauma correlate with or predict PTSD symptoms. Most of these studies supported the hypothesis that decreased hippocampal volume early post-trauma is a risk factor for the development of chronic PTSD [ 117 , 118 , 119 , 120 , 121 ]. However, one study found no associations between hippocampal volume, or any of its subregions, and PTSD symptoms across time [ 122 ]. These differences are likely due to differences in trauma experienced, the timing of neuroimaging measurements, analytic strategy, and other sample characteristics [ 122 ]. Reduced FA of the UF [ 123 , 124 ] and greater FA of the dorsal cingulum [ 125 ] collected early post-trauma predicted greater PTSD symptoms at 3 months, 6 months, and 4 years later (respectively).

Cross-sectional studies comparing three groups - PTSD, TENC, and HC - found reduced hippocampal [ 126 , 127 , 128 ] and right amygdala volume [ 128 ] in the PTSD and TENC groups compared to the HC group. However, one study found that only the PTSD group showed significantly less hippocampal volume compared to the TENC and HC groups [ 129 ]. When examining hippocampal subregions, the CA1 and CA2-3/DG were significantly smaller in PTSD patients than in TENC and HC groups [ 130 ]. Differences in findings may be attributed to different trauma types endured, as has been found previously [ 131 ]. For example, the studies that found differences only in the PTSD group used samples that experienced combat-related trauma [ 129 ] or a terrorist attack [ 130 ] versus the loss of a loved one [ 126 , 127 ] or a natural disaster [ 128 ].

Functional MRI

Using a prospective longitudinal study design, Admon and colleagues (2013) found that service members who exhibited reduced hippocampal volume post-pre-trauma also displayed reduced hippocampus-vmPFC FC, which was related to greater PTSD symptoms post-trauma [ 68 ]. In a separate study from the same research group, the authors found that greater amygdala activation in response to risk anticipation at pre- and post-trauma was related to more PTSD symptoms post-trauma [ 132 ] and reduced nucleus accumbens activation to reward post-trauma was related to greater PTSD symptoms post-trauma [ 132 ]. Zhang and colleagues (2022) [ 133 ] recently used a network-based approach to measure stress-induced connectivity, changing patterns of large-scale brain networks at baseline to the subsequent symptom development post-trauma. In this prospective sample of police trainees, increased coupling between the SN and anterior cerebellum was observed in participants with greater PTSD symptoms (particularly intrusion symptoms) [ 133 ]. Nevertheless, as this work focused on a relatively healthy and resilient sample, future studies in more severe PTSD samples are needed.

Greater hippocampal activation, collected early post-trauma, during fear extinction [ 134 ], but not when looking at fearful versus neutral face stimuli [ 135 ], predicted more severe PTSD symptoms at 3 months post-trauma. In comparison, lesser hippocampal activation during response inhibition predicted greater PTSD symptom severity post-trauma [ 136 ]. Highlighting the unique contribution of the hippocampus in these different constructs. Greater amygdala activation early post-trauma when viewing fearful facial expressions significantly predicted symptoms at 3 [ 137 ] and 12 months post-trauma [ 138 ]. In combat veterans, greater dACC activation to negative images predicted greater PTSD symptom severity four years later [ 125 ]. Similarly, more negative amygdala-cerebellum FC at rest and amygdala-post-central gyrus FC during trauma recall at 2 weeks post-trauma predicted 6-month PTSD symptom severity post-trauma [ 139 ]. In a longitudinal study of n = 171 recent trauma survivors, PTSD severity at 14 months after trauma was associated with decreased neural activity in the ventral striatum (VS) and the amygdala toward rewards versus punishments at 1 month after trauma [ 140 ]. Surprisingly, decreased VS activity and connectivity with the vmPFC were more predictive of PTSD symptoms compared to the amygdala’s activity, highlighting the important role of reward processing in PTSD development or recovery [ 140 ]. Similarly, lesser activation in cortical regions early post-trauma during fear conditioning [ 141 ] and response inhibition [ 142 ] is related to greater PTSD symptoms 3 and 6 month post-trauma, respectively. However, greater dmPFC activation to fearful versus neutral face stimuli early post-trauma was associated with greater PTSD symptoms 3 months later [ 137 ]. Finally, a longitudinal study showed that while FC changes at 3 weeks post-trauma involved the DMN and frontal–limbic–striatal network, only changes in the DMN persisted at the 2 year follow-up [ 143 ].

Using a three-group design, one study examined the neural correlates of memory suppression in PTSD and found that the PTSD and TENC groups exhibited disrupted MFG activation while attempting memory suppression compared to HC, suggesting that disruptions in the MFG are apparent even in those trauma-exposed, regardless of PTSD status [ 144 ]. Regional parameters of the insular lobe, putamen, and precuneus of typhoon-related PTSD patients, TENC, were abnormal compared to HCs [ 145 ].

Recent twin studies have shown that PTSD patients exhibit reduced activation in the rostral ACC and MFG compared to their non-trauma-exposed cotwins and trauma-exposed individuals without PTSD. This diminished response, observed during exposure to trauma-related cues and to surprised faces, indicates that changes in these cortical areas are likely acquired traits of the disorder [ 146 , 147 ].

One study found that increased hippocampal activation to threatening images over one year predicted a non-remitting PTSD trajectory, compared to a remission trajectory and HC groups [ 148 ].

Overall, across longitudinal prospective study designs and studies utilizing three groups, hippocampal alterations (lesser hippocampal volume and function) appear to be a pre-exposure risk factor for the development of PTSD [ 68 , 114 , 116 , 117 , 118 , 119 , 120 , 121 , 126 , 127 , 128 , 129 , 130 , 134 , 135 , 136 ]. Creating interventions that promote hippocampal neurogenesis will be important to use to prevent the development of PTSD early after trauma. Furthermore, alterations in cortical regions such as the vmPFC, ACC, and MFG are apparent early after trauma and predictive of later PTSD symptoms [ 115 , 125 , 137 , 138 , 141 , 142 , 144 , 145 , 146 , 147 ]. As such, interventions introduced early post-trauma that promote greater FC between frontal-limbic networks can potentially strengthen these connections. There are many limitations to the studies reviewed above, including limited sample sizes, many of the longitudinal studies reviewed included participants with sub-threshold PTSD, and there was not much variability concerning trauma type. Thus, the generalizability of the findings across trauma types is questionable. For a pictorial overview of findings, see Fig. 1 .

Question 2: which neural correlates predict treatment outcomes and define treatment improvement?

To date, while trauma-focused cognitive behavioral therapies are gold-standard treatment options for PTSD, many people do not respond well to treatment [ 19 , 20 ]. Uncovering the neural mechanisms that predict symptom improvement and define treatment response will be crucial in helping guide clinician-decision making and provide a more precision-medicine approach to treatment. Given the recent reviews published on this topic [ 40 , 149 , 150 , 151 ], we review studies not included in these reviews, provide an overall summary of findings, and discuss limitations.

Baseline prediction of PTSD symptom improvement

In females who developed PTSD as a result of interpersonal trauma, pre-treatment FA values of the internal capsule, cingulate gyrus, superior longitudinal fasciculus, and splenium of the corpus callosum were positively correlated with changes in PTSD symptoms after cognitive processing therapy [ 152 ]. One study showed that lesser pre-treatment amygdala activation and greater MFG to fearful versus happy facial expressions were associated with a better response to prolonged exposure therapy (PE) [ 153 ]. Furthermore, this study found a greater decrease in the amygdala activation across blocks of fearful facial expression was associated with better symptomatic improvement [ 153 ]. Lower pre-treatment vmPFC-amygdala connectivity during an emotional face-viewing task predicted symptom improvement in individuals with PTSD, an effect that was strongest in individuals who received ketamine (versus midazolam) [ 154 ]. Additionally, this study showed symptom improvement following ketamine was predicted by decreased dACC activity during an emotional conflict regulation task and an increased resting-state FC between the vmPFC and anterior insula [ 154 ]. On the other hand, ketamine did not promote a greater increase in amygdala-mPFC resting-state FC but elicited a stronger transient decrease in vmPFC-amygdala compared to midazolam [ 155 ]. A longitudinal resting-state fMRI study employing support vector machine learning highlighted the precuneus, dmPFC, lingual gyrus, supplementary motor area, and cerebellum showed the highest prognostic remittance value from paroxetine treatment [ 156 ]. Lastly, Korgaonkar and colleagues (2020) found that lower pre-treatment connectivity in the cingulo-opercular, salience, and dorsal attention networks was associated with a better response to trauma-focused cognitive behavioral therapy (TF-CBT) [ 157 ].

Few studies have explored whether neuroimaging measures can predict treatment response in youth diagnosed with PTSD. Decreased pre-treatment activation in the posterior cingulate, mid-cingulate, and hippocampus predicted greater symptom improvement [ 158 ]. Another study trained a support vector machine from brain networks created from an ICA, finding that the bilateral superior temporal gyrus center network distinguished between non-responders and responders to trauma-focused therapies [ 159 ]. This may indicate that auditory processing and social cognition may be important for PTSD remission [ 160 ]. Girls who experienced greater reductions in PTSD symptoms exhibited decreased amygdala-insula connectivity during reappraisal compared to those experiencing milder reductions [ 161 ].

Neuroimaging correlates of PTSD symptom improvement

Increased hippocampal volume appeared in PTSD patients who completed CBT [ 162 ], eye-movement desensitization and realization (EMDR) alone [ 163 ] or paired with a Tetris video game intervention [ 164 ], and in those who remitted following psychotherapy [ 165 ]. Over time, lesser dorsal cingulum FA was found in individuals whose PTSD symptoms decreased after trauma-focused treatment [ 166 ]. Interestingly, recent work reported the normalization of CEN connectivity following cognitive processing therapy for PTSD [ 167 ]. Greater reduction in PTSD symptoms was associated with larger pre- to post-treatment increases in the inferior frontal junction inhibition of the amygdala [ 168 ]. PTSD patients who showed clinical improvement exhibited a reduced relative influence of the anterior insula over motor, affective, and self-other distinction regions [ 169 ]. Upon completion of PE, PTSD patients showed increased pre-post FC in basolateral amygdala-OFC, centromedial amygdala-OFC, and hippocampus-vmPFC. In contrast, TENC saw no significant pre-post changes in connectivity after PE, suggesting that amygdala FC normalized similarly to TENC [ 170 ]. One study showed that a reduction in PTSD symptom severity was associated with decreased connectivity between the visual cortex and temporal lobe regions and increased connectivity between the superior frontal gyrus and temporal pole regions after EMDR and TF-CBT, suggesting minor differences exist in neurophysiological outcome that is therapy-specific, particularly in those who experienced natural-disaster [ 171 ].

Overall, the studies reviewed here and previously published reviews [ 40 , 149 , 150 , 151 ] suggest that treatment non-response in adults was predicted by greater activation in regions responsible for threat detection, lesser activation in emotion regulation, executive function, and contextual processing regions, and altered crosstalk between regions within the DMN and regions important in emotion processing, cognitive function, and salience. In youth, studies are sparse but show a pattern of greater activation in memory-related regions, while lesser connectivity between fear learning-related regions predicted symptom reduction. There are many limitations of the studies reviewed. First, given the stringent inclusion/exclusion criteria many of these intervention studies endorse, their sample sizes are limited. Second, the definition of a responder versus a non-responder to treatment is not objective, and studies define this differently. Third, some variables are not controlled for, making it hard to determine the effect of treatment. For example, no direct comparison exists between groups undergoing different treatment options. Fourth, the analyses are largely ROI-specific. Fifth, no study have examined longitudinal treatment response outcomes. Lastly, many studies did not include a wait-list control group; only one study explored neural differences in treatment response between treatment types. For a pictorial overview of findings, see Fig. 2 .

Question 3: are there neuroimaging-based biotypes that define PTSD?

Psychiatry is moving towards a more precision-medicine approach, aiming to improve objective diagnosis, prediction, and treatment of mental disorders. Currently, to be diagnosed with PTSD, participants need to meet a certain number of symptoms that are largely self-reported and subjective, making the disorder highly heterogeneous [ 172 ]. To overcome the weak link between subjective-based diagnostic methods and objective-based neuroimaging assessments, recent studies have aimed to stratify PTSD to identify consistent subgroups based on objective brain-based markers [ 173 , 174 , 175 ]. Accordingly, Stevens and colleagues (2021) conducted a pioneering study to identify brain-based biotypes of psychiatric vulnerability shortly after trauma [ 176 ]. Using two cohorts from the AURORA longitudinal study of trauma survivors (n = 69 discovery cohort; n = 77 internal replication cohort) [ 112 ], the authors found and replicated three clusters based on early post-trauma brain activity during fMRI tasks assessing threat and reward reactivity, as well as response inhibition. These clusters were associated with distinct clinical trajectories up to 6 months post-trauma, with the group showing increased reactivity to threat and reward experiencing the most severe subsequent PTSD and anxiety symptoms [ 176 ]. In collaboration with Stevens and colleagues, Ben-Zion and colleagues (2023) conducted a conceptual replication of these brain-based biotypes [ 177 ] using a comparable dataset from the NMPTDT longitudinal study of trauma survivors [ 111 ]. While the authors found four clusters based on task-based fMRI data, they were not identical to the previously identified biotypes and were associated with prospective PTSD or anxiety symptoms. While there were many differences between the studies (AURORA and NMPTDT) that could contribute to the non-replication, this study highlights that additional replication studies are needed to identify more stable and generalizable neuroimaging-based biotypes before treatment implications can be fully realized [ 177 , 178 ].

Overall implications, future directions, and limitations

This narrative review aimed at exploring progress made in the past decade on three major questions in the field: (1) Which neural alterations serve as predisposing (pre-exposure) risk factors for PTSD development, and which are acquired (post-exposure)? (2) Which neural alterations can predict treatment outcomes and define clinical improvement? and (3) Can neuroimaging measures be used to define brain-based biotypes of PTSD? We present a synthesis of neuroimaging studies from the past decade in adults and youth with PTSD. Below, we present implications, provide areas of future research to be explored for each question, and highlight the limitations of our narrative review.

In the past decade, neuroimaging research on PTSD has advanced our understanding of the causal pathways of neural alterations within the disorder. However, we still cannot use the current neuroimaging knowledge to predict PTSD symptom trajectories or improve prevention and treatment options. Many of the above findings require replication in larger and more diverse samples with different trauma types across different methodologies. Importantly, future models used to determine the risk of developing trauma-related psychopathology will likely include information regarding demographics, socioeconomic status, and other clinical characteristics; thus, it is important to consider these factors when designing forthcoming studies. In the last ten years, we have seen a surge of longitudinal studies that collect neuroimaging measures early post-trauma and again at subsequent time points. While such studies are resource-intensive, scientists can answer questions not asked before, largely because of the development of large collaborations across multiple sites such as NMPTDT and AURORA research initiatives. The continuation and creation of more collaborations like these, with a focus on the collection of neuroimaging data shortly after trauma (and if possible, even pre-trauma) and at subsequent time points post-trauma, will be crucial in providing evidence to answer the vulnerability versus acquired characteristics of PTSD. To capture the dynamic evolution of the post-traumatic stress response, it is essential to incorporate multiple time points and ensure an adequately long follow-up period post-trauma (e.g., more than a year post-trauma), during which most of the recovery is anticipated.

Much work has been done to determine neural pre-treatment predictors of response and whether treatment normalizes alterations found in the disorder. While we have a relative understanding of potential predictors and changes associated with treatment response, much work still needs to be done to use this information in the clinic. Many of the studies reviewed had small sample sizes, used different treatment options, and samples were not diverse regarding sociodemographic factors and trauma type. Future studies should seek to replicate previous findings with bigger sample sizes, comparisons should be made between treatments, and more community-based samples should be prioritized.

The significant clinical heterogeneity observed in PTSD (and other post-traumatic psychopathologies), coupled with recent advancements in statistical and computational techniques, has spurred the pursuit of identifying homogeneous PTSD subtypes using data-driven methodologies. However, the assumption of distinct and homogeneous subgroups may not be clinically useful or accurately reflect the underlying biology of PTSD. For instance, most clustering methods will invariably produce clusters, even without any inherent data structure, highlighting the importance of differentiating between biologically and clinically relevant subtypes and random data fluctuations or noise [ 179 , 180 ]. Future research aiming to identify brain-based biotypes of PTSD will benefit from global collaborations between research teams, combining unique large-scale datasets and sharing of analytic pipelines (as exemplified recently by Stevens [ 176 ] and Ben-Zion [ 177 ]). Furthermore, subsequent studies will benefit from employing hybrid methodologies that integrate theory- and data-driven approaches Field [195,196] and implementing open science protocols (e.g., preregistration, transparent reporting of all results).

Few investigations explored here explicitly examined sex as a biological variable. As has been recently reviewed [ 13 ], the underlying neurobiological correlates of sex differences in PTSD are unknown. Most of the studies discussed here did not include a direct comparison between males and females. However, a handful of studies did examine female-only or male-only samples, which do not allow for the generalization of findings to the opposite sex. Thus, more studies should examine sex differences in their samples.

We have highlighted findings in youth. Still, much more work is needed to parse better the brain’s natural development versus the impact trauma may have on brain regions. Few studies have explored the questions posed in youth samples. Though resources are a limiting factor, future studies should execute longitudinal study designs that start in youth to determine the role of childhood trauma, potentially before it happens, in the development of trauma-related psychopathology in adulthood. Additionally, genetic and neurobiological studies linking transgenerational PTSD presentation would be beneficial in parsing preventative markers for developing PTSD. Thus, focusing on youth populations would be optimal in answering our first main question.

Limitations

There are notable strengths of this narrative review, including providing a synthesis of neuroimaging studies in both adult and youth samples that explore three leading questions in the PTSD field. Despite these strengths, limitations do exist. First, the authors have tried to include all the pertinent studies to answer the three questions, though a systematic protocol was not used when exploring studies. Second, given the number of studies available to be reviewed, the conclusions drawn from each question are limited. Further, as outlined above, methodological variability exists in the studies reviewed, including differences in scanning parameters and PTSD samples. This variability limits the reliability and validity of the conclusions made. Regardless of these limitations, this review is important as it provides insight into where the field stands on these three questions, highlighting that much research still needs to be conducted to make stronger conclusions.

Despite the limitations of the studies reviewed and of this narrative review, PTSD neuroimagers have made much progress in the last decade and have much more to make, especially in answering questions related to disparities in the development of the disorder and translating the knowledge collected beyond academia, to the communities we serve.

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CAH is supported under an NIAAA Award, K99AA031333. GCG is supported under a NIMH T32 grant, T32MH125786. ZB-Z is supported by Yale University School of Medicine (Dr. Ifat Levy & Dr. Ilan Harpaz-Rotem). We would like to thank Drs. Sanne van Rooij and Jennifer Stevens for providing critical feedback on the manuscript, and Bona Kim, M.A., C.M.I. for creating the figures.

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CAH was responsible for conceptualization, data curation for all sections, project administration, visualization, validation, writing the original draft, and reviewing and editing the manuscript. GCG helped with data curation for subsections, writing the original draft, and reviewing and editing the manuscript. ZBZ helped with data curation for subsections, writing the original draft, and reviewing and editing the manuscript.

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Hinojosa, C.A., George, G.C. & Ben-Zion, Z. Neuroimaging of posttraumatic stress disorder in adults and youth: progress over the last decade on three leading questions of the field. Mol Psychiatry (2024). https://doi.org/10.1038/s41380-024-02558-w

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MERS indicates Middle East respiratory syndrome; SARS, severe acute respiratory syndrome.

Improving the Assessment of COVID-19–Associated Posttraumatic Stress Disorder—Reply JAMA Psychiatry Comment & Response July 1, 2021 Delfina Janiri, MD; Georgios D. Kotzalidis, MD, PhD; Gabriele Sani, MD
Improving the Assessment of COVID-19–Associated Posttraumatic Stress Disorder JAMA Psychiatry Comment & Response July 1, 2021 Brian P. Marx, PhD; Paula P. Schnurr, PhD; Matthew J. Friedman, MD, PhD

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Janiri D , Carfì A , Kotzalidis GD, et al. Posttraumatic Stress Disorder in Patients After Severe COVID-19 Infection. JAMA Psychiatry. 2021;78(5):567–569. doi:10.1001/jamapsychiatry.2021.0109

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Posttraumatic Stress Disorder in Patients After Severe COVID-19 Infection

1 Department of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
2 Department of Geriatrics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
Comment & Response Improving the Assessment of COVID-19–Associated Posttraumatic Stress Disorder—Reply Delfina Janiri, MD; Georgios D. Kotzalidis, MD, PhD; Gabriele Sani, MD JAMA Psychiatry
Comment & Response Improving the Assessment of COVID-19–Associated Posttraumatic Stress Disorder Brian P. Marx, PhD; Paula P. Schnurr, PhD; Matthew J. Friedman, MD, PhD JAMA Psychiatry

Posttraumatic stress disorder (PTSD) may occur in individuals who have experienced a traumatic event. Previous coronavirus epidemics were associated with PTSD diagnoses in postillness stages, with meta-analytic findings indicating a prevalence of 32.2% (95% CI, 23.7-42.0). 1 However, information after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is piecemeal. We aimed at filling this gap by studying a group of patients with coronavirus disease 2019 (COVID-19) who sought treatment at the emergency department, most of whom required hospitalization, eventually recovered, and were subsequently referred to a postacute care service for multidisciplinary assessment.

A total of 381 consecutive patients who presented to the emergency department with SARS-CoV-2 and recovered from COVID-19 infection were referred for a postrecovery health check to a postacute care service established April 21, 2020, at the Fondazione Policlinico Universitario Agostino Gemelli IRCCS in Rome, Italy. Patients were offered a comprehensive and interdisciplinary medical and psychiatric assessment, detailed elsewhere, 2 which included data on demographic, clinical, psychopathological, and COVID-19 characteristics. Trained psychiatrists diagnosed PTSD using the criterion-standard Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), reaching a Cohen κ interrater reliability of 0.82. To meet PTSD criteria, in addition to traumatic event exposure (criterion A), patients must have had at least 1 DSM-5 criterion B and C symptom and at least 2 criterion D and E symptoms. Criteria F and G must have been met as well. Additional diagnoses were made through the Structured Clinical Interview for DSM-5 . Participants provided written informed consent, and the study was approved by the Università Cattolica and Fondazione Policlinico Gemelli IRCCS Institutional Ethics Committee.

Data for patients with and without PTSD were compared with the χ 2 test for nominal variables and one-way analysis of variance for continuous variables. Factors significantly associated with PTSD were subjected to a binary logistic regression. P values were 2-tailed, and significance was set at a P value less than .05. Analyses were performed using R version 4 0.0 (The R Foundation).

From April 21 to October 15, 2020, the postacute care service assessed 381 White patients who had recovered from COVID-19 infection within 30 to 120 days, 166 (43.6%) of whom were women. The mean (SD; range) age was 55.26 (14.86; 18-89). During acute COVID-19 illness, most patients were hospitalized (309 of 381 [81.1%]), with a mean (SD) length of hospital stay of 18.41 (17.27) days.

PTSD was found in 115 participants (30.2%). In the total sample, additional diagnoses were depressive episode (66 [17.3%]), hypomanic episode (3 [0.7%]), generalized anxiety disorder (27 [7.0%]), and psychotic disorders (1 [0.2%]). Patients with PTSD were more frequently women (64 [55.7%]), reported higher rates of history of psychiatric disorders (40 [34.8%]) and delirium or agitation during acute illness (19 [16.5%]), and presented with more persistent medical symptoms in the postillness stage (more than 3 symptoms, 72 [62.6%]) ( Table ). Logistic regression specifically identified sex (Wald 1 = 4.79; P = .02), delirium or agitation (Wald 1 = 5.14; P = .02), and persistent medical symptoms (Wald 2 = 12.46; P = .002) as factors associated with PTSD.

This cross-sectional study found a PTSD prevalence of 30.2% after acute COVID-19 infection, which is in line with findings in survivors of previous coronavirus illnesses 1 compared with findings reported after other types of collective traumatic events ( Figure ). 3 - 5 Associated characteristics were female sex, which has been extensively described as a risk factor for PTSD, 1 , 3 , 5 history of psychiatric disorders, and delirium or agitation during acute illness. In the PTSD group, we also found more persistent medical symptoms, often reported by patients after recovery from severe COVID-19. 6

This study had limitations, including the relatively small sample size and cross-sectional design, as PTSD symptom rates may vary over time. Furthermore, this was a single-center study that lacked a control group of patients attending the emergency department for other reasons. Further longitudinal studies are needed to tailor therapeutic interventions and prevention strategies.

Accepted for Publication: January 26, 2021.

Published Online: February 18, 2021. doi:10.1001/jamapsychiatry.2021.0109

Corresponding Author: Delfina Janiri, MD, Department of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Francesco Vito 1, 00168 Rome, Italy ( [email protected] ).

Author Contributions: Dr Janiri had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design : Janiri, Carfì, Sani.

Acquisition, analysis, or interpretation of data : All authors.

Drafting of the manuscript : Janiri, Kotzalidis, Sani.

Critical revision of the manuscript for important intellectual content : Carfì, Kotzalidis, Bernabei, Landi, Sani.

Statistical analysis : Janiri, Sani.

Administrative, technical, or material support : Carfì.

Supervision : Kotzalidis, Bernabei, Landi, Sani.

Conflict of Interest Disclosures: Dr Sani reports personal fees from Janssen, Angelini Spa, and Lundbeck outside the submitted work. No other disclosures were reported.

Additional Contributions: We thank the Gemelli Against COVID-19 Post-Acute Care Study Group and the patients who contributed their time and effort to participate in this study.

Additional Information: The members of the Gemelli Against COVID-19 Post-Acute Care Study Group are listed in reference 2.

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CASE REPORT article

5-meo-dmt for post-traumatic stress disorder: a real-world longitudinal case study.

1 Integrated Research Literacy Group, Draper, UT, United States
2 Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
3 Department of Psychology and Neuroscience, Duke University, Durham, NC, United States
4 Neuroscience Interdepartmental Program, University of California, Los Angeles, Los Angeles, CA, United States
5 Department of Family and Consumer Studies, University of Utah, Salt Lake City, UT, United States
6 School of Humanities and Creativity, Sheridan College, Oakville, ON, Canada
7 Department of Pediatrics, Division of Pediatric Psychology and Developmental Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
8 Children’s Wisconsin, Milwaukee, WI, United States
9 The Mission Within, Baja California, Mexico
10 Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
11 Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States
12 Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States

Psychedelic therapy is, arguably, the next frontier in psychiatry. It offers a radical alternative to longstanding, mainstays of treatment, while exciting a paradigm shift in translational science and drug discovery. There is particular interest in 5-methoxy- N,N -dimethyltryptamine (5-MeO-DMT)—a serotonergic psychedelic—as a novel, fast-acting therapeutic. Yet, few studies have directly examined 5-MeO-DMT for trauma- or stress-related psychopathology, including post-traumatic stress disorder (PTSD). Herein, we present the first longitudinal case study on 5-MeO-DMT for chronic refractory PTSD, in a 23-year-old female. A single dose of vaporized bufotoxin of the Sonoran Desert Toad ( Incilius alvarius ), containing an estimated 10−15 mg of 5-MeO-DMT, led to clinically significant improvements in PTSD, with next-day effects. This was accompanied by marked reductions in hopelessness and related suicide risk. Improvements, across all constructs, were sustained at 1-, 3-, 6-, and 12-months follow-up, as monitored by a supporting clinician. The subject further endorsed a complete mystical experience, hypothesized to underly 5-MeO-DMT’s therapeutic activity. No drug-related, serious adverse events occurred. Together, results showed that 5-MeO-DMT was generally tolerable, safe to administer, and effective for PTSD; however, this was not without risk. The subject reported acute nausea, overwhelming subjective effects, and late onset of night terrors. Further research is warranted to replicate and extend these findings, which are inherently limited, non-generalizable, and rely on methods not clinically accepted.

Introduction

5-methoxy- N,N -dimethyltryptamine (5-MeO-DMT) is a natural, short-acting psychoactive indolealkylamine ( 1 ). It was first synthesized in 1936 ( 2 ), later found in several plant (e.g., Dictyoloma incanescens ), fungi (e.g., Amanita citrina ), and animal (e.g., Incilius al var ius ) species ( 2 , 3 ). In humans, 5-MeO-DMT is likely endogenous, with trace amounts detected in urine (2 of 113 people), blood (20 of 39 people), and cerebrospinal fluid (40 of 136 people) ( 2 ). However, various studies contradict this finding ( 2 , 4 ); and its physiological role, if any, remains unclear. Based on ethnographic reports, 5-MeO-DMT may have been used by indigenous cultures, as part of plant extracts and botanical preparations (e.g., yopo or cohoba snuff), specifically for spiritual and ritualistic practices ( 5 , 6 ). These reports date back to ancient People of Mesoamerica ( 5 , 6 ). Yet, there is little evidence to support such claims. Further, contrary to published work, 5-MeO-DMT is not found in traditional or analog ayahuasca ( 7 , 8 ). This points to its use being a more recent phenomenon ( 9 , 10 ).

Regarding its pharmacology, 5-MeO-DMT is a nonselective serotonin (5-HT) receptor agonist ( 11 , 12 ). It also binds to other receptors, including dopamine and serotonin, as well as norepinephrine transporters ( 12 ). The entheogen mildly inhibits 5-HT reuptake, yet exerts no appreciable effects on monoamine release ( 13 ). 5-MeO-DMT has the highest affinity for 5-HT 1A (K i , < 10 nM) over 5-HT 2A (K i , >1,000 nM), with 300–1,000-fold greater selectivity ( 11 , 12 , 14 ). This is notable, given that most serotonergic psychedelics, like LSD and psilocybin, are mediated by 5-HT 2A activation ( 15 ). Other non-5-HT 2A receptors have not been studied as widely ( 16 ). Metabolically, 5-MeO-DMT is processed via oxidative deamination—catalyzed by monoamine oxidase A (MAO A )—into the active metabolite, bufotenine ( 17 ). Use of 5-MeO-DMT with MAO inhibitors (MAOIs), such as antidepressants, can augment and prolong neurochemical and behavioral effects, by blocking biotransformation of 5-MeO-DMT and increasing its exposure ( 18 ). Nonetheless, MAOIs can induce serotonergic toxicity ( 19 ), or ‘serotonin syndrome’, a potentially life-threatening drug reaction caused by excess serotonin in the brain ( 20 ). This can present as shivering or diarrhea, as well as muscle rigidity, high fever, and epileptic seizure. Combining 5-MeO-DMT with harmala alkaloids, short-term MAOIs found in ayahuasca, can also produce toxic interactions, and even death ( 21 ).

There are several routes for administering 5-MeO-DMT. This includes inhalation (~6–20 mg), intranasal (~10 mg), intravenous (~1–3 mg), sublingual (~10 mg), and oral (~30 mg) methods ( 18 , 22 ). Inhalation by vapor is most commonly reported, given its accessibility and relative ease of use, particularly in naturalistic settings ( 6 , 10 ). However, it can lead to intense rapid onset, relative to other dosage forms, like intramuscular injection. The onset, duration, and magnitude of subjective effects, occasioned by 5-MeO-DMT, are both route- and dose-dependent. For example, vaporization induces effects within ~10–15 s and peak experiences within ~2–5 min, resolving within ~25–30 min ( 6 , 22 , 23 ). Conversely, insufflation has a slower onset of action, due to delayed absorption, inducing effects within ~3–4 min and peak experiences within ~35–40 min, resolving within ~60–70 min ( 24 ). Irrespective of route, 5-MeO-DMT produces diverse subjective effects, including visual and auditory hallucinations, distorted time perception, and memory impairment ( 4 ). It also occasions peak mystical experiences comparable to high-dose psilocybin ( 25 ). Ego dissolution, a complete loss of self-identity, is frequently reported, as are profound near-death experiences ( 22 , 25 – 28 ). 5-MeO-DMT can, therefore, be challenging to navigate, with reports of fear, extreme anxiety, and paranoia ( 29 ). Users also describe perceptual isolation, seeing “all white” or “all black” ( 30 ). This contrasts to classic psychedelics, like N,N -DMT and LSD, that produce highly detailed, complex mental imagery. From a clinical standpoint, 5-MeO-DMT shows signals of benefit to mental health and well-being ( 3 , 4 ). However, there is a paucity of evidence in the field, particularly for trauma- and stress-related psychopathology.

Here, in accordance with CARE (CAse REport) guidelines ( 31 ), we present the first real-world, longitudinal case study on 5-MeO-DMT for post-traumatic stress disorder (PTSD). The subject provided written consent for publication and authorized disclosure of private health information. The data presented here were collected by the subject for their own interest and safety, and to monitor their progress over time. We then gained access to and analyzed the data retrospectively. To protect anonymity, the materials are not publicly available. This case study was exempt from ethics review and approval, in line with the Baylor College of Medicine Human Research Protections Manual, including Institutional Review Board procedures.

Subject information

A 23-year-old female presented with chronic refractory PTSD. She reported night terrors, trauma avoidance, negative affect, and hypervigilance. This developed from repeat sexual abuse, spanning six years as an adolescent. There was no relevant family history. Past interventions included variants of cognitive behavioral therapy (CBT), namely prolonged exposure (PE: 10 sessions), cognitive processing therapy (CPT: 12 sessions), and stress inoculation training (SIT: 8 sessions). These techniques targeted feared stimuli, maladaptive beliefs, and stress reactivity, respectively. However, each resulted in marginal improvements. She was then prescribed sertraline (Zoloft: 50 mg daily), a selective serotonin reuptake inhibitor (SSRI), following one week at 25 mg daily. This regimen adhered to pharmacotherapy guidelines for PTSD. Notwithstanding, the subject failed to respond adequately, reporting notable side effects, such as lethargy and disturbed sleep. She was, therefore, tapered off sertraline over the course of four weeks. This led to protracted symptoms and increased night terrors. Eventually, the subject was prescribed trazodone (Desyrel: 75 mg daily), a serotonin antagonist and reuptake inhibitor (SARI), for mixed insomnia. She experienced partial symptom relief and continued taking the medication, accordingly. The subject had no history of psychedelic use; however, she periodically smoked cannabis to manage her anxiety. See Figure 1 for a timeline of events.

Figure 1 . Timeline of historical and clinical events. 5-MeO-DMT, 5-methoxy- N,N -dimethyltryptamine (experimental treatment); COVID-19, coronavirus disease pandemic; CPT, cognitive processing therapy (cognitive behavioral therapy); PE, prolonged exposure (cognitive behavioral therapy); SARI, serotonin antagonist and reuptake inhibitor (trazadone); SCID-5, Structured Clinical Interview for DSM-5 (diagnostic assessment); SIT, stress inoculation therapy (cognitive behavioral therapy); SSRI, selective serotonin reuptake inhibitor (sertraline); T0, baseline; T1, 24 h follow-up; T2, 1 month follow-up; T3, 3 months follow-up; T4, 6 months follow-up; T5, 12 months follow-up.

The coronavirus (COVID-19) pandemic, restricting social contact with friends and family, further aggravated the subject’s condition. Critically, she desired to end “intense emotional pain” and “chronic sadness.” Isolated in lockdown, desperate for help, and at risk of suicide, the subject pursued self-treatment with 5-MeO-DMT. This was motivated by (1) her resistance to first- and second-line therapies for PTSD, having attempted multiple interventions; (2) evidence on the potential benefits of 5-MeO-DMT for anxiety and trauma, acquired from reading news articles and research studies; (3) new legislation approved in her state (Oregon, Measure 110), which decriminalized the possession of controlled substances, including psychedelics; and (4) access to a trauma-informed 5-MeO-DMT facilitator, to whom a friend referred her to.

Diagnostic assessment

The subject was diagnosed with PTSD at 19 years of age. This was provided by her treating psychiatrist who, at the time, administered the Structured Clinical Interview for DSM-5 (SCID-5) ( 32 ), specifically the PTSD Module. The interview revealed a chronic course with severe PTSD symptoms and comorbid depression. Four years later, the subject pursued 5-MeO-DMT, independent from her psychiatrist, supported by a trauma-informed facilitator. The facilitator had extensive experience with 5-MeO-DMT, who advised on dosing and guided her experience. A licensed clinician, likewise, supported the subject in this pursuit. The clinician administered assessments, monitored her experience, and completed follow-ups. Assessments included the PTSD Checklist for DSM-5 [PCL-5; ( 33 )], the Beck Hopelessness Scale [BHS; ( 34 )] and the Clinical Global Impressions [CGI; ( 35 )] questionnaire. These were used to track the subject’s progress over time, administered prior to 5-MeO-DMT dosing (i.e., at baseline), and again 24 h-, 1 month-, 3 months-, 6 months-, and 12 months later (i.e., at follow-ups). For safety purposes, the clinician took vital signs before, during, and after 5-MeO-DMT dosing. This consisted of blood pressure (mmHg), heart rate (bpm), and peripheral oxygen saturation (SpO 2 ). To assess acute, subjective effects, the Mystical Experiences Questionnaire [MEQ-30; ( 36 )] was administered 3 h post-dosing. The clinician observed the subject for a total of 5 h after her 5-MeO-DMT experience, and conducted follow-ups via phone 24, 36, and 72 h later, before switching to once a month.

PTSD checklist for DSM-5

The PCL-5 is a 20-item measure of PTSD symptoms. It has excellent internal consistency (α = 0.94) ( 33 ), comprising four factors: ‘thought intrusion’, ‘stimuli avoidance’, ‘negative mood and cognitions’, and ‘altered reactivity’. Items are rated on a 5-point scale, with ‘not at all’ (0) and ‘extremely’ (4) as endpoints. The PCL-5 is scored by summing items within a given factor, as well as all items together. Total scores range from 0 to 80. Higher scores reflect greater symptom severity, with 31–33 typically used as the cut-off point for probabilistic PTSD. When monitoring symptoms, a 5–10-point difference indicates reliable change, not due to chance, whereas a 10–20-point difference indicates clinically significant change. The ‘past week’ version of the PCL-5 was utilized in this case study.

Impressions

At baseline, the subject’s total score was 72 of 80 (3.79 ± 0.42), meeting threshold criteria for ‘severe’ PTSD, and a provisional diagnosis. Regarding PCL-5 factors, she scored the highest on ‘altered reactivity’ (4.00 ± 0.00), followed by ‘thought intrusion’ (3.80 ± 0.45), ‘negative mood and cognitions’ (3.71 ± 0.49), and ‘stimuli avoidance’ (3.50 ± 0.71).

Beck hopelessness scale

The BHS is a 20-item measure of hopelessness. It has excellent internal consistency (α = 0.97) ( 37 ), comprising three factors: ‘feelings about the future’, ‘loss of motivation’, and ‘future expectations’. Items are rated on a 2-point scale, using dichotomous ‘true’ (0/1) and ‘false’ (0/1) statements. The BHS is scored by summing items within a given factor, as well as all items together. Total scores range from 0 to 20. Higher scores reflect greater hopelessness, categorized into four levels: ‘normal’ (0–3), ‘mild’ (4–8), ‘moderate’ (9–14), and ‘severe’ (>14). A cut-off score of 9 is frequently used to detect risk of suicidal ideation and behavior.

At baseline, the subject’s total score was 17 of 20 (0.85 ± 0.37), meeting threshold criteria for ‘severe’ hopelessness and suicide risk. Regarding BHS factors, she scored the highest on ‘feelings about the future’, (1.00 ± 0.00) and ‘future expectations’ (1.00 ± 0.00), followed by ‘loss of motivation’ (0.63 ± 0.52).

Clinical global impressions

The CGI is a 3-item measure of global functioning. It was developed for clinical trials, aimed at capturing change after initiating a study drug. The CGI includes three factors. The first factor measures ‘illness severity’, rated on a 7-point scale, anchored by ‘normal and not at all ill’ (1) and ‘among the most extremely ill’ (7). The second factor measures ‘global improvement’, also rated on a 7-point scale, with ‘very much improved’ (1) and ‘very much worse’ (7) as endpoints. Finally, the third factor measures ‘therapeutic response’, rated on a 5-point scale, anchored by ‘marked improvement and no side effects’ (0) and ‘unchanged or worse and side effects outweigh therapeutic effect’ (4). This third factor considers both therapeutic efficacy and drug-related adverse events. A zero is allocated if there is no assessment. Each factor is rated separately, yielding no total scores.

At baseline, the subject’s score for ‘illness severity’, regarding PTSD, was 6 of 7, meeting threshold criteria for ‘severely ill’. In particular, she exhibited disruptive trauma- and stress-related psychopathology, with symptoms considerably impairing her behavior and function. The other two factors, ‘global improvement’ and ‘therapeutic response’, were not assessed at baseline, as they measure changes after treatment.

Therapeutic intervention

5-MeO-DMT was obtained and administered by the subject. The experience occurred in the comfort of her home. Guided by the facilitator, she first set an intention for the experience. “I want to understand and accept the roots of my trauma.” This was designed to help navigate potentially difficult psychedelic states and material, by re-centering the subject’s attention. Next, she engaged in body scan meditation, a specific form of mindfulness practice. This involved deep breathing and mind–body awareness, aimed at relaxation. The subject then inhaled 50 mg of vaporized bufotoxin, derived from the Sonoran Desert Toad ( Incilius alvarius ), slowly and consistently. This was estimated to contain 10–15 mg of 5-MeO-DMT [20–30% of total dried weight ( 38 )]. Using a torch lighter, the bufotoxin was heated in a glass vial until its contents were vaporized. She held the dose for 10 s, exhaled slowly and consistently, and lied down with an eye mask on. Ambient music played in the background. The onset of effects was rapid (15–30 s), with peak effects lasting 10–15 min, resolving within 25–30 min. After the effects had subsided, the subject re-engaged in body scan meditation. She then discussed her experience with the facilitator, integrating newfound insights. Finally, the clinician reviewed the subject’s vital signs and asked about her experience, recording any undesirable reactions. Three hours later, the clinician administered the MEQ-30.

Follow-up and outcomes

5-MeO-DMT was generally tolerated by the subject. Mild nausea was reported, which resolved within 30 min. There were slight increases in systolic blood pressure (126.00 ± 3.54), diastolic blood pressure (89.00 ± 4.24), and heart rate (81.50 ± 4.95), whereas oxygen saturation (97.50 ± 0.71) remained stable. See Table 1 and Figure 2 . Overall, no drug-related, serious adverse events occurred. However, the subject reported “profoundly strong” subjective effects. She described being “instantly blasted” into another dimension. At first, colors were extremely vivid, then morphed into “complete whiteness.” The subject failed to make sense of psychedelic content, stating that visuals were “bright and god-like,” yet vague and fleeting. She also reported increased body temperature and euphoria. “I felt really warm, like my body was melting. It was calm and blissful.” This was accompanied by radical ego dissolution. “I had no identity. I was still alive, but my body was gone. It was quite overwhelming. I just had to surrender.”

Table 1 . Clinician-reported vital signs.

Figure 2 . Vital signs taken before and after 5-MeO-DMT dosing. 5-MeO-DMT, 5-methoxy- N,N -dimethyltryptamine; DBP, diastolic blood pressure (mmHg); HR, heart rate (bmp); SBP, systolic blood pressure (mmHg); SpO 2 , peripheral blood oxygenation (%).

On the MEQ-30, the subject endorsed strong mystical-like effects. Her total score was 135 of 150 (4.47 ± 0.62). She also met criteria for a ‘complete mystical experience’. This was evidenced by scoring ≥60% of the maximum possible scores on all four factors of the MEQ-30: ‘mysticism’ (4.47 ± 0.62 [89.3%]), ‘positive mood’ (4.33 ± 0.75 [86.7%]), ‘transcendence’ (4.67 ± 0.47 [93.3%]), and ‘ineffability; (4.33 ± 0.47 [86.7%]). See Figure 3 for details.

Figure 3 . Mystical effects of 5-MeO-DMT. Blue dotted line indicates the cut-off point for a complete mystical experience (≥60% of total scores across factors). 5-MeO-DMT, 5-methoxy- N,N -dimethyltryptamine; MEQ-30, Mystical Experience Questionnaire.

On the PCL-5, the subject had a clinically significant change in PTSD, which sustained across time. This was evidenced by a ≥ 10-point reduction in total scores from baseline to 24 h (−54 points), 1 month (−49 points), 3 months (−37 points), 6 months (−46 points), and 12 months (−50 points) follow-up. In particular, her symptoms decreased by 75.0% from baseline to 24 h (3.79 ± 0.42 vs. 0.95 ± 0.71), increased by 27.8% from 24 h to 1 month (0.95 ± 0.71 vs. 1.21 ± 0.63), increased by 52.2% from 1 month to 3 months (1.21 ± 0.63 vs. 1.84 ± 0.76), decreased by 25.7% from 3 months to 6 months (1.84 ± 0.76 vs. 1.37 ± 0.68), and finally decreased by 15.4% from 6 months to 12 months (1.37 ± 0.68 vs. 1.16 ± 0.60) follow-up. From baseline to 12 months follow-up, she experienced the greatest improvement in ‘negative mood and cognitions’ (3.71 ± 0.49 vs. 1.10 ± 0.69), followed by ‘thought intrusion’ (3.80 ± 0.45 vs. 1.00 ± 0.71), ‘altered reactivity’ (4.00 ± 0.00 vs. 1.40 ± 0.55), and ‘stimuli avoidance’ (3.50 ± 0.71 vs. 1.00 ± 0.00). See Table 2 and Figures 4A , B .

Table 2 . Self-reported outcome measures.

Figure 4 . Change in PTSD symptoms by time point [ (A) , line graph]. Change in PTSD symptoms across time [ (B) , bar chart]. Change in hopelessness symptoms by time point [ (C) line graph]. Change in hopelessness symptoms across time [ (D) , bar chart]. BHS, Beck Hopelessness Scale; CB, cluster B (thought intrusion); CC, cluster C (stimuli avoidance); CD, cluster D (negative mood and cognitions); CE, cluster E (altered reactivity); EF, expectations about the future (hopelessness); FF, feelings about the future (hopelessness); LM, loss of motivation (hopelessness); PCL-5, PTSD Checklist for DSM-5; PTSD, post-traumatic stress disorder; SS, symptom severity; T0, baseline; T1, 24 h follow-up; T2, 1 month follow-up; T3, 3 months follow-up; T4, 6 months follow-up; T5, 12 months follow-up.

On the BHS, the subject showed robust improvement in hopelessness. This also sustained across time. Her symptoms decreased by 52.9% from baseline to 24 h (0.85 ± 0.37 vs. 0.40 ± 0.50), decreased by 50.0% from 24 h to 1 month (0.40 ± 0.50 vs. 0.20 ± 0.41), increased by 125.0% from 1 month to 3 months (0.40 ± 0.50 vs. 0.45 ± 0.51), decreased by 66.7% from 3 months to 6 months (0.45 ± 0.51 vs. 0.15 ± 0.37), and remained stable from 6 months to 12 months (0.15 ± 0.37 vs. 0.15 ± 0.37) follow-up. From baseline to 12 months follow-up, she experienced the greatest improvement in ‘loss of motivation’ (0.63 ± 0.52 vs. 0.00 ± 0.00) and ‘future expectations’ (1.00 ± 0.00 vs. 0.17 ± 0.41), followed by ‘feelings about the future’ (0.63 ± 0.52 vs. 0.33 ± 0.52). Further, the subject had a clinically significant change in suicide risk. This was evidence by scoring ≤9 at 24 h (score = 8), 1 month (score = 4), 3 months (score = 9), 6 months (score = 3), and 12 months (score = 8) follow-up. See Table 2 and Figures 4C , D .

On the CGI, the clinician reported marked reductions in PTSD, which sustained across time. Rated at each time point, she presented as ‘severely ill’ at baseline (score = 6), ‘mildly ill’ at 24 h (score = 3), ‘borderline ill’ at 1 month (score = 2), ‘mildly ill’ at 3 months (score = 3), ‘not at all ill’ at 6 months (score = 1), and ‘not at all ill’ at 12 months (score = 1) follow-up. These ratings considered the clinician’s total experience treating PTSD. Relative to baseline, the subject’s global functioning changed from ‘much improved’ at 24 h post-dosing (score = 2), representing a significant change, with increased functioning and moderate symptoms, to ‘very much improved’ at 12 months follow-up (score = 1), indicating a substantial change, with good functioning and minimal symptoms. This was judged independent from any beliefs about 5-MeO-DMT. Finally, based on drug effect, her therapeutic response was ‘marked’ at 24 h post-dosing (score = 2), with side effects that did not significantly interfere with functioning, and ‘marked’ again at 12 months-follow-up (score = 1), with no side effects. See Table 3 .

Table 3 . Clinician-reported outcome measures.

In this case study, a single dose of vaporized toad bufotoxin, containing 5-MeO-DMT, led to clinically significant improvements in PTSD, with next-day effects. These gains were sustained at 1-, 3-, 6-, and 12-months follow-up. Moreover, the subject showed striking reductions in hopelessness and related suicide risk. These changes were, likewise, durable across time. Self-reported improvements further reflected clinician-observed changes in global functioning. 5-MeO-DMT was generally tolerated. No drug-related, serious adverse events occurred. However, there were nominal increases in blood pressure and heart rate. This did not extend to oxygen saturation. Subjective effects were also overwhelming. Interestingly, 5-MeO-DMT produced more visual content than previously described ( 30 ). Colors appeared at the beginning of her experience, then faded into transcendent light; the latter being more consistent with literature ( 30 ). The subject’s dose and setting likely impacted her perceptual experience ( 38 ). Regardless, more data is needed to characterize the phenomenology of 5-MeO-DMT, and how this compares to other psychedelics. This is particularly important for optimizing facilitation and harm reduction practices, in helping patients navigate psychedelic states, as well as for targeting PTSD and chronic stress pathology.

Furthermore, the subject endorsed a strong and complete mystical experience. While the mechanism underlying her therapeutic response is unknown, it may be explained, in part, by the epistemological or ‘noetic quality’ of mystical states, occasioned by 5-MeO-DMT ( 39 ). These psychological states are characteristic of psychedelics, namely serotonergic compounds ( 39 ); have been shown to correlate, mediate, and predict therapeutic efficacy ( 40 ); and include feelings of transcendence, ego dissolution, and ineffability as well as unity, love, and peace ( 41 ). Thus, people have rated mystical experiences in their top five most important life events, in terms of personal meaning and spiritual significance, next to giving birth or losing a loved one ( 42 , 43 ). These effects can persist up to 30 years after taking a psychedelic ( 44 ). In the present case study, the subject described the mystical effects of 5-MeO-DMT as both substantial and enduring. “It was the most profound and frightening experience of my life. I saw bright colors. I was connected to all things. I disappeared into space. I smiled for the first time in a long time. I cried and screamed. I forgot about [my] pain and trauma… then relived it. My body had permission to heal. I moved on. It’s hard to put it into words… beautiful and challenging I guess…feeling everything and nothing at once. But it allowed me to view my trauma in a different way. Like a superpower. That insight has stayed with me.” Other possible mechanisms of change, from a psychological standpoint, include re-processing and transforming traumatic material.

This case study aligns with previous findings in the literature. For instance, in a retrospective, epidemiology survey on 5-MeO-DMT ( n = 515; M age = 35.4; male = 79%), 79% of participants with psychiatric disorders reported improved PTSD following 5-MeO-DMT use ( 22 ). Most participants (90%) had moderate-to-strong mystical experiences, while a significant proportion (37%) had challenging ones. In another retrospective, international survey ( n = 99; M age = 37.4; male = 74%), 79% of participants with past or present PTSD, who had used 5-MeO-DMT at least once in their lifetime, reported improved symptomatology ( 45 ). They also endorsed significantly stronger mystical experiences than those who did not experience symptom improvement or regressed. Most recently, Davis et al. ( 46 ) examined ibogaine and 5-MeO-DMT for trauma-related psychological and cognitive impairment, specifically among U.S. Special Operations Forces Veterans ( n = 51; M age = 40.0; male = 96%). They analyzed retrospective data collected 30 days before and 30 days after a clinical psychedelic program in Mexico. The results showed significant and large reductions in depression, suicidal ideation, anxiety, PTSD, and cognitive impairment. Participants additionally reported increased psychological flexibility, which was strongly associated with improvements in all constructs, excluding suicidality.

Other studies have investigated 5-MeO-DMT in naturalistic settings. For example, in an observational group study, using structured dosing protocols, researchers examined clinical correlates of 5-MeO-DMT ( 27 ). Among healthy participants ( n = 362; M age = 47.7; male = 55%), 80% with depression and 79% with anxiety reported spontaneous, unintended reductions in symptoms. This was associated with stronger mystical experiences, as well as higher ratings of spirituality and meaning in life. In another observational study, Uthaug et al. ( 47 ) investigated sub-acute and long-term effects of 5-MeO-DMT on affect and cognition. Among healthy participants ( n = 42; M age = 38.0; male = 60%), ratings of depression, anxiety, and stress decreased 24 h post-intake and reached significance at 4 weeks follow-up. Those who experienced high levels of ego dissolution or oceanic boundlessness, two markers of a mystical experience, displayed lower levels of depression and stress. However, this did not extend to anxiety.

Of note, the subject partially regressed at 3-months follow-up. She reported new onset of night terrors, the nature of which could not be recalled. These night terrors reflect higher scores across all measures at this time point, relative to the others. A phenomenon known as ‘reactivation’, similar to flashbacks, is commonly reported by 5-MeO-DMT users ( 22 , 48 ). This involves re-experiencing parts of a drug-induced state post-administration, which can occur days, weeks, or even months later ( 49 , 50 ). Additionally, the probability of 5-MeO-DMT reactivation increases with being female, dosing in a structured group format, and having a stronger mystical experience ( 48 ). All three of these factors applied to this case study. As such, the subject may have endured a reactivation event following 5-MeO-DMT, presenting as negatively-valenced night terrors. Alternatively, the benefits of 5-MeO-DMT may have only lasted for three months. Despite the partial regression, scores across all measures remained below clinical thresholds, with symptoms naturally remitting overtime. The onset of night terrors was not considered a ‘serious adverse event’, as its association with 5-MeO-DMT could not be definitively concluded. It neither was life-threatening, required intervention or hospitalization, resulted in persistent or significant disability, nor led to the subject’s death.

Strengths and limitations

The longitudinal nature of this case study serves as its primary strength, with repeated observations collected over a 1-year period. Findings are more robust, given the subject’s treatment resistance and disease chronicity, the complexity of this clinical population, and the limitation in available effective, evidence-based interventions. Further, the presence of psychiatric comorbidities, the lack of polypharmacy or medication washout, and the naturalistic setting better reflect patients in the real world. The use of well-validated measures, capturing both subject- and clinician-reported changes, is an additional strength. Notwithstanding, this case study is inherently limited.

First, it describes the presentation, treatment, and follow-up of a single person. Hence, the results cannot be generalized to others with PTSD. Second, the dose of 5-MeO-DMT was estimated by the subject, based on visual inspection. The precise amount cannot be determined, accordingly. Third, the source for obtaining toad bufotoxin, containing the 5-MeO-DMT, is unknown. The compound’s integrity may have been compromised as a result. Fourth, 5-MeO-DMT was self-administered by the subject. This is not considered a suitable clinical or pharmaceutical application, primarily due to safety reasons. Finally, there is no evidence that 5-MeO-DMT, in and of itself, produced therapeutic activity reported in this case study. Facilitation practices, like body scan meditation, for instance, may have confounded the results, magnifying or diminishing therapeutic effects. Findings should, therefore, be interpreted with caution, and only serve to catalyze future research. This is particularly important, as the field is far from establishing clinical efficacy, real-world effectiveness, and standard treatment protocols for 5-MeO-DMT in PTSD and beyond. Additionally, naturalistic psychedelic use has steadily increased over the past decade ( 51 ). This is likely due to media coverage, advances in research, and changes to legislation. It is, thus, critical to balance discussions on 5-MeO-DMT and other psychedelics with clear and careful acknowledgement of safety risks.

Looking ahead, the next logical step is to conduct pilot studies that explore the safety, tolerability, and preliminary efficacy of 5-MeO-DMT for PTSD, in larger and more diverse samples. Including a richer battery of psychometric instruments is highly encouraged. Results could then inform open-label, randomized, and adaptive trials to further characterize 5-MeO-DMT for this patient population; and to explore different therapeutic approaches, including adjunctive psychotherapy, which may augment patient adherence and therapeutic outcomes. Incorporating moderated mediation models, as statistical analyses, is also encouraged in future work. This would allow researchers to control for covariates, like age and gender, while examining potential underlying mechanisms, such as mystical experiences.

This case study is the first to report the longitudinal effects of 5-MeO-DMT for chronic refractory PTSD, complicated by hopelessness and suicidality. The results showed that 5-MeO-DMT offered fast-acting, robust, and sustained improvements in symptomatology, and was generally tolerable and safe to administer. However, this was not without risks, as evidenced by acute nausea, overwhelming subjective effects, and late onset of night terrors. Further research is warranted to replicate and extend these findings, which are inherently limited, non-generalizable, and rely on methods not clinically accepted. This can be achieved through clinical and naturalistic studies, in controlled and uncontrolled environments, to effectively converge on safety, efficacy, effectiveness, and durability of 5-MeO-DMT for PTSD. Evidence can then be leveraged to optimize therapeutic delivery, as well as develop standard clinical practice guidelines.

Data availability statement

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

Ethics statement

Ethical approval was not required for the study involving humans in accordance with the local legislation and institutional requirements. Written informed consent to participate in this study was not required from the participants or the participants’ legal guardians/next of kin in accordance with the national legislation and the institutional requirements. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

Author contributions

AR: Conceptualization, Formal analysis, Project administration, Visualization, Writing – original draft. RK: Investigation, Writing – original draft, Writing – review & editing. PS: Conceptualization, Funding acquisition, Project administration, Supervision, Writing – review & editing. LB: Writing – original draft, Writing – review & editing. RA: Writing – original draft, Writing – review & editing. MK: Writing – original draft, Writing – review & editing. NB: Validation, Writing – review & editing. LJ: Validation, Writing – review & editing. MG: Validation, Writing – review & editing. JB: Supervision, Validation, Writing – review & editing. LA: Conceptualization, Supervision, Validation, Writing – review & editing.

The author(s) declare financial support was received for the research, authorship, and/or publication of this article. The authors declare that this study received funding from Cubed Biotech. The funder was not involved in the study design, collection, analysis, interpretation of data, the writing of this article, or the decision to submit it for publication. All research in the Department of Psychiatry at the University of Cambridge was supported by the National Institute for Health and Care Research Cambridge Biomedical Research Centre (NIHR203312) and the National Institute for Health and Care Research Applied Research Collaboration East of England. The views expressed are those of the author(s) and not necessarily those of the National Institute for Health and Care Research or the Department of Health and Social Care. LA receives some salary support from the US Department of Veterans Affairs (IK2CX001873) and the American Foundation for Suicide Prevention (YIG-0-004-16).

Acknowledgments

We express our gratitude to the subject, facilitator, and clinician—described in this case study—for collecting and sharing their data; and for their valuable contributions to science, specifically in understanding the potential of 5-MeO-DMT for PTSD and beyond.

Conflict of interest

AR is the Founding Director of the Integrated Research Literacy Group. PS is the Director of Psychological Science at the Integrated Research Literacy Group. He also receives some salary/research support from Cubed Biotech. MK is the Director of Ethnographic Studies at the Integrated Research Literacy Group. JB is the Clinical Advisor to The Mission Within, Journey Colab, Beond, Kaivalya Kollective, Tandava Retreats, Kernel, Woven Science, Brain Health Restoration, and Lionheart Ventures. LA has served as a Consultant, Speaker and/or Advisory Board Member for Guidepoint, Transcend Therapeutics, Beond, Source Research Foundation, Reason for Hope, Beond, The Cohen Foundation, Ampelis, and is owner of NPSYT, PLLC.

The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

The reviewer BS declared a shared research group 5 MEO Education with the author JB to the handling editor.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Author disclaimer

The authors do not condone the illegal use of any psychedelic substance, including 5-MeO-DMT.

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Keywords: 5-methoxy- N , N -dimethyltryptamine, 5-MeO-DMT, psychedelic therapy, post-traumatic stress disorder, PTSD, trauma, case report

Citation: Ragnhildstveit A, Khan R, Seli P, Bass LC, August RJ, Kaiyo M, Barr N, Jackson LK, Gaffrey MS, Barsuglia JP and Averill LA (2023) 5-MeO-DMT for post-traumatic stress disorder: a real-world longitudinal case study. Front. Psychiatry . 14:1271152. doi: 10.3389/fpsyt.2023.1271152

Received: 01 August 2023; Accepted: 03 November 2023; Published: 23 November 2023.

Reviewed by:

Copyright © 2023 Ragnhildstveit, Khan, Seli, Bass, August, Kaiyo, Barr, Jackson, Gaffrey, Barsuglia and Averill. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Anya Ragnhildstveit, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

Case Report
Open access
Published: 25 November 2008

A case of PTSD presenting with psychotic symptomatology: a case report

Georgios D Floros 1 ,
Ioanna Charatsidou 1 &
Grigorios Lavrentiadis 1

Cases Journal volume 1 , Article number: 352 ( 2008 ) Cite this article

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A male patient aged 43 presented with psychotic symptomatology after a traumatic event involving accidental mutilation of the fingers. Initial presentation was uncommon although the patient responded well to pharmacotherapy. The theoretical framework, management plan and details of the treatment are presented.

Recent studies have shown that psychotic symptoms can be a hallmark of post-traumatic stress disorder [ 1 , 2 ]. The vast majority of the cases reported concerned war veterans although there were sporadic incidents involving non-combat related trauma (somatic or psychic). There is a biological theoretical framework for the disease [ 3 ] as well as several psychological theories attempting to explain cognitive aspects [ 4 ].

Case presentation

A male patient, aged 43, presented for treatment with complaints tracing back a year ago to a traumatic work-related event involving mutilation of the distal phalanges of his right-hand fingers. Main complaints included mixed hallucinations, irritability, inability to perform everyday tasks and depressive mood. No psychic symptomatology was evident before the event to him or his social milieu.

Mental state examination

The patient was a well-groomed male of short stature, sturdy build and average weight. He was restless but not agitated, with a guarded attitude towards the interviewer. His speech pattern was slow and sparse, his voice low. He described his current mood as 'anxious' without being able to provide with a reason. Patient appeared dysphoric and with blunted affect. He was able to maintain a linear train of thought with no apparent disorganization or irrational connections when expressing himself. Thought content centred on his amputated fingers with a semi-compulsive tendency to gaze to his (gloved) hand. The patient was typically lost in ruminations about his accident with a focus on the precise moment which he experienced as intrusive and affectively charged in a negative and painful way. He could remember wishing for his fingers to re-attach to his hand almost as the accident took place. A trigger in his intrusive thoughts was the painful sensation of neuropathic pain from his half-mutilated fingers, an artefact of surgery.

He denied and thoughts of harming himself and demonstrated no signs of aggression towards others. Hallucinations had a predominantly depressive and ego-dystonic character. He denied any perceptual disturbances at the time of the examination. Their appearance was typically during nighttime especially in the twilight. Initially they were visual only, involving shapes and rocks tumbling down towards the patient, gradually becoming more complex and laden with significance. A mixed visual and tactile hallucination of burning rain came afterwards while in the time of examination a tall stranger clad in black and raiding a tall steed would threaten and ridicule the patient. He scored 21 on a MMSE with trouble in the attention, calculation and recall categories. The patient appeared reliable and candid to the extent of his self-disclosure, gradually opening up to the interviewer but displayed a marked difficulty on describing his emotions and memories of the accident, apparently independent of his conscious will. His judgement was adequate and he had some limited Insight into his difficulties, hesitantly attributing them to his accident.

He was married and a father of three (two boys and a girl aged 7–12) He had no prior medical history for mental or somatic problems and received no medication. He admitted to occasional alcohol consumption although his relatives confirmed that he did not present addiction symptoms. He had some trouble making ends meet for the past five years. Due to rampant unemployment in his hometown, he was periodically employed in various jobs, mostly in the construction sector. One of his children has a congenital deformity, underwent several surgical procedures with mixed results and, before the time of the patient's accident, it was likely that more surgery would be forthcoming. The patient's father was a proud man who worked hard but reportedly was victimized by his brothers, they reaping the benefits of his work in the fields by manipulating his own father. He suffered a nervous breakdown attributed to his low economic status after a failed economic endeavour ending in him being robbed of the profits, seven years before the accident. There was no other relevant family history.

Before the accident the patient was a lively man, heavily involved as a participant and organizer in important local social events from a young age. He was respected by his fellow villagers and felt his involvement as a unique source of pride in an otherwise average existence. Prior to his accident, the patient was repeatedly promised a permanent job as a labourer and fate would have it that his appointment was supposedly approved immediately after the accident only to be subsequently revoked. He viewed himself as an exploited man in his previous jobs, much the same way his father was, while he harboured an extreme bitterness over the unavailability of support for his long-standing problems. His financial status was poor, being in sick-leave from his previous job for the last four months following the accident and hoping to receive some compensation. Although his injuries were considered insufficient for disability pension he could not work to his full capacity since the hand affected was his primary one and he was a manual labourer.

Given that the patient clearly suffered a high level of distress as a result of his hallucinatory experiences he was voluntary admitted to the 2nd Psychiatric Department of the Aristotle University of Thessaloniki for further assessment, observation and treatment. A routine blood workup was ordered with no abnormalities. A Rorschach Inkblot Test was administered in order to gain some insight into patient's dynamics, interpersonal relations and underlying personality characteristics while ruling out any malingering or factitious components in the presentation as suggested in Wilson and Keane [ 5 ]. Results pointed to inadequate reality testing with slight disturbances in perception and a difficulty in separating reality from fantasy, leading to mistaken impressions and a tendency to act without forethought in the face of stress. Uncertainty in particular was unbearable and adjustment to a novel environment hard. Cognitive functions (concentration, attention, information processing, executive functions) were impaired possibly due to cognitive inability or neurological disease. Emotion was controlled with a tendency for impulsive behaviour; however there was difficulty in processing and expressing emotions in an adaptive manner. There were distinct patterns of aggression and anger towards others but expressing those patterns was avoided, switching to passivity and denial rather than succumbing to destructive urges or mature competitiveness. Self-esteem was low with feelings of inferiority and inefficiency.

A neurological examination revealed a left VI cranial nerve paresis, reportedly congenital, resulting in diplopia while gazing to the extreme left, which did not significantly affect the patient. The patient had a chronic complaint of occasional vertigo, to which he partly attributed his accident, although the symptoms were not of a persisting nature.

Initial diagnosis at this stage was 'Psychotic disorder NOS' and pharmacological treatment was initiated. An MRI scan of the brain with gadolinium contrast was ordered to rule out any focal neurological lesions. It was performed fifteen days later and revealed no abnormalities.

Patient was placed on ziprasidone 40 mg bid and lorazepam 1 mg bid. He reported an immediate improvement but when the attending physician enquired as to the nature of the improvement the patient replied that in his hallucinations he told the tall raider that he now had a tall doctor who would help him and the raider promptly left (sic). Apparently, the random assignment of a strikingly tall physician had an unexpected positive effect. Ziprasidone gradually increased to 80 mg bid within three days with no notable effect to the perceptual disturbances but with the development of akathisia for which biperiden was added, 1 mg tid. Duloxetine was added, 60 mg once-daily, in a hope that it could have a positive effect to his mood but also to this neuropathic pain which was frequent and demoralising. The patient had a tough time accommodating to the hospital milieu, although the grounds were extended and there was plenty of opportunity for walks and other activities. He preferred to stay in bed sometimes in obvious agony and with marked insomnia. He presented a strong fear for the welfare of his children, which he could not reason for. Due to the apparent inability of ziprasidone to make a dent in the psychotic symptomatology, medication was switched to amisulpride 400 mg bid and the patient was given a leave for the weekend to visit his home. On his return an improvement in his symptoms was reported by him and close relatives, although he still had excessive anxiety in the hospital setting. It was decided that his leave was to be extended and the patient would return for evaluation every third day. After three appointments he had a marked improvement, denied any psychotic symptoms while his sleep pattern improved. A good working relationship was established with his physician and the patient was with a schedule of follow-up appointments initially every fifteen days and following two months, every thirty days. His exit diagnosis was "Psychotic disorder Not Otherwise Specified – PTSD". He remained asymptomatic for five months and started making in-roads in a cognitively-oriented psychotherapeutic approach but unfortunately further trouble befell him, his wife losing a baby and his claim to an injury compensation rejected. He experienced a mood loss and duloxetine was increased to 120 mg per day to some positive effect. His status remains tenuous but he retains a strong will to make his appointments and work with his physician. A case conceptualization following a cognitive framework [ 6 ] is presented in Figure 1 .

Case formulation – (Persistent PTSD, adapted from Ehlers and Clark [ 6 ] ) . Case formulation following the persistent PTSD model of Ehlers and Clark [ 6 ]. It is suggested that the patient is processing the traumatic information in a way which a sense of immediate threat is perpetuated through negative appraisals of trauma or its consequences and through the nature of the traumatic experience itself. Peri-traumatic influences that operate at encoding, affect the nature of the trauma memory. The memory of the event is poorly elaborated, not given a complete context in time and place, and inadequately integrated into the general database of autobiographical knowledge. Triggers and ruminations serve to re-enact the traumatic information while symptoms and maladaptive coping strategies form a vicious circle. Memories are encoded in the SAM rather than the VAM system, thus preventing cognitive re-appraisal and eventual overcoming of traumatic experience [ 4 ].

The value of a specialized formulation is made clear in complex cases as this one. There is a relationship between the pre-existing cognitive schemas of the individual, thought patterns emerging after the traumatic event and biological triggers. This relationship, best described as a maladaptive cognitive processing style, culminates into feelings of shame, guilt and worthlessness which are unrelated to similar feelings, which emerge during trauma recollection, but nonetheless acts in a positive feedback loop to enhance symptom severity and keep the subject in a constant state of psychotic turmoil. Its central role is addressed in our case formulation under the heading "ruminations" which best describes its ongoing and unrelenting character. The "what if" character of those ruminations may serve as an escape through fantasy from an unbearably stressful cognition. Past experience is relived as current threat and the maladaptive coping strategies serve as negative re-enforcers, perpetuating the emotional suffering.

The psychosocial element in this case report, the patient's involvement with a highly symbolic activity, demonstrates the importance of individualising the case formulation. Apparently the patient had a chronic difficulty in expressing his emotions and integrating into his social surroundings, a difficulty counter-balanced somewhat with his involvement in the local social events which gave him not only a creative way out from any emotional impasse but also status and recognition. His perceived inability to continue with his symbolic activities was not only an indicator of the severity of his troubles but also a stressor in its own right.

Complex cases of PTSD presenting with hallucinatory experiences can be effectively treated with pharmacotherapy and supportive psychotherapy provided a good doctor-patient relationship is established and adverse medication effects rapidly dealt with. A cognitive framework and a Rorschach test can be valuable in deepening the understanding of individuals and obtaining a personalized view of their functioning and character dynamics. A biopsychosocial approach is essential in integrating all aspects of the patients' history in a meaningful way in order to provide adequate help.

Patient's perspective

"My life situation can't seem to get any better. I haven't had any support from anyone in all my life. Leaving home to go anywhere nowadays is hard and I can't seem to be able to stay anyplace else for a long time either. Just getting to the hospital [where the follow-up appointments are held] makes me very nervous, especially the minute I walk in. Can't seem to stay in place at all, just keep pacing while waiting for my appointment. I am only able to open up somewhat to my doctor, whom I thank for his support. Staying in hospital was close to impossible; I was very stressed and particularly concerned for my children, not being able to be close to them. I still need to have them near-by. Getting the MRI scan was also a stressful experience, confined in a small space with all that noise for so long. I succeeded only after getting extra medication.

I hope that things will get better. I don't trust anyone for any help any more; they should have helped me earlier."

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Abbreviations

stands for 'Post Traumatic Stress Disorder'

for 'Verbally Accessible Memory'

for 'Situationally Accessible Memory'

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Acknowledgements

The authors wish to acknowledge the valuable support and direction offered by the department's chair, Professor Ioannis Giouzepas who places the utmost importance in creating a suitable therapeutic environment for our patients and a superb learning environment for the SHO's and registrars in his department.

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GF was the attending SHO and the major contributor in writing the manuscript. IC performed the psychological evaluation and Rorschach testing and interpretation. GL provided valuable guidance in diagnosis and handling of the patient. All authors read and approved the final manuscript.

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Floros, G.D., Charatsidou, I. & Lavrentiadis, G. A case of PTSD presenting with psychotic symptomatology: a case report. Cases Journal 1 , 352 (2008). https://doi.org/10.1186/1757-1626-1-352

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DOI : https://doi.org/10.1186/1757-1626-1-352

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Post Traumatic Stress Disorder: PTSD Case Study: One Man's Journey

Abstract This paper is a case study on a client who has been diagnosed with Post Traumatic Stress Disorder (PTSD) from the Vietnam War. A narrative case description is included, which supports the clinical diagnosis and as well as an empirical treatment plan. The treatment plan has included the necessary identifying information with appropriate changes to shield the client’s real identity. The client was referred from the Veteran’s Administrative (VA) hospital in La Jolla, California. As part of the treatment plan the presenting problems will be identified and correlated to the criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition text revision (DSM-IV-TR) multi-axial diagnosis. This case study is based upon a holistic foundation, which includes the inter-connectedness of: the presenting problems, long-term goals, objectives, methods or interventions, treatment length, and measurement of potential outcomes. This paper concludes with a self-critique by the therapist regarding every aspect of the presented case study. Key Words: PTSD, Treatment Plan for Vietnam Vets, Holistic Foundation. Post-Traumatic Stress.

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Combat Stress in Pre-modern Europe pp 15–35 Cite as

Post-traumatic Stress Disorder: An Ancient Greek Case Study in Retrospective Diagnosis

Owen Rees 6
First Online: 01 November 2022

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Part of the book series: Mental Health in Historical Perspective ((MHHP))

Within socio-military history, the diagnosis of post-traumatic stress disorder has aroused a lot of attention, with many scholars claiming its existence in the pre-modern world while sceptics have challenged this claim in no uncertain terms. However, the debates surrounding historic PTSD have been made without due consideration of the wider medical history debates surrounding retrospective diagnosis of biological disease. There is a fundamental methodological challenge in that psychiatric diagnoses frequently emphasise behavioural symptoms, this in turn gives historians a twofold problem: (1) Can we know whether these behavioural symptoms are predominantly characteristic of our own social normality, and thus their observation by clinicians confirms simply antithetical and undesirous behaviours in the modern day? (2) If those same behaviours appeared in another cultural sphere do they still hold the same diagnostic capabilities? This chapter will focus on one such diagnosis, post-traumatic stress disorder, and address some of the pressing methodological issues surrounding such a practice.

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For discussion on this field of scholarship, and its tradition, see A. Cunningham, ‘Identifying Disease in the Past: Cutting the Gordian Knot’, Asclepio 54, 2002, 13–34; J. Arrizabalaga, ‘Problematizing Retrospective Diagnosis in the History of Disease’, Asclepio 54, 2002, 51–70; K.H. Leven, ‘“At Times These Ancient Facts Seem to Lie Before Me Like a Patient on a Hospital Bed”—Retrospective Diagnosis and Ancient Medical History’, in Manfred Horstmanshoff and Marten Stol (eds), Magic and Rationality in Ancient Near Eastern and Graeco-Roman Medicine (Leiden: Brill, 2004), pp. 369–86; A. Karenberg and F.P. Moog, ‘Next Emperor Please! No End to Retrospective Diagnosis’, Journal of the History of the Neurosciences 13.2, 2004, 143–49.

C. Thumiger, A History of the Mind and Mental Health in Classical Greek Medical Thought (Cambridge: Cambridge University Press, 2017), pp. 2–8.

N.M. Bark, ‘On the History of Schizophrenia: Evidence of Its Existence Before 1800’, New York State Journal of Medicine 88.7, 1988, 374–83; C.V. Haldipur, ‘Madness in Ancient India: Concept of Insanity in Charaka Samhita (first century A.D.)’, Comprehensive Psychiatry 25.3, 1984, 335–44; D.V. Jeste, R. del Carmen, J.B. Lohr, and R.J. Wyatt, ‘Did Schizophrenia Exist Before the Eighteenth Century?’, Comprehensive Psychiatry 26.6, 1985, 493–503; K. Otsuka and A. Sakai, ‘Haizmann’s Madness: The Concept of Bizarreness and the Diagnosis of Schizophrenia’, History of Psychiatry 15.1, 2004, 73–82; M.H. Stone, Healing the Mind: A History of Psychiatry from Antiquity to the Present (New York: W. W. Norton, 1997); H.A. Youssef and F.A. Youssef, ‘Evidence for the Existence of Schizophrenia in Medieval Islamic Society’, History of Psychiatry 7, 1996, 55–62; D. Fraguas, ‘Problems with Retrospective Studies of the Presence of Schizophrenia’, History of Psychiatry 20.1, 2009, 61–71.

Erwin H. Ackerknecht, ‘Psychopathology, Primitive Medicine and Primitive Culture’, Bulletin of the History of Medicine 14.1, 1943, 37.

E. DePoy and S.F. Gilson, Studying Disability: Multiple Theories and Responses (London: Sage, 2011), pp. 9–10, 96–97; Dana Lee Baker, The Politics of Neurodiversity: Why Public Policy Matters (Boulder: Lynne Reiner, 2011), pp. 12–5.

O. Rees, ‘We Need to Talk About Epizelus: PTSD and the Ancient World’, Medical Humanities 46.1, 2020, 46.

Edgar Jones and Simon Wessely, ‘War Syndromes: The Impact of Culture on Medically Unexplained Symptoms’, Medical History 49, 2005, 56.

D. Fraguas, ‘Problems with Retrospective Studies of the Presence of Schizophrenia’, History of Psychiatry 20.1, 2009, 62.

J. Shay, Achilles in Vietnam (New York: Athenaeum, 1994), pp. 166–69; L. Tritle, Melos to My Lai (London: Routledge, 2000), pp. 57–8.

J. Shay, ‘Moral Injury’, Intertexts 16.1, 2012, 57–66.

D. Fraguas, ‘Problems with Retrospective Studies of the Presence of Schizophrenia’, History of Psychiatry 20.1, 2009, 63.

In his follow up book Odysseus in America , 149, he makes the observation that combat adaptations may account of the symptoms of PTSD in the DSM , but equally advised his readers to go and read the list of symptoms themselves.

G.E. Berrios, ‘Classifications in Psychiatry: A Conceptual History’, Australian and New Zealand Journal of Psychiatry 33.2, 1999, 145–60.

C. Thumiger, A History of the Mind and Mental Health in Classical Greek Medical Thought (Cambridge: Cambridge University Press), pp. 72–3.

C. Thumiger, ‘The Early Greek Medical Vocabulary of Insanity’, in William V. Harris (ed), Mental Disorders in the Classical World (Leiden: Brill, 2013), pp. 61–4.

Aretaeus of Cappadocia, On Chronic Diseases , 1.6; Aetius, Iatrika , 6.8; W.V. Harris, ‘Thinking About Mental Disorders in Classical Antiquity’, in William V. Harris (ed), Mental Disorders in the Classical World (Leiden: Brill, 2013), pp. 1–2.

D. Fraguas, ‘Problems with Retrospective Studies of the Presence of Schizophrenia’, History of Psychiatry 20.1, 2009, 64.

J. Shay, Achilles in Vietnam: Trauma and the Undoing of Character (New York: Athenaeum, 1994), xx.

This pan-cultural, universalist model has led at least one team of researchers to use the ancient world to argue that the same is true of treatment: ‘it indicates that modern Western approaches to the psychological treatment of trauma are not entirely culturally dependent and may be applied to the treatment of trauma with patients from different cultural traditions.’—Y. Ustinova and E. Cardeña, ‘Combat Stress Disorders and Their Treatment in Ancient Greece’, Psychological Trauma: Theory, Research, Practice, and Policy 6.6, 2014, 746.

For a historical case study that examines the differing reception of the ‘traumatised’ warrior, see O. Rees, ‘We Need to Talk About Epizelus: PTSD and the Ancient World’, Medical Humanities 46.1, 2020, 46–54.

A. Young, The Harmony of Illusions (Princeton: Princeton University Press, 1995).

L.J. Kirmayer, ‘Confusion of the Senses: Implications of Ethnocultural Variations in Somatoform and Dissociative Disorders for PTSD’, in A.J. Marsella, M.J. Friedman, E.T. Gerrity, and R.M. Scurfield (eds), Ethnocultural Aspects of Posttraumatic Stress Disorder: Issues, Research, and Clinical Applications (Washington, DC: American Psychological Association, 1996), p. 150.

P.J. Bracken, ‘Post-modernity and Post-traumatic Stress Disorder’, Social Science & Medicine 53.6, 2001, 742.

S. O’Brien, Traumatic Events and Mental Health (Cambridge: Cambridge University Press, 1998), p. 5.

N. Metzger, ‘Railway Spine, Shell-shock and Psychological Trauma: The Limits of Retrospective Diagnosis’, in Eve-Marie Becker, Jan Dochhorn, Else Holt (eds), Trauma and Traumatization in Individual and Collective Dimensions: Insights from Biblical Studies and Beyond (Gottingen: Vandenhoek & Ruprecht GmBH, 2014), p. 56.

Jason Crowley, ‘Beyond the Universal Soldier: Combat Trauma in Classical Antiquity’, in P. Meineck and D. Konstan (eds), Combat Trauma and the Ancient Greeks (New York: Palgrave Macmillan, 2014), p. 117.

See for instance Thucydides, History of the Peloponnesian War 2.8, and similar sentiments expressed in the works of poets such as Pindar, fr. 110.

Walid Khalid Abdul-Hamid and Jamie Hacker Hughes, ‘Nothing New under the Sun: Post-traumatic Stress Disorders in the Ancient World’, Early Science and Medicine 19.6, 2014, 549–57.

J. Scurlock and Burton Anderson, Diagnoses in Assyrian and Babylonian Medicine (Chicago: University of Illinois Press, 2005), p. 349.

Ibid., p. 351.

L. Tritle, Melos to My Lai (London: Routledge, 2000), p. 59.

Ibid., p. 56.

Aislinn Melchior, ‘Caesar in Vietnam: Did Roman Soldiers Suffer from Post-traumatic Stress Disorder’, Greece & Rome 58.2, 2011, 216.

Homer, Iliad 16.65; 16.90; 16.836; 17.194; 17.224; 19.269; 20.351; 21.86; 23.5; 23.129.

Diodorus Siculus, Library 15.19.4.

Plutarch, Life of Agesilaus 35.3.

Diodorus Siculus, Library 15.50.5.

J. Roisman, ‘Klearchos in Xenophon’s Anabasis’, Scripta Classica Israelica , 8/9, 1985–1989, 50.

Xenophon, Anabasis 2.6.6.

Xenophon, Anabasis 2.6.7, 10.

Xenophon, Cyropaedia 2.1.22 (Translator Walter Miller, 1914). He repeats this sentiment in his Hellenica , 6.1.6.

Pericles: Plutarch, Life of Pericles 7.1. Alcibiades: Plutarch, Life of Alcibiades 18.1. Heracles: Isocrates, Helen 10.17.

S.S. Monoson, ‘Socrates in Combat: Trauma and Resilience in Plato’s Political Theory’, in P. Meineck and D. Konstan (eds), Combat Trauma and the Ancient Greeks (New York: Palgrave Macmillan, 2014), p. 134; B. Steinbock ‘Sufferings Too Great for Tears: The Destruction of the Athenian Expeditionary Corps in Sicily’, in Melanie Jonasch (ed), The Fight for Greek Sicily Society, Politics, and Landscape (Oxford: Oxbow Books, 2020), pp. 76–8.

Renato D. Alarcón, ‘Culture, Cultural Factors and Psychiatric Diagnosis: Review and Projections’ World Psychiatry 8, 2009, 131–39; Andrew Roderick Gilmoor, Adithy Adithy, and Barbara Regeer, ‘The Cross-Cultural Validity of Post-traumatic Stress Disorder and Post-traumatic Stress Symptoms in the Indian Context: A Systematic Search and Review’ Frontiers in Psychiatry 10.439, 2019; Guerda Nicolas, Anna Wheatley, and Casta Guillaume, ‘Does One Trauma Fit All? Exploring the Relevance of PTSD Across Cultures’, International Journal of Culture and Mental Health 8, 2015, 34–45.

The best discussions of this methodological issue are found in ‘Thinking About Mental Disorders in Classical Antiquity’, in William V. Harris (ed), Mental Disorders in the Classical World (Leiden: Brill, 2013), and C. Thumiger and P.N. Singer, ‘Introduction: Disease Classification and Mental Illness: Ancient and Modern Perspectives’, in C. Thumiger and P.N. Singer (eds), Mental Illness in Ancient Medicine: From Celsus to Paul of Aegina (Leiden: Brill, 2018), 1–32.

Or, as Otto Wahl observed, the common default is to portray a caricatured form of schizophrenia—Otto Wahl, Media Madness: Public Images of Mental Illness (New Brunswick: Rutgers University Press, 1995/2003), pp. 89–90.

C. Thumiger, A History of the Mind and Mental Health in Classical Greek Medical Thought (Cambridge: Cambridge University Press, 2017), p. 48.

B. Simon, ‘“Carving Nature at the Joints”: The Dream of a Perfect Classification of Mental Illness’, in William V. Harris (ed), Mental Disorders in the Classical World (Leiden: Brill, 2013), p. 37.

S. Minsky, W. Vega, T. Miskimen, M. Gara, and J. Escobar, ‘Diagnostic Patterns in Latino, African American, and European American Psychiatric Patients’, Arch Gen Psychiatry 60.6, 2003, 637–44.

B. Liddell and L. Jobson, ‘The Impact of Cultural Differences in Self-representation on the Neural Substrates of Posttraumatic Stress Disorder’, European Journal of Psychotraumatology 7:1, 2016, 1–13, https://doi.org/10.3402/ejpt.v7.30464 , accessed 22 December 21.

Arousal response: K.G. Martinez, J.A. Franco-Chaves, M.R. Milad, and G.J. Quirk, ‘Ethnic Differences in Physiological Responses to Fear Conditioned Stimuli’, PLoS One 9, 12, 2014, e114977, http://dx.doi.org/10.1371/journal.pone.0114977 , accessed 22 December 21.

Amygdala: B. Derntl, U. Habel, S. Robinson, C. Windischberger, I. Kryspin-Exner, R.C. Gur, and E. Moser, ‘Culture But Not Gender Modulates Amygdala Activation During Explicit Emotion Recognition’, BMC Neuroscience 13, 2011, 54; J.Y. Chiao, T. Iidaka, H.L. Gordon, J. Nogawa, M. Bar, E. Aminoff, N. Sadato, and N. Ambady, ‘Cultural Specificity in Amygdala Response to Fear Faces’, Journal of Cognitive Neuroscience 20.12, 2008, 2167–74.

American Psychological Association, Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry (2013 edition), 7.3: ‘it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.’

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My thanks to my fellow editors for their feedback on this chapter, and also to Dr Jo Edge who read an earlier draft and gave me invaluable comments.

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Rees, O. (2022). Post-traumatic Stress Disorder: An Ancient Greek Case Study in Retrospective Diagnosis. In: Rees, O., Hurlock, K., Crowley, J. (eds) Combat Stress in Pre-modern Europe. Mental Health in Historical Perspective. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-031-09947-2_2

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v.9(3); 2018 Sep

A Case Study of the Effects of Posttraumatic Stress Disorder on Operational Fire Service Personnel Within the Lancashire Fire and Rescue Service

Associated data.

Lancashire Fire and Rescue Service (LFRS), the subject of this evaluative research document employs 1400 people. 80% of employees are operational firefighters and officers whom operate across a range of duty systems and support functions, providing prevention, protection and emergency response to the communities of Lancashire.

The overarching purpose of this epidemiological study is to assess the prevalence of post-traumatic stress disorder (PTSD) amongst operational LFRS personnel and to analyse the effects upon those who may be suffering from it, whether brought about by a single traumatic event or by repeated exposure to traumatic occurrences over a period of time. A combination of primary and secondary research was carried out. Primary data was collated using two recognised clinical questionnaires and statistical analysis was conducted with the aid of the software package SPSS.

The findings and statistical analysis showed that out of the 100 people surveyed, 30% of respondents had signs of probable distress. Of this quota, 4% showed symptoms of PTSD. The study considers how an organisation can recognise and manage PTSD and provides recommendations to assist in better recognising and managing the associated risks.

Based upon the findings, the authors conclude that the level of PTSD within LFRS is slightly lower than those found in other studies undertaken within the Fire and Rescue Service sector. The paper provides recommendations for future studies and a series of actions for consideration by LFRS senior management to improve PTSD support services for employees.

1. Introduction

1.1. background.

Fire and Rescue Service operational personnel are often exposed to highly pressured, dynamic, and rapidly evolving situations. The work can be extremely demanding, both physically and psychologically [2] . During their careers, most personnel will, at some point, be subjected to particularly traumatic and often tragic events [3] , and evidence suggests that most firefighters' mortality and morbidity are related either directly or indirectly to the stressful nature of their work [4] .

A study undertaken by Dahlan et al [5] reported that past traumatic incidents were the highest ranked source of stress among UK firefighters. For the purpose of this article, the definition of a traumatic event (or incident) is taken to be “an event that involves actual or threatened death or serious injury; a threat to the physical health of self or others in which the person felt frightened, horrified, and helpless” [6] .

Some earlier studies argue that firefighters are at increased risk of developing a variety of psychological, social, and physical reactions [7] , [8] , [9] , [10] , [11] , [12] , one of which is the condition known as post-traumatic stress disorder (PTSD). According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association) [13] , the essential feature of PTSD is the development of characteristic symptoms after exposure to an extremely traumatic event or a stressor, which may manifest in feelings of arousal, intrusion, and avoidance. Linked to this trauma exposure a number of other common health sequelae, such as alcohol and drug abuse, depression, anxiety, and suicide [5] , [14] , are frequently documented

Few empirical studies have systematically examined the cause and effect of work stresses affecting firefighters [5] . However, a number of authors have studied the prevalence rates of PTSD among firefighters and reported wide variances, from 6.5% [15] to 37% [16] , but the sample size, profile, and measures used differed from one report to another [3] .

Baker and Williams [17] also determined that individuals in different ranks reported differing levels of both organizational and operational stress (with those at “Leading Firefighter”, now known as the “Crew Manager” role, reporting the highest levels). Significantly, they also identified that those persons reporting higher levels of psychological distress also reported lower levels of confidence. This then raises the question of a potential link to fireground competency and safety.

Within Lancashire Fire and Rescue Service (LFRS) and neighboring counties, anecdotal evidence suggests that psychological impacts are acknowledged and receive attention through services such as occupational health; however, conditions such as PTSD tend to remain low profile, with minimal visibility and little or no education or awareness being raised among staff. This is a very different situation to the United States where a recent article published in the NFPA Journal [14] , entitled “Trouble in Mind”, highlighted a growing problem of firefighter suicides (c.360 from 2000 to 2013; with a notable increase, more recently, of sixty in both 2012 and 2013). The more worrying aspect, however, is that the information used within the article is based solely on voluntary submissions, and therefore, the actual numbers could be significantly higher. Wilmoth [18] agrees with this standpoint, citing a stigma that makes it difficult for emergency responders to admit to behavioral issues linked to PTSD.

The view that firefighters are “rough and tough and can take on anything that the world can dish out” [19] is a common theme across the evidence base used in the preparation of this article. Haslam and Mallon [15] recognized this situation, explaining that the culture is one of nonadmission, whereas Baker and Williams [17] explain the culture as being one of stoicism and self-discipline, in which the very armor that firefighters use to protect themselves mentally could also be the blocker to maintaining their own mental health. Haslam and Mallon [15] concluded that many respondents felt unable to seek support within the workplace because of the macho image associated with the job; this is a position that is commonly inferred in many case studies [20] , [21] , [22] .

Of equal significance are the organizational impacts that may arise as a result of PTSD cases, such as depression, anxiety, and substance abuse to name a few, going undiagnosed or misdiagnosed [6] . All these can result in extended periods of staff absence, increased health and safety risks, resignations, dismissals, or claims against employers [23] .

This study aims to outline the effects that traumatic events may have on an individual, determine the various factors, which may result in symptoms being exhibited, and specifically consider the prevalence of PTSD within LFRS. It will provide evidence of how the FRS sector locally, nationally, and internationally is prepared to deal with such effects on their staff and assesses the adequacy of the services provided.

To achieve this, the study will focus on the published work on PTSD to provide appropriate definitions and determine signs and symptoms. These may present after traumatic short-term exposure or after repeated exposure to lower level incidents over more prolonged periods [24] . It will consider causal factors and investigate variables, which may or may not result in an individual developing PTSD.

1.2. Study significance

This study investigates the prevalence of PTSD among the operational LFRS personnel. Its significance lies in the insights it offers to the public sector organizations and its management in which their employees deal with traumatic and life-threatening events with the potential health risks of PTSD. The management structure of these organizations need to be aware of the range of the health conditions that might manifest as a result of exposure to these extreme traumatic events and as a result must be able to put into place programs of rehabilitation when necessary.

1.3. The problem

PTSD is defined by the National Institute for Health and Care Excellence [25] as “a disorder that develops in response to a stressful event or situation of exceptionally threatening or catastrophic nature (e.g., assault, road accident, disaster, or rape)”. It is the term used by psychiatrists to describe reactions that clinically cause significant impairment or distress within the functioning of people [6] .

PTSD is clinically diagnosed by meeting the criteria in the DSM-V [26] . According to the DSM-V, the diagnosis of PTSD requires exposure to an event that involved or threatened death, violence, or serious injury. It may be firsthand (primary exposure) but can also result from a third party trauma and the human desire to want to help another, known as secondary stress. Table 1 shows PTSD exposure sources and symptoms.

PTSD exposure sources and symptoms—World Health Organization and DSM-V

DSM-V, Diagnostic and Statistical Manual of Mental Disorders; PTSD, posttraumatic stress disorder.

For a diagnosis to be made, these symptoms need to be impacting significantly on an individual's ability to function with a level of normality [26] for a period longer than 1 month [6] . The characteristics have been recognized in previous studies [28] as frequently manifesting in symptoms of reexperiencing, avoidance, and arousal.

1.4. Study area

Lancashire is a coastal county, bordered to the north by Cumbria, to the south by Merseyside, and to the east by North and West Yorkshire and the metropolitan county of Greater Manchester. It comprises 14 local authority areas, covering 1,189 square miles and has an estimated population of c. 1.5 million people [29] . This study will be conducted with data gathered from a cross section of 1,100 LFRS operational staff who operate countywide from 41 locations on a variety of shift systems see Table 2 :

Table 2

LFRS shift systems

LFRS, Lancashire Fire and Rescue Service.

The shift system worked at each location is depicted within the map shown below in Fig 1 :

An external file that holds a picture, illustration, etc.
Object name is gr1.jpg

LFRS locations and duty systems. LFRS, Lancashire Fire and Rescue Service.

The study compares the prevalence of PTSD levels within the LFRS sample of 150 people against the quoted lifetime prevalence levels of c.10.4% for women and 5% for men [6] (the variance between genders is thought to be due to exposure to different types of events and different ways of coping).

1.5. Study purpose

1.5.1. aims.

• To determine the extent of the prevalence of PTSD among operational personnel from LFRS.
• To investigate a range of variables that may affect the development of PTSD.
• To make recommendations to the LFRS that aims to mitigate threats derived from PTSD among firefighters.

1.5.2. Objectives

• To gain an understanding of the variations of PTSD among staff from LFRS and the effect of different contributory factors.
• To use a variety of statistical techniques to present and analyze the variations.
• To use a range of different modeling techniques to explore the significance of a number of variables.

2. Materials and methods

2.1. literature review.

This literature review explores existing literature on the topic of PTSD and the factors that may lead to its development. The findings of this review shape the remainder of this case study and enable conclusions to be considered alongside the findings of previous studies.

2.1.1. Child involvement

In traumatic events faced by firefighters, a common theme was the involvement of children in incidents. Clohessy and Ehlers [24] identified that such incidents were often perceived as the most stressful and frequently lead to intrusive memories. Boxer and Wild [30] , Baker and Williams [17] , and Haslam and Mallon [15] identified that reports of children being involved/killed were the highest ranked stressors. Haslam and Mallon [15] cited more than 50% of respondents as being emotionally upset when reminded of the incident, with 33% having upsetting thoughts or images and 25% with sleep-related problems. Commonly cited reasons were that “it was a waste of a life” or that “familiarity” was a feature (i.e., the firefighter having children of his/her own). The second most traumatic aspect was purely the witnessing of gore, death, or a human undergoing severe pain and suffering [15] . Frequently respondents in such studies refer to thoughts of “I should have done more” and feelings of guilt and helplessness [28] .

2.1.2. Coping strategies

No one knows in advance how they will react to a particular stressful event, [6] but crisis theory states that when a stressful event takes place, balancing factors can be implemented which can help one regain a sense of equilibrium [31] .

Moran and Colless [32] suggest that coping is the most significant variable in being able to predict an individual's psychological well-being. However, wider factors such as what was happening in a person's life before the event (family difficulties, bereavements etc.) may also play a part in their ability to cope [6] . Equally, it is acknowledged that events which may cause emotional upset to one person may not have the same impact on others and that people will adapt in different ways to their environment [5] .

Moran and Britton [33] found that their sample of emergency workers was in fact “no hardier than most nor did they possess any particular coping styles”. In fact, their research supported the earlier findings of Kessler et al [34] whose study found little evidence to support intervention types that aim to aid coping efforts to master, tolerate, or reduce demands of fire service stress.

Moran [35] surmised that firefighters frequently describe their approach to emergency work as being a case of having a job to do and simply getting on with it. Various writers have referred to this phenomenon as “the employing of a professional armor” [17] or “the trauma membrane” [36] .

Lou [37] suggested that coping behaviors are key factors in the link between managing stress and levels of job satisfaction achieved by individuals. This study provided evidence to support the somewhat logical rationale that a firefighter who can manage his/her stressors is likely to be happier in his work. Dahlan et al [5] drew a similar conclusion that a firefighter's ability to cope is actually more important and relevant to their effectiveness than their levels of personal motivation.

2.1.3. Informal social support

A number of studies have been undertaken to consider the importance of informal social support (i.e., postincident discussions and debriefing) within the FRS context. Fullerton et al [9] suggested that the use of humor can increase social support and relieve stress [38] , [39] . In effect, it acts as a safety valve to release tension. This is a situation that occurs frequently in most fire stations around the country and indeed overseas in developed countries such as Canada [40] .

Interestingly however, while concluding that high levels of social support may ostensibly buffer firefighters from PTSD, Haslam and Mallon [15] identified that in most cases, the respondents relied on their partners to be their listener and relief mechanism. This offers a contrary opinion to the personal view of Meroney [21] who indicated that the stress of the job and associated traumatic effects were somewhat normalized and effects were never discussed at home.

Mitani et al [41] and Prag [42] postulate that social support improves the ability to manage stress and is effective in reducing burnout. It also reduces PTSD symptoms of fire service workers [42] . Boscarino et al [43] and Jonsson and Segesten [44] both support this view.

Conversely, Harris et al [45] consider that seeking treatment for personal mental health issues within the context of coworkers and the workplace, generally, may not be the most conducive way to achieve results, and Dahlan et al [5] found during their study that the fostering of positive attitudes was actually the key contributing factor to their participants' health and well-being. This indicates that there is no firm conclusion as to what is the most useful way to support staff after traumatic incidents happen, and further investigations would be useful.

2.1.4. Common physiological responses

Haslam and Mallon [15] found that PTSD symptoms frequently manifested (33%) in the form of trouble sleeping, bad dreams, and reoccurring nightmares. Interestingly, almost double (65%) shared feelings of rumination, that is, they worried about, or visualized, the same event happening to themselves or members of their family ( [15] ). In the same study, 33% of respondents experienced, or had thoughts of, avoidance (e.g., taking a detour from a particular route to not pass a location or avoid a particular type of activity or smell which may remind them of the event). Such visual stimuli/smells are characteristic of PTSD [15] , [46] .

While Joseph et al [47] and Ingledew and Cooper [48] determined that those exhibiting avoidance behaviors are more likely to be suffering greater psychological distress, Raphael et al [8] explained that avoidance was more likely to be a defense mechanism. Substance abuse and addictive behaviors such as eating, smoking, pornography, extreme exercising, shopping, gambling, and sex/love addiction are other functions commonly cited as being indicative of PTSD [9] , [14] , [19] , [24] .

2.1.5. Age, length of service, and exposure

This factor has two clear viewpoints. The first is that the age and length of service are both protecting mechanisms. Mitani et al [41] reason that fire service workers with a long work history exhibit lower job stressors because they have learned skills that enable them to cope; essentially, they desensitize. They also considered that years of service moderate various job-related stressors which is similar to a view shared by Hytten and Hasle [49] that “seasoned emergency workers possess more effective cognitive and behavioral coping strategies”.

Conversely, there are counter arguments; Corneil [50] reported a positive relationship between years of service and PTSD, while Baker and Williams [17] also found it unsurprising that junior officers (who experienced and responded first to the majority of incidents) reported higher incident-related stress levels.

Moran and Britton [33] found that length of service as a volunteer firefighter was positively associated with both severity and chronicity of psychological reaction, citing possible reasons as less preparatory training or frequency of exposure when compared with the whole-time counterparts.

Contrarily, Beaton et al [12] found no evidence of “seasoning” in their study, nor did they find a correlation between years of service and PTSD.

2.1.6. Selection

Mitchell and Bray [51] posited that selection acts as a factor on PTSD vulnerability, and more attention needs to be paid when selecting new entrants. They shared a view that firefighters are undoubtedly a self-selected occupational group and, therefore, may not be representative of the general population in terms of personalities or coping strategies. Harris and Stacks [52] cite data from the Federal Emergency Management Agency survey that suggests that firefighters are overall a healthy group in terms of predisposition to mental health issues.

2.1.7. Alcohol and substance abuse

The World Health Organization [53] defines substance abuse as the harmful or hazardous use of psychoactive substances including alcohol and illicit drugs. Substance abuse may be regarded as just one of many forms of addiction (highlighted earlier).

Boxer and Wild [30] examined whether a link existed between psychological distress and alcohol use among firefighters. On considering the various stressors used in the self-report instruments, they found that, of the 145 participants, between 33% and 41% showed evidence of significant psychological distress, and of these, 29% had possible or probable problems with alcohol use. This compared to a US adult norm of around 13%. However, when logistic regression analysis was undertaken, no link was established between alcohol use and the 10 most highly ranked work stressors:

➢ Hearing that children are in a burning building
➢ Being concerned about possible exposure to unknown toxic substances
➢ Being concerned about exposure to AIDS, hepatitis, tuberculosis, etc.
➢ Believing that reverse prejudice exists toward nonminority groups
➢ Being disturbed by tone or intensity of bells
➢ Feeling responsible for other peoples' lives
➢ Feeling a lack of support from the local government
➢ Feeling that the public has the wrong idea of what firefighting work involves
➢ Feeling that there is insufficient manpower to deal with the workload
➢ Feeling overutilized for emergency medical service runs for nonemergency purposes.

This study failed to examine any further, whether the cumulative effect of repeated exposure could form the underlying reason for the higher levels of alcohol use among firefighters.

By comparison, the National Volunteer Fire Council [19] in the United States undertook a study and, while not directly diagnosing alcoholism among participants, did highlight that 42.5% (male) and 60% (female) respondents had engaged in binge-drinking activities in the previous 30 days. This formed a call for vigilance within the sector.

Boxer and Wild [30] cited a phenomenon known as the “healthy worker effect” that postures that among firefighters, healthier staff enter the workforce and remain employed whereas less healthy personnel may be derepresented either due to sickness or leaving the service, therefore presenting a form of selection bias. In essence, one could then postulate that the real levels of substance abuse may be considerably higher and that the same phenomenon may be applicable to PTSD too.

2.1.8. Formal debriefing/mental health professionals

A “critical incident” can be described as being exposed to personal loss or injury, traumatic stimuli, mission failure, or human error [45] . Such experiences have previously been reported to be capable of overwhelming a firefighter's normal ability to cope [51] , [54] .

Critical incident stress management originated in the United States in the 1980s as a peer support intervention for emergency service workers [6] . One component part of critical incident stress management was Critical Incident Stress Debriefing [54] , also commonly referred to as psychological debriefing [55] or critical incident debriefing (CID) [6] .

CID is a peer counseling group procedure with psychoeducational aspects which aims to deliver information on stress reactions after exposure to critical incident(s) [54] . Ideally, the CID is held between 72 hours and 14 days after incident [6] and aims to prevent psychological damage [56] .

The concept is generally credited to the work of Jeffrey Mitchell [54] and thereafter Mitchell and Everly [57] and is led by one mental health professional, supported by trained sector peers [57] . The seven-step approach [6] , [57] aims to teach the recipients about their stress reaction:

➢ Facts
➢ Thoughts
➢ Reactions
➢ Normalization
➢ Future planning
➢ Coping
➢ Disengagement

It also aims to enable individuals and groups to have their needs assessed and receive practical support to reduce psychological distress post exposure [58] . CID aims to promote and facilitate recovery and develop/enhance natural resilience [6] .

Sessions last for 1.5–3 hours and start with materials that the participants are more comfortable discussing before entering into more emotionally intense dialogs. The session is brought to a close with psychoeducational input.

While in widespread use, CID has its critics. Harris et al [45] refer to the rapid increase in the provision of CID services among operational and nonoperational personnel but point out that there is little empirical evidence of the effectiveness of CID, a point also made by Rose et al [58] . Harris et al [45] report a number of studies [59] , [60] , [61] that have made assumptions based on relatively small sample sizes and posture a hypothesis that CID has no effect on PTSD. Similarly, Rose et al [58] cite other such reports [62] , [63] , [64] . These quote variables significantly affect the outcomes, examples being a lack of clarity on which disorders CID is intended to improve; a lack of evidence on the level of disorders which requires large-scale interventions; and a lack of evidence that correlates intervention with outcomes [62] , [63] , [64] .

Rose et al [58] noted that the timing of such a debrief also has relevance because the prevalence of initial distress is much higher than that of PTSD, and therefore, owing to the short timescales involved in delivery, the potential exists that interventions (involving confronting distressing experiences) may be delivered needlessly to participants whose short-term symptoms may otherwise rapidly subside. They expressed a view that the use of single-session debriefing “cannot be recommended in either military or civilian life” and that CID did not prevent the onset of PTSD nor did it reduce any psychological distress, morbidity, depression, or anxiety, instead suggesting that it may increase the risk of PTSD and depression. Their recommendation was an endorsement of the National Institute for Health and Care Excellence (2005) approach of “screen and treat”.

Hytten and Hasle [49] found that there was no difference between those formally debriefed and those who received social support by chatting to colleagues.

Regel and Joseph [6] refute the critics of CID on the basis that only two studies may have had any such relevance, and in both cases, the participants were not of the groups that the interventions were intended for (i.e., one was a fire casualty and one from a road traffic collision). They also refer to flaws in methodologies used for those studies. They instead argue that a number of studies exist which do demonstrate positive outcomes from CID.

2.1.9. Recovery

Regel and Joseph [6] explained a concept of how individuals sometimes deal with their exposure to traumatic events. They likened it to a “hurriedly and poorly packed bag that when banged against something could burst open”, resulting in the psychological effects associated with PTSD. As recognized leading writers in this field, Regel and Joseph [6] explain that persons can “unpack and repack the bag in several ways” to make it better and produce a situation where one can “look into the bag” without any undue distress:

• Using numbness—a remoteness approach whereby only limited and gradual feelings are encountered;
• Reconsidering—try to make sense of what happened and rationalize it;
• Receiving physical and emotional support from others—benefits from informal social support;
• Monitoring own behavior/avoidance behaviors—confronting a situation but at a scale and speed that are not detrimental;
• Taking time out to process thoughts fully and avoid “packing the bag too hastily”;
• Physical exercise—to maintain psychological well-being;
• Effecting an early return to normal routines and considering new interests—although not so as to distract or prevent healing.

This literature review has examined the concept of PTSD and the various factors that may lead to the condition arising. It has also offered detail on why some people appear to be more at risk of succumbing to PTSD than others and why some are able to cope more effectively in the aftermath of a traumatic event.

Importantly, this review has also provided insight into protective factors, support mechanisms, and the arguments that continue to exist on the benefits and limitations of each.

The areas discussed within this literature review will be considered further in the context of an in-depth analysis into the potential prevalence of PTSD among LFRS staff. It allows for an academic approach to be adopted and enables a comprehensive study into the risk posed to LFRS and the suitability of current arrangements that are in place to manage PTSD risk.

2.2. Methodology

2.2.1. introduction.

The first step was to conduct secondary research on PTSD which was carried out through the university search engine known as Scopus and through various internationally based organizations, such as the World Health Organization, etc. This was to collect various standpoints, opinions, and hypotheses that could be explored.

A level of knowledge and understanding was then reached by the researcher whereby opinions and perspectives could be discussed and either substantiated or rebuffed by virtue of the case studies, reports, and texts that were available. This enabled the researcher to remain objective throughout the study to differentiate fact from supposition or opinion.

The next stage was to conduct quantitative research in the form of questionnaires to establish the prevalence of PTSD within LFRS. Kienzler and Pedersen [65] advise that almost every trauma-related study should include some measures of PTSD symptoms to provide information about how respondents view their symptoms in a context that is not influenced by direct interaction with an interviewer.

It should be noted that although a number of different measures of PTSD exist, no single measure can definitely determine whether or not an individual has PTSD; instead, multiple measures should be administered [66] . Therefore, the adopted methodology was to settle on the use of two recognized clinical questionnaires. Solomon et al [66] stated that with the help of self-report instruments, response accuracy may be increased, especially for those informants who are reluctant to reveal their experiences to another person directly.

While a number of historic USA-derived screening tools were available, the development of culturally sensitive psychological tests and symptom checklists for assessing anxiety and depression is promoted [67] . These include among others the Impact of Event Scale–Revised, the General Health Questionnaire-28 (GHQ-28), the Harvard Trauma Questionnaire, the Hopkins Symptom Checklist-25, and the Posttraumatic Stress Disorder Symptom Scale (PSS). Accordingly, the GHQ-28 and PSS questionnaires were subsequently selected.

2.2.2. General Health Questionnaire

The GHQ-28 [68] is used to indicate psychological well-being and detect possible cases of psychiatric disorders (psychiatric morbidity) [69] . The reason for using this questionnaire was to identify aspects of poor physical health [70] and problems in intimate and family relationships [71] which are frequently associated with PTSD.

The GHQ-28 is commonly used as a community-screening tool and for the detection of nonspecific psychiatric disorders among individuals in primary care settings [65] . It is a self-report instrument comprising four subscales measuring somatic symptoms (physical rather than psychological), anxiety/insomnia, social dysfunction, and severe depression. It has been recommended in previous studies for screening trauma victims [8] , and although developed in the United Kingdom, it has been widely employed in other countries (translated into c.38 languages and >50 validity studies completed) [68] .

A number of different scoring systems can be applied, but for the purposes of this study, the preferred Likert scale was applied (0-1-2-3) [72] to the descriptive answers. This produces a maximum score of 84 across the 28 questions.

2.2.3. Posttraumatic Stress Disorder Symptom Scale

The PSS consists of two pages; the first is essentially a set of “qualifying questions” which lists a set of traumatic events or situations. Page 2 details 17 further questions that diagnose PTSD according to DSM criteria and assess the severity of PTSD symptoms. Questions are grouped around “reexperiencing” (5 questions), “avoidance” (7 questions), and “arousal” (5 questions). Under DSM, PTSD is diagnosed if at least one reexperiencing, three avoidance, and two arousal symptoms are revealed (at a rating of 2 or 3). The exposure had to have taken place more than one month before. As per the GHQ, these questions are answered using the Likert scale with the maximum score across the 17 questions being 51, representing the total severity score [1] . This allows the PSS to be used as either a categorical or dimensional measure. Where this questionnaire differs from the GHQ-28 is in the scoring descriptors of “0 = Not at all”, “1 = Once per week or less/A little bit/Once in a while”, “2 = 2–4 times per week/Somewhat/Half the time”, “3 = 3–5 or more times per week/Very much/Almost Always”; these were altered to reflect the same scoring descriptors used within the GHQ-28. This was to make interpretation and analysis of the results more consistent.

Although the application of the PSS for emergency service workers has been limited in other studies, it is frequently referred to as being used for circumstances such as rape victims; for this reason access to psychometric data for such samples was also very limited; nonetheless, the questionnaire draws some correlations with aspects considered under the GHQ-28. A modified version of this scale exists which includes both frequency and intensity ratings. This allows assessment of symptoms related to multiple traumatic events [66] , and perhaps, this assessment type could also be a useful alternative to the PSS.

2.3. Collection of data

Operational staff were approached during the late 2014 and early 2015 and asked to provide consent to participate. Stations, watches, or groups who offered willingness to participate were then sent copies of the consent form, GHQ-28 and PSS for completion privately and confidentially. To ensure anonymity, completed questionnaires were return mailed in a self-addressed envelope to the authors. From this point, the completed returns were kept securely stored and not shared with third parties.

The aim was to collect 150 responses representing 13.5% of the operational workforce; 100 responses were returned. This number is lower than expected, possibly due to unwillingness to assist in the study because of ongoing industrial action over pension changes within the UK FRS.

Responses came from a cross section of the operational staff; however, it should be noted that LFRS, in common with most other UK FRS, remains a predominantly male environment (c.96%), but no specific reference was made to gender, ethnicity, or age; therefore, these factors will be outside of the scope of this study.

2.4. Analysis of data

Once the data were collated, statistical analysis using a combination of thematic and graphical analysis was then completed. In addition, appropriate for our case study was to use descriptive and summary statistics such as the mean and standard deviation to indicate what the average numbers and variations for different phenomena were, so as to determine if relationships existed.

On completion of the analysis, the findings were then compared with observations from other literature sources to determine how our results fitted with their findings. The outcomes of this analysis are discussed in the remainder of this article along with the conclusions that were drawn.

3. Results and discussion

3.1. general health questionnaire.

Within the range of 0–84, a score of 23 or 24 is deemed to be the threshold for the presence of distress [73] . For this study, a total score of 23 or above has been taken as being the baseline. Of the 100 persons sampled, 30 individuals showed probable signs for the presence of distress (30%). The GHQ results are divided into four sections based on the subject headings within the questionnaire:

A. Somatic Symptoms
B. Anxiety/Insomnia
C. Social Dysfunction
D. Severe Depression

The results collected have provided ordinal data that produce greater opportunities for analysis because it not only classifies subjects but also ranks them in terms of the degree to which a characteristic is present [74] . Table 3 shows the results of the respective surveys and the analysis following it. Generally, categories 0 and 1 are positive responses i.e., no real change from before, and categories 2 and 3 are negative response i.e., a bigger change than normal.

Table 3

Responses to the General Health Questionnaire (GHQ-28)

Within Section A (Somatic Symptoms), the first four questions tend toward psychological symptoms whereas the other three relate more toward physical symptoms. The questions which provoked the most negative responses were A1, A2, and A3 with question A3 “Feeling run down and out of sorts” and A2 “Been feeling in need of a good tonic” presenting the highest negative responses (26%). Question A5 “Been getting any pains in your head” and A7 “Been having hot or cold spells” received answers of a “0” or “1” (90%) which for the purpose of this survey have been classed as positive responses. In summary, Section A showed that there is a prevalence of more psychological symptoms than physical, and these represent a situation that is worse than the norm.

Within Section B (Anxiety/Insomnia), the first two questions relate to insomnia and the remainder to anxiety. Question B2 “Had difficulty in staying asleep once you are off” had the highest proportion of negative responses (36%) followed by B3 “Felt constantly under strain” and B4 “Been getting edgy and bad-tempered,” both scoring 26%. It is worth noting that B3 scored the highest number of the most negative response “Much more than usual” (10%).

Section C (Social Dysfunction) is a measure of the impact of PTSD on an individual's ability to conduct normal social interactions. For all questions, most responses were positive with respondents either “Better than usual” or “Same as usual” (responses ranging from 82% to 98%). In summary, most responses were of a positive nature when compared with the other sections of the GHQ-28.

Most questions within Section D (Severe Depression) scored a “0” or “1”. Owing to the serious nature of the questions, this is expected. The question with the most notable response was D1, “Been thinking of yourself as a worthless person,” with 30% of respondents scoring a “2” or “3,” which being a significantly higher negative response than normal.

It was also notable that the number of respondents to D6 “Found yourself wishing you were dead and away from it all” had no negative responses, whereas D7 “Found that the idea of taking your own life kept coming into your mind” had two negative responses (termed as “Has crossed my mind”). In summary, the vast majority of responses within this section were of positive nature.

3.2. Posttraumatic Stress Disorder Symptom Scale

Given that the responding group was operational fire service personnel, it was expected that many would answer positively to having experienced or witnessed the “qualifying” situations listed on page 1 of the questionnaire, and indeed, this was so in 100% of occasions.

As previously discussed, the PSS questionnaire's questions can be divided into three sections: reexperiencing, arousal, and avoidance. Table 4 shows the results and analysis of the following categories.

0 Not at all
1 Once per week or less/a little bit/once in a while
2 2–4 times a week/somewhat/half the time
3 3–5 or more times a week/very much/almost always

Table 4

Responses to the Posttraumatic Stress Disorder Symptom Scale (PSS) questionnaire

The first five questions summarize the questions relating to reexperiencing from the PSS. Most respondents scored 0, “Not at all” for most questions, with approximately 7% of the sample scoring 2–3 relating to “Rather more than usual” and “Much more than usual”.

For the avoidance questions 6–12, most respondents scored 0, “Not at all”. Approximately 7% of the sample scored 2–3 relating to “Rather more than usual” and “Much more than usual”. This was similar to that seen for the reexperiencing questions.

The arousal questions 13–17 saw the highest number of respondents scoring 2–3 “Rather more than usual” and “Much more than usual” compared with the other sections with approximately 13% of the sample.

For the final part on the questionnaire, the results are given in Table 5 .

Table 5

Positive responses for “Have any of the above problems interfered with the following?”

To summarize, arousal saw the largest variation in responses with more respondents scoring “2” “Rather more than usual” or “3” “Much more than usual” than in the other sections. Reexperiencing saw the least variation with most respondents scoring “0” “Not at all”. These results will be discussed further in the following sections.

The analysis has been divided into two sections, first the GHQ-28 and then the PSS.

3.3. General Health Questionnaire

From looking at the results of the GHQ-28, it was decided to divide the findings into three sections corresponding to physical symptoms, positive emotions, and negative emotions. This was to determine how the most significant symptoms manifest in the most significant emotions. The categories are shown in Table 6 below:

Table 6

Categories applied to GHQ-28 questionnaire results

GHQ, General Health Questionnaire.

To determine the most significant variables, the average number of negative responses from the GHQ-28 has been calculated by adding together those responses that scored ≥2. Standard deviation was then applied to determine which variables were significant. The results are shown in the Table 7 .

Table 7

Application of standard deviation to GHQ-28 results

Any variables that were higher than one standard deviation above the average were considered a warning sign and therefore significant. For sections A and B (symptoms), this affected the following one variable B2, “Had difficulty in staying asleep once you are asleep”, which with a score of 36 was over two standard deviations above the mean. The same methodology was then applied to Section C, Social Dysfunction, and D, Severe Depression (Emotions). For Section C, no variables were found to be significant. In Section D, just one variable was found to be more than one standard deviation above the average. This was (D1), “Been thinking of yourself as a worthless person” with a score of 30. This variable was over two standard deviations above the mean and was, therefore, seen as being very significant.

3.4. Posttraumatic Stress Disorder Symptom Scale

Of the 100 people questioned using the PSS, four people were identified as having symptoms of PTSD. This accounts for 4% of the total sample. All these four people surprisingly did not score significantly in the GHQ-28 as expected (with scores ranging from 9–43). In fact, only two people identified as high risk from the GHQ-28 (scoring 43) went on to show symptoms of PTSD. The other two participants identified in the sample as having PTSD scored GHQ-28 scores of below 10.

The PSS questionnaire is divided into three sections: reexperiencing, avoidance, and arousal. Based on the findings from the literature and results, this analysis aims to see how the different sections of the PSS manifest in people's everyday lives.

Again, to determine the most significant variables, the average number of negative responses from the GHQ-28 has been calculated by adding together those responses that scored ≥2. Standard deviation was then applied to determine which variables were significant. The results are shown in the Table 8 .

Table 8

Application of standard deviation to PSS results

PSS, Posttraumatic Stress Disorder Symptom Scale.

For the reexperiencing section, only one variable question 5 “experiencing physical reactions when reminded of the traumatic event (sweating, increased heart rate)” was significant. For the avoidance section, question 7 “trying to avoid activities or people that remind you of the traumatic event” was significant. For the arousal section, again only one question 14 “feeling irritable or having fits of anger” was significant.

From the results section, counts were also made on each of the variables that were identified as interfering with aspects of everyday life after exposure to a traumatic event. These were “work”, “household duties”, “friendships”, “fun/leisure activities”, “schoolwork”, “family relationships”, “sex life”, “general life satisfaction”, and “overall functioning” as shown in Fig. 2 .

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Count of variables interfering with aspects of everyday life.

The variables that showed the highest count and were supported from secondary research were “work”, “family relationships”, and “general life satisfaction”. However, it is seen that sex and education seem to have the lowest count and may suggest that there may be some strategies used to deal with matters of distress.

3.5. Discussion

On completing this research, some interesting observations have been made. The most important being the number of people within LFRS who show signs of distress as highlighted from the GHQ-28 questionnaire and those people who exhibit probable symptoms of PTSD as identified by the PSS questionnaire.

The results from the GHQ-28 highlighted that 30% of the respondents surveyed showed signs of probable distress. If this number was multiplied to represent the number of LFRS employees, approximately 300 operational members of staff could hypothetically be suffering from distress.

Although the research provides evidence that the vulnerability to PTSD does not directly correlate with the GHQ-28 outcomes, it does show that those with poor general health are more susceptible to developing PTSD. This means that potentially 30% of LFRS operational personnel are at risk of developing PTSD.

On analyzing the results of the PSS, four of the 100 people surveyed showed symptoms of PTSD. By scaling these responses up in the same way as for the GHQ-28, LFRS potentially could have approximately 40 cases of PTSD which are presently undiagnosed and untreated, accounting for 4% of the operational workforce. This is lower than what has typically been found in the previously published reports where scores as low as 5% have been obtained [3] .

As the analysis shows, both the GHQ-28 and PSS questionnaires were completed. This was to determine whether general health affected PTSD. The results were inconclusive as of the four people who showed symptoms of PTSD, only two people were identified as high risk from the GHQ-28 (scoring 43). The other two participants identified in the sample as having PTSD scored GHQ-28 scores of below 10. As a result, it was not possible to establish whether general health did influence the development of PTSD symptoms.

The analysis of the results produced some interesting findings. From the GHQ-28, it was determined that emotions affect physical symptoms, supporting the theory that comorbid mental health issues could potentially bring about the development of PTSD.

Interestingly, from a productivity perspective, some of the evidence suggests that the coping strategies used by firefighters are actually more important than their levels of personal motivation, as motivation itself may be directly affected by an individual's ability to cope with the trauma that they witness. Certainly, this survey of LFRS staff highlighted that some will throw themselves into distraction activities (such as sex or education).

LFRS currently adopt an “opt-in” approach to CID; however, this has both advocates and critics. The cultural appetite for engaging in this process is presently limited, and a number of variables exist which may determine the effectiveness of CID such as the timing of the debrief, the duration, or the qualifications, expertise, and training of the facilitator.

The literature review highlighted that CID supporters claim some highly positive outcomes, yet their findings tend not to appear within professional journals. Conversely, several of the less positive studies referred to earlier within this text, which cast doubt over the success of CID, are visible throughout a number of professional medicine and psychology journals. Equally, if no baseline assessment has been undertaken, the outcomes may not be valid, given that the subject may have had existing conditions such as a premorbid personality.

3.6. Recommendations from the study

Current practices within the LFRS are carried out on an optional basis on the part of employees. There is a nonmandatory CID process which employees can take part in if they wish. There is also voluntary counseling service that is available if required and generally, staff is expected to keep an eye on anyone who has recently experienced a traumatic event within the organization.

Based on the findings of both the primary and secondary research completed, this article proposes that LFRS should consider the provision of organizational and leadership practices that aim to mitigate threats derived from PTSD among firefighters; these include the following:

• Delivery of education packages aimed at increasing awareness of stress and PTSD in order that individuals are able to identify the symptoms in themselves and their colleagues at an early stage.
• Mental health screening for new entrants to take into account dispositional variables, which may already exist in applicants.
• Routine screening to facilitate identification and assessment of behavioral issues (such as PTSD) by the means of annual fitness tests and routine medical examinations. This provides a “background reading” for staff in the event of a traumatic event occurring which may require CID or professional health-care involvement.
• Liaison with the military (using existing associations) to learn from their findings and adapt and introduce training for implementation within LFRS.
• Revising the workplace significant incident protocol to include automatic directing of affected staff to trained behavioral health experts.
• An option for immediate access to professional services in the first instance rather than via CID, so as to offer sufferers the earliest and perhaps optimum chance of recovery.
• Development of a Web/mobile app, similar to Pocket Peer that combines Web training with information on symptom recognition and provides direct links to professional services.
• As the UK FRS broadens its skill base to adopt new work streams such as Community First Responding, FRSs should recognize that the increased activity levels and exposure to new incident types (many of which may involve children) could have health impacts for staff, both immediate and longer term.

4. Conclusions

The primary research shows that a PTSD problem does exist within LFRS but at a level which is lower than that found in other similar studies and indeed lower than the quoted lifetime prevalence levels of c.10.4% for women and 5% for men. This supports the position of Brown et al [72] that exposure does not automatically mean the development of psychological distress.

From studying the variables that affect PTSD, it can be determined that no conclusive relationship exists between general health and PTSD within LFRS, with the main variables affecting the development of PTSD being emotions which manifest themselves into physical symptoms.

Secondary research has shown that incidents involving children are the most commonly cited factor for the development of PTSD within FRS personnel. Evidence from Haslam and Mallon [15] suggests that this difficulty in dealing with child victims is borne mainly from a sense of identification between the victims and one's own children.

While research suggests that PTSD manifests itself in a person's day-to-day life through reexperiencing, avoidance, and arousal, it was clear from the respondents to this study that arousal was the most significant detriment to a person's everyday life. This was displayed through the existence of anxiety, depression, addictive behaviors, and insomnia.

Conclusions from the secondary research show that although the culture of the UK FRS remains one of required fortitude and endurance, this strength may also present a risk in the form of lower levels of self-reported stress, probably for many years. Based on the primary research undertaken, it is clear that LFRS presently has a number of personnel experiencing adverse psychological and physical reactions, many of which may be going undiagnosed and untreated at the present time.

Where incidents are discussed in the social setting i.e., after incident, they can tend to be done so using humor, so one could argue that the historic culture within the UK FRS actually presents a natural remedy within the workplace. Whereas this may benefit some personnel and help them to contextualize and perhaps “place in a box” that specific occurrence, for others it may place pressure on them to conceal or deny their true feelings again leading to PTSD symptoms going undiagnosed and untreated.

It is clear from the research undertaken that the role of an emergency responder, and specifically a UK firefighter, has the potential for exposure to traumatic sights, smells, and sounds, creating memories which in some cases will last a lifetime. This article supports the continued development of organizational and leadership practices to assist LFRS in planning for, and mitigating against, the inevitable threat that arises from exposure to traumatic incidents.

4.1. Limitations of study and suggestions for future research

One of the limitations of the study was that the intention was to draw findings from a larger sample size than was achieved; national environmental factors (the ongoing industrial dispute) within the sector affected the ability to deliver this. It is therefore a recommendation of this article that a wider study be undertaken, perhaps on a north-west regional footprint to obtain both a wider sample and detect variances between FRS and between firefighters working in urban and rural environments. With the relevant consents, such a study could also consider the implications of gender, age, ethnicity, position within the organizational structure, and whether whole time or retained duty system. This would then allow for the prevalence of PTSD to be compared with sociodemographic factors and any geographical variations.

It should also be noted that the sample used was from within a single county. Lancashire is predominantly rural with several large conurbations. It does not face the same level of challenges and perhaps more serious threats and events as may be seen by some larger metropolitan FRS. As a result, caution should be applied to the current findings when considered in the context of other FRS areas.

To fully appreciate the benefits associated with CID, further research could be undertaken within LFRS (or regionally) to examine more closely the interactions of participants, the outcomes, and the how CID or the involvement of professionals may deliver better outcomes for staff.

Finally, as the nature of a UK firefighter's role continues to evolve with greater exposure via new aspects such as emergency medical response, the exposure to distressing events within our communities also increase. It is recommended that LFRS commission further works to explore the expected implications of such new work streams and the potential impacts to inform the future needs of the service.

Conflicts of interest

All authors have no conflicts of interest to declare.

Acknowledgments

The authors are grateful to the Lancashire Fire and Rescue Service for their kind cooperation that enabled them to pursue this research successfully.

Appendix A Supplementary data related to this article can be found at https://doi.org/10.1016/j.shaw.2017.11.002 .

Appendix A. Supplementary data

The following is the supplementary data related to this article:

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Introduction. Post-traumatic stress disorder (PTSD), also known as the "invisible wound" [] or the "signature illness" [] among Iraq and/or Afghanistan combat veterans, has an estimated prevalence rate of 10%-30% [1-8], with higher rates in those with multiple combat tours [3,7].]. However, most combat veterans do not seek medical care [] often because of stigma [1,2,6,8].
A Review on Post-traumatic Stress Disorder (PTSD): Symptoms ...
Abstract. Post-traumatic stress disorder (PTSD), previously known as battle fatigue syndrome or shell shock, is a severe mental disturbance condition that is normally triggered by the experience of some frightening/scary events or trauma where a person undergoes some serious physical or mental harm or threatened.
Post Traumatic Stress Disorder Case Study
This case study presents information about post traumatic stress disorder in older adults. It is divided into different sections including the history, presentation and examination, diagnosis, case discussion, post traumatic stress disorder explained, take home points, and additional resources.
Self-treatment of psychosis and complex post-traumatic stress disorder
In Switzerland, since 2014, two psychotherapists obtained 50 licenses on a case-by-case basis and developed a psychedelic-assisted group therapy model utilizing MDMA and LSD for patients suffering from chronic complex post-traumatic stress disorder (C-PTSD), dissociative, and other post-traumatic disorders (Oehen and Gasser, 2022). The authors ...
Post-Traumatic Stress Disorder: Treatment and Case Studies, Part 2 of 2
The case study of Rich (see Case Study 1) demonstrates that the body can be an ally and a catalyst in the process of healing from trauma. Such physical changes often help to resolve the habitual trauma-related responses and provide improved stability to handle future stressors (Ogden et al., 2006).
Post Traumatic Stress Disorder: PTSD Case Study: One Man's Journey
This paper concludes with a self-critique by the therapist regarding every aspect of the presented case study. Post Traumatic Case Study (PTSD): Case Study; Dick's Journey Descriptive Narrative Dick is a retired military man, in his late fifties, suffering from DSM-IV-TR chronic military-related posttraumatic stress disorder (PTSD).
Post-traumatic stress disorder and GI endoscopy: a case study
Post-traumatic stress disorder (PTSD) can be caused by experiencing or witnessing a variety of harsh traumatic events. Rape, burglary, war, torture, violence, and other catastrophic events have been known to precipitate flashbacks, nightmares, and inability to cope with the demands of daily life. ... This case study describes a 42-year-old man ...
Post-Traumatic Stress Disorder: Evidence-Based Research for the Third
Post-traumatic stress disorder, or PTSD, is the psychiatric disorder that can result from the experience or witnessing of traumatic or life-threatening events such as terrorist attack, violent crime and abuse, military combat, natural disasters, serious accidents or violent personal assaults. ... Best case studies in evidence-based research ...
Post-traumatic Stress Disorder: An Ancient Greek Case Study in
Within socio-military history, the diagnosis of post-traumatic stress disorder has aroused a lot of attention, with many scholars claiming its existence in the pre-modern world while sceptics have challenged this claim in no uncertain terms. ... Rees, O. (2022). Post-traumatic Stress Disorder: An Ancient Greek Case Study in Retrospective ...
A Case Study of the Effects of Posttraumatic Stress Disorder on
Methods. The overarching purpose of this epidemiological study is to assess the prevalence of post-traumatic stress disorder (PTSD) amongst operational LFRS personnel and to analyse the effects upon those who may be suffering from it, whether brought about by a single traumatic event or by repeated exposure to traumatic occurrences over a period of time.
Speaker's Regional Youth Debating Competition 2024 District ...
Speaker's Regional Youth Debating Competition 2024 District 11, Round 1 (Match 1)

Breakthrough Study on Post-Traumatic Stress Disorder

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Introduction

Epidemiology and prognosis

Current narrative review

Neuroimaging techniques

Functional techniques

Neural alterations in PTSD

Question 1: which neural alterations serve as predisposing (pre-exposure) risk factors for PTSD development, and which are acquired (post-exposure)?

Structural neuroimaging

Functional MRI

Question 2: which neural correlates predict treatment outcomes and define treatment improvement?

Baseline prediction of PTSD symptom improvement

Neuroimaging correlates of PTSD symptom improvement

Question 3: are there neuroimaging-based biotypes that define PTSD?

Overall implications, future directions, and limitations

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Posttraumatic Stress Disorder in Patients After Severe COVID-19 Infection

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Introduction

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Diagnostic assessment

PTSD checklist for DSM-5

Impressions

Beck hopelessness scale

Clinical global impressions

Therapeutic intervention

Follow-up and outcomes

Strengths and limitations

Data availability statement

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A case of PTSD presenting with psychotic symptomatology: a case report

Case presentation

Mental state examination

Patient's perspective

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Post-traumatic stress disorder and GI endoscopy: a case study