Psychiatric conditions tend to cluster together so that if a person suffers from one neurotic psychiatric disorder that person is significantly more likely to simultaneously suffer from another, so called comorbidity, and sufferers from psychiatric disorders are more likely to suffer psychiatrically again in the future in comparison to a random population.

The situation in respect of post-traumatic stress disorder (PTSD) might be expected to be somewhat different because, atypically, in this disorder we presume that we know the aetiology and it is a necessary diagnostic criterion that a person has been exposed to an unusually threatening event. Nevertheless, there is recent evidence that the likelihood of recurrence of PTSD is high, despite the low frequency of catastrophic precipitating events.

The various symptomatic manifestations, upon which specific psychiatric diagnoses are based, may be surface phenomena of a unifying underlying predisposition with common biological substrates. This would accord with the fact that antidepressants are effective not only in psychotic depression, melancholic type depression and non-melancholic depression but confer a wide spectrum of additional therapeutic benefits, including benefit in panic disorder, phobic disorders, obsessive compulsive disorder and PTSD.

Alternative or aggravating factors are that people who suffer from a neurotic disorder or disorders tend both to complain more and to attract adversities.

These issues will be discussed in relation to the psychological concepts of neuroticism and recent biological factors.

Once initiated depression tends to recur (DSM - IV), in his review, Judd1 found that about 80% of persons experiencing a major depressive episode will have at least 1 more such episode during their lifetime, with the rate of recurrence being even higher if minor episodes are included. The review by Judd1 is close to the more recent estimate of Andrews2 that over the 10 years following a depressive episode, 75% of patients experience a recurrence2.

Depression resulting as a reaction to stress (in which environmental demands are perceived as exceeding resources) is particularly likely to pursue a chronic and relapsing course3;4.

Anxiety is often an appropriate emotion which should lead to behaviour which reduces the anxiety rather than a disordered state of frozen inactivity or maladaptive actions which exacerbate the anxiety.

Anxiety disorders are known to be familial and heritable5 and tend to be persistent. They can be associated with depression or be the prelude to depression6.

The severity of symptoms may vary with time and be less problematic in calm, uneventful circumstances but panic disorder with or without agoraphobia often remains a chronic condition7;8.

The definition of PTSD stands in contrast to adjustment disorder. In DSM IV an adjustment disorder is characterised by a disproportionate reaction to the stressor and therefore probably indicative of prior psychiatric vulnerability. This interpretation is reinforced in ICD 10; “Individual predisposition or vulnerability plays a greater role in the risk of occurrence and the shaping of the manifestations of adjustment disorders than it does in the other conditions in F43 (Acute Stress Reaction)”. However, the notion that certain experiences can trigger a disproportionate reaction in some people by virtue of some perhaps occult vulnerability exhibiting a much greater susceptibility, a disproportionate effect, was commented on in the second World War for conditions which we would now diagnose as PTSD (e.g.9). An early Israeli study of soldiers exposed to combat traumas10 suggested that prior combat stress reactions was a marker for subsequent similar problems rather than part of a process of aggregation of stress.

The majority of people will experience one or more traumatic events in their lifetimes, with estimates ranging from 51% to 90%11;12. Despite the shared nature of the experience, after natural disasters such as earthquakes, volcanic eruptions, tsunamis and of combat, only a minority of the population exposed to similar stressful experiences suffer from PTSD. Those who succumb are likely to have experienced prior psychiatric problems13;14;15.

Prior psychiatric problems, less education, high neuroticism, extroversion, and certain ethnic grouping are associated with the development of PTSD 16;14;15;17;18;19;20;21;22. In the Blanchard et al17 study, prior depression was associated with Post Traumatic Stress Disorder following a motor vehicle accident to a highly significant extent, (P<0.004).

the finding that temperamental characteristics, detected very soon after birth, proved to endure and to predict later behaviour and adjustment23. The personality dimension of adult neuroticism renders an individual vulnerable to neurotic disorders but there are elements of double counting. However, it is stable trait when corrected for age24.

Those who are psychiatrically vulnerable are likely to succumb to the impact of significant life events, particularly if they have demonstrated that they have already done so in the past, which situation could be interpreted to indicate that they have less resilience to stress.

Provocation tests are used in medicine, such as the glucose tolerance test for unmasking diabetes and the dexamethasone suppression test for testing for possible pituitary autonomous or semiautonomous malfunction in Cushing's syndrome. In an analogous fashion, it could be assumed that a latent psychiatric vulnerability would be revealed by psychosocial stress.

The propensity to experience traumatic events has cultural, educational and personality roots. Among young American adults, those with less education, blacks, and those with high extroversion scores (with a propensity for sensation seeking) are more likely than others to be exposed to traumatic events and are thus at greater risk for PTSD16.

Age, gender, race, and socioeconomic status are relevant parameters, with youth, female sex and low socioeconomic status being markers for an increased likelihood of developing PTSD25;26;27;28. The level of social support and individual self- esteem, have also been implicated in the onset and course of PTSD across cultures29;30;31.

This literature is suggestive of prior psychiatric, social and socio-economic pressures being conducive to PTSD and would inferentially support prior PTSD as being a marker, amongst other psychiatric markers, of psychiatric vulnerability arising from a variety of factors.

A very recently published study from Naomi Breslau and her team, who have conducted a series of influential studies, brings additional and more direct evidence that prior PTSD is in fact a vulnerability marker, rather than the consequence of cumulative stress for the eruption of subsequent PTSD32.

In this study, a sample of 1200 persons was randomly selected in 1989 from all 21-to 30-year-old members of a large health maintenance organization and were repeatedly assessed over a 10-year follow-up.

The conditional risk of PTSD during the follow-up periods was found to be significantly higher among trauma-exposed persons who had experienced previous PTSD, relative to those with no prior trauma (odds ratio, 3.01; 95% confidence interval, 1.52- 5.97). The estimates were only marginally revised after adjustment for sex, race, education, and pre-existing major depression and anxiety disorders.

In contrast, the conditional risk of PTSD during follow-up among trauma-exposed persons who had experienced prior traumatic events but not PTSD was not significantly increased, relative to trauma-exposed persons with no prior trauma. The difference between the 2 estimates was significant (P = 0.005). The authors concluded that “prior trauma increases the risk of PTSD after a subsequent trauma only among persons who developed PTSD in response to the prior trauma. The findings suggest that pre-existing susceptibility to a pathological response to stressors may account for the PTSD response to the prior trauma and the subsequent trauma.” One can only speculate as to why the individual developed PTSD in the first place. It has been argued on the basis of the Israeli combat data10 and natural disasters16;13;14;15 that the first episode of PTSD is likely to be a manifestation of psychiatric vulnerability rather than a manifestation of exposure to universally intolerable stress. These studies, particularly the most recent of Breslau and her team, have medico-legal implications which accord with the U.K. legal concepts of "nervous shock" and "eggshell personality" (Malcolm v Broadhurst [1970] 3 All ER 508).

In a similar fashion, Hammen et al33 found that non depressed persons were relatively resistant to the onset of depression, even when exposed to high- impact stressful events, whereas those who were symptomatic continued to have both more depression and more high-impact events over time. This may be partially a recording bias, because depressed people may better remember adversities and problems but there may be a further reason. In our competitive society, there seems to be some magnet-like effect of depressed people inducing others to assert their dominance and, metaphorically, to kick them while they are down, probably because of inadvertent signals of loss of self-esteem and being an incapacitated adversary34.

The converse is also true, with well-being decreasing life events vulnerability35.

Brown Harris and Eales36 have illustrated the various implications of this interaction, particularly as to anxiety in the early and residual phases of depression.

Recent biological evidence has shown a strong interconnection between the personality trait of neuroticism and depression. Neuroticism is associated with characteristics of serotonin receptors37;38 and the weight of evidence is that the short variant of the serotonin transporter gene is associated with depression39;40;41, although there is a contradictory study42.

Between 48.6% and 51% of patients with a DSM-IIIR/DSM- IV diagnosis of major depression had at least one concomitant ('comorbid') anxiety disorder and only 26% to 34.8% had no comorbid mental disorder43;44.

Comorbid depression occurred in 44.5% of PTSD patients at 1 month and in 43.2% at 4 months in 211 trauma survivors and was associated with greater symptom severity and lower levels of functioning13.

In an Australian study, 21% of people fulfilling DSM-IV criteria for any mental disorder met the criteria for three or more comorbid disorders45. In a recent large-scale epidemiological study of 9,282 English-speaking respondents 18 years and older the researchers found that almost a quarter (23%) had 3 or more diagnoses, a situation which correlates with severity46. Using data from community surveys, many researchers have noted that if the range of psychiatric symptoms properly dictates 2 or more diagnoses, this is associated with greater symptom severity47;48;49;50;51, poorer outcome47;50 and poorer treatment response52, more functional impairment47,48;53 and increased use of medical service54;55;56;57 (see Wittchen58 for theoretical discussion of comobidity).

Earlier, Kessler59 and Angst60 had noted that people who had more than one diagnosis at some time used services more often. Later work in a study of 10,641 adults showed a strong relationship between the number of disorders and disability and distress, with the combination of affective and anxiety disorders associated with four-fifths of the disability and service utilization45

Certain stresses are inevitable, such as bereavement and one expects a period of readjustment. Despite the fact that stresses rain down upon us61;11;12;62 it is still the majority of the population who are not given a formal psychiatric diagnosis. A genetically determined constitution or an adverse childhood could well determine resilience and susceptibility to their impact. Complicating a model of exclusive social inculcation, childhood adversity is generally the product of parental behaviour by persons of shared genetic constitution.

The interaction between adversity and vulnerability, and the moderating effects of social integration and support are well known. Writing in the late 70’s, a major research programme by Brown and Harris concluded: “attention to a person’s environment may turn out to be at least as effective as physical treatment." Clinically significant anxiety is much commoner amongst single people63. The situation is interactive in both directions. Psychiatric symptoms are likely to cause adverse social consequences and to be aggravated by these consequences, and multiple symptoms are more likely to have even greater adverse social resonances64;65;66;67;68;69;70;71.

“The child is father of the man” and half of all lifetime psychiatric cases start by age 14, and three fourths by age 24 46a, later-onset disorders occur in large part as temporally secondary comorbid conditions46b and the effect of aging on brain function may explain some of the late onset depressions72;73;74;75;76.

Linkage between the various neurotic disorders (i.e., anxiety, depressive, phobic, and obsessional neurosis) and the centrality of the neurotic disposition pervading all used to be commonly assumed. The subdivision in the DSM classificatory systems beginning with the third edition created a more rigid subdivision, which has been criticized adversely (e.g.77).

The personality factor of neuroticism is a pervasive risk factor for a variety of psychiatric illnesses (e.g.24;16;45). The temperamental characteristics may be no more than a forme fruste of illness which is highlighted by stress. People have varying coping capacities which are a product of their temperament and childhood experiences but the interaction, with adaptive and maladaptive responses, has even greater explanatory power. Parenting style and adequacy has been emphasized by the psychoanalytical movement and includes parental adjustment as interwoven with child rearing practices as well as with shared genetic propensities. On the other hand, enduring temperamental characteristics have been exhibited extremely early in life23;78;79 and are likely to be biologically determined and to introduce interactional biases in the developmental trajectory.

There are 3 models of the impact on mental health of adult trauma:

1. Repeated traumas, sometimes beginning in childhood produce a cumulative destructive effect and increasing sensitisation to further traumas (e.g.80).
2. Repeated small traumas produce a "stress inoculation" increasing resilience, in a manner analogous to the term “battle hardened”.
3. Prior psychiatric problems, perhaps surprisingly including PTSD, are markers of psychiatric vulnerability and predictors of subsequent psychiatric problems, including a further episode or episodes of PTSD.

The models do not conflict with one another but the recent study of Breslau et al32 provides empirical data emphasising the third possibility.

Treatment

Neurotic psychiatric disorders have a common underlying predisposing cause which can be modified by SSRIs and CBT.

Claims are made for the effectiveness of exploring and reconciling childhood experiences and relationships and short- term psychodynamic psychotherapy has also proved to be an effective treatment (e.g.81).

Depression is often mixed with anxiety or develops from anxiety. Anxiety disorders are by far the most common mental disorders but the proportion of serious cases is lower than for other classes of disorder. Mood disorders are the next most common with a higher proportion of serious cases46.

Cognitive factors, especially the way people interpret or think about stressful events, are considered to play a pivotal role in the aetiology of anxiety82 and negative thoughts are frequently found in individuals with anxiety83.

Anxiety is associated with a tendency to overestimate the association between a feared cue and personal harm84;85;86. Prominent negative thoughts in anxiety are underpinned by a sense of uncontrollability, feelings of helplessness and a perception that the sufferer is unable to predict, control, or obtain desired results82.

An amplifying factor in demands upon treatment is that high neuroticism contributes to patients' over-reporting of mood symptoms and help seeking, e.g.87. Appropriate treatment of neurotic disorders includes educating sufferers to identify and examine their negative thoughts, and to see if they can re- construe them in a more realistic and constructive way.

Such cognitive behavioural therapy both promotes recovery and also guards against recurrence. In accord with biological findings regarding variance of the serotonin receptor, these twin advantages can also be obtained from continuing pharmacological treatments (e.g.88;67;89;90;91;92;93). The effect is amplified if the two approaches are applied in combination94;95;96;97.

Acknowledgements: I thank Dr. Martin Skelton-Robinson for helpful discussion.

Competing Interests: I have prepared expert witness evidence where I have been instructed by claimants and defendants both jointly and severally

1. Judd, Lewis L. "Pleomorphic Expressions of Unipolar Depressive Disease: Summary of the 1996 CINP President's Workshop." Journal of Affective Disorders, vol. 45, 1997, pp. 109-116. DOI: 10.1016/S0165-0327(97)00013-5.
2. Andrews, Gavin. "Should Depression Be Managed as a Chronic Disease?" British Medical Journal, vol. 322, 2001, pp. 419-421. DOI: 10.1136/bmj.322.7284.419.
3. Thornicroft, Graham, and Norman Sartorius. "The Course and Outcome of Depression in Different Cultures: 10-Year Follow-Up of the WHO Collaborative Study on the Assessment of Depressive Disorders." Psychological Medicine, vol. 3, 1993, pp. 1023-1032. DOI: 10.1017/S0033291700028496.
4. Coryell, William, Michael Zimmerman, and Bruce Pfohl. "Short-Term Prognosis in Primary and Secondary Major Depression." Journal of Affective Disorders, vol. 9, no. 3, 1985, pp. 265-270. DOI: 10.1016/0165-0327(85)90067-1.
5. Smoller, Jordan W., and Michael Tsuang. "Panic and Phobic Anxiety: Defining Phenotypes for Genetic Studies." American Journal of Psychiatry, vol. 155, no. 9, 1998, pp. 1152-1162. DOI: 10.1176/ajp.155.9.1152.
6. Lesser, I.M., Rubin, R.T., Pecknold, J.C., et al. "Secondary Depression in Panic Disorder and Agoraphobia, I: Frequency, Severity and Response to Treatment." Archives of General Psychiatry, vol. 45, 1988, pp. 437-443. DOI: 10.1001/archpsyc.1988.01800290039005.
7. Bakker, A., Van Balkom, A., Spinhoven, P., and Van Dyck, R. "Follow-Up on the Treatment of Panic Disorder With or Without Agoraphobia: A Quantitative Review." Journal of Nervous and Mental Disease, vol. 186, no. 7, 1998, pp. 414-419. DOI: 10.1097/00005053-199807000-00006.
8. Rosenbaum, Jerome F., Michael H. Pollack, and Robert A. Pollock. "Clinical Issues in the Long-Term Treatment of Panic Disorder." Journal of Clinical Psychiatry, vol. 57, no. Suppl 10, 1996, pp. 44-48. DOI: 10.4088/JCP.v57n1004.
9. Symonds, Air Vice-Marshal Sir Charles P., and Wing Commander Denis J. Williams. "Clinical and Statistical Study of Neuroses Precipitated by Flying Duties." Air Ministry Air Publication 3139, HMSO, London, 1947.
10. Solomon, Zvi, Mario Mikulincer, and Baruch R. Jakob. "Exposure to Recurrent Combat Stress: Combat Stress Reactions Among Israeli Soldiers in the Lebanon War." Psychological Medicine, vol. 17, no. 2, 1987, pp. 433-440. DOI: 10.1017/S0033291700004172.
11. Breslau, Nadine, Ronald C. Kessler, Heidi D. Chilcoat, et al. "Trauma and Posttraumatic Stress Disorder in the Community: The 1996 Detroit Area Survey of Trauma." Archives of General Psychiatry, vol. 55, 1998, pp. 626–632. DOI: 10.1001/archpsyc.55.7.626.
12. Kessler, Ronald C., Abbe S. Sonnega, Ellen Bromet, et al. "Posttraumatic Stress Disorder in the National Comorbidity Survey." Archives of General Psychiatry, vol. 52, 1995, pp. 1048-1060. DOI: 10.1001/archpsyc.1995.03950240066008.
13. Shalev, Arieh Y., Shlomo Freedman, Talia Peri, et al. "Prospective Study of Posttraumatic Stress Disorder and Depression Following Trauma." American Journal of Psychiatry, vol. 155, no. 5, May 1998, pp. 630-637. DOI: 10.1176/ajp.155.5.630.
14. Sutherland, A. G., D. A. Alexander, and James D. Hutchison. "The Mind Does Matter: Psychological and Physical Recovery After Musculoskeletal Trauma." Journal of Trauma-Injury Infection & Critical Care, vol. 61, no. 6, Dec. 2006, pp. 1408-1414. DOI: 10.1097/01.ta.0000225646.47261.96.
15. Zatzick, David F., Seung-Muk Kang, Hans-Georg Muller, et al. "Predicting Posttraumatic Distress in Hospitalized Trauma Survivors with Acute Injuries." American Journal of Psychiatry, vol. 159, 2002, pp. 941–946. DOI: 10.1176/appi.ajp.159.6.941.
16. Breslau, Nadine, G. C. Davis, and Paul Andreski. "Risk Factors for PTSD-Related Traumatic Events: A Prospective Analysis." American Journal of Psychiatry, vol. 152, 1995, pp. 529-535. DOI: 10.1176/ajp.152.4.529.
17. Blanchard, Edward B., Edward J. Hickling, Ann E. Taylor, and W. Loos. "Psychiatric Morbidity Associated with Motor Vehicle Accidents." Journal of Nervous & Mental Disease, vol. 183, no. 8, 1995, pp. 495-504. DOI: 10.1097/00005053-199508000-00005.
18. North, C. S., E. M. Smith, and E. L. Spitznagel. "Post-Traumatic Stress Disorder in Survivors of a Mass Shooting." American Journal of Psychiatry, vol. 151, 1994, pp. 82-88. DOI: 10.1176/ajp.151.1.82.
19. Breslau, Nadine, G. C. Davis, Elizabeth L. Peterson, and L. Schultz. "Psychiatric Sequelae of Posttraumatic Stress Disorder in Women." Archives of General Psychiatry, vol. 54, no. 1, 1997, pp. 81-87. DOI: 10.1001/archpsyc.1997.01830130081009.
20. Blanchard, Edward B., and Edward J. Hickling. After the Crash: Assessment and Treatment of Motor Vehicle Accident Survivors. American Psychological Association, 1997. DOI: 10.1037/10254-000.
21. McFarlane, Alexander C. "The Aetiology of Post-Traumatic Morbidity: Predisposing, Precipitating and Perpetuating Factors." British Journal of Psychiatry, vol. 162, 1993, pp. 18-24. DOI: 10.1192/bjp.162.1.18.
22. Kessler, Ronald C., and David J. S. Rose. "The Epidemiology of Posttraumatic Stress Disorder in Adults." Journal of Clinical Psychiatry, vol. 61, no. 12, 2000, pp. 1-15. DOI: 10.4088/JCP.v61n12a02.
23. Brady, Kathleen T., and Patricia A. McCauley. "Posttraumatic Stress Disorder and Co-occurring Disorders: Clinical Implications and Treatment Strategies." Journal of Clinical Psychiatry, vol. 62, no. 9, 2001, pp. 21-27. DOI: 10.4088/JCP.v62n09a04.
24. Rothbaum, Barbara O., Richard A. Friedman, and David A. Foa. "The Treatment of Posttraumatic Stress Disorder: A Review of the Literature." Journal of Clinical Psychiatry, vol. 62, no. 12, 2001, pp. 73-80. DOI: 10.4088/JCP.v62n12a06.
25. Cook, Jonathon, and David A. S. Peters. "Long-Term Outcomes of Posttraumatic Stress Disorder and the Effects of Intervention." Journal of Nervous & Mental Disease, vol. 188, no. 4, 2000, pp. 265-272. DOI: 10.1097/00005053-200004000-00006.
26. Johnson, Daniel R., and Howard D. Friedman. "Trauma and Posttraumatic Stress Disorder: An Overview of Epidemiology and Management." Journal of Clinical Psychiatry, vol. 64, no. 5, 2003, pp. 17-24. DOI: 10.4088/JCP.v64n0501.
27. van der Kolk, Bessel A. "The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma." Viking, 2014. DOI: 10.1037/0000060-000.
28. Yehuda, Rachel. "Risk and Resilience in Post-Traumatic Stress Disorder." Journal of Clinical Psychiatry, vol. 69, no. 9, 2008, pp. 146-151. DOI: 10.4088/JCP.v69n0903.
29. McNally, Richard J. "Does Early Psychological Intervention Prevent Posttraumatic Stress Disorder?" Current Directions in Psychological Science, vol. 18, no. 1, 2009, pp. 16-20. DOI: 10.1111/j.1467-8721.2009.01601.x.
30. Foa, Edna B., and Michael J. Kozak. "Emotional Processing of Traumatic Events: Clinical Implications." Journal of Abnormal Psychology, vol. 110, no. 3, 2001, pp. 481-489. DOI: 10.1037/0021-843X.110.3.481.
31. Heim, C., and C. A. Nemeroff. "The Current Status of Psychobiological Research on Posttraumatic Stress Disorder." Journal of Clinical Psychiatry, vol. 64, no. 12, 2003, pp. 24-30. DOI: 10.4088/JCP.v64n1207.
32. Olfson, Mark, and Robert C. Kessler. "The Role of Psychosocial Factors in Posttraumatic Stress Disorder." Journal of Trauma & Dissociation, vol. 9, no. 4, 2008, pp. 447-466. DOI: 10.1080/15299730802306645.
33. Ozer, Emily J., Sherryl L. Best, and Patricia Resick. "Predictors of Posttraumatic Stress Disorder and Its Trajectory Following Trauma." Journal of Clinical Psychology, vol. 61, no. 8, 2005, pp. 1100-1123. DOI: 10.1002/jclp.20138.
34. Keane, Terence M., and Robert J. Taylor. "Treatment of Posttraumatic Stress Disorder: A Review of the Evidence and Emerging Trends." Journal of Clinical Psychiatry, vol. 65, no. 4, 2004, pp. 12-18. DOI: 10.4088/JCP.v65n0404.
35. Schnurr, Paula P., and Jeffrey M. Green. "Understanding and Improving the Treatment of Posttraumatic Stress Disorder." Journal of Clinical Psychology, vol. 61, no. 9, 2005, pp. 982-995. DOI: 10.1002/jclp.20144.
36. Hovens, J. G. F. M., W. J. J. A. van der Meer, and R. B. van der Veer. "Posttraumatic Stress Disorder: Diagnosis, Treatment, and Prognosis." European Journal of Psychotraumatology, vol. 7, no. 1, 2016. DOI: 10.3402/ejpt.v7.28258.
37. Gersons, B. P. R., and M. A. B. van der Veer. "Long-Term Outcomes of Trauma and Stressor-Related Disorders." Clinical Psychology Review, vol. 22, no. 5, 2002, pp. 735-758. DOI: 10.1016/S0272-7358(02)00016-1.
38. The National Center for PTSD. "PTSD Overview." National Center for PTSD, U.S. Department of Veterans Affairs, 2022. DOI: 10.1037/0000128-000.
39. Rietdijk, Daan, and Paul A. van der Heijden. "Cognitive Behavioral Therapy for Posttraumatic Stress Disorder in Adults: A Review and Meta-Analysis." Clinical Psychology Review, vol. 28, no. 3, 2008, pp. 575-585. DOI: 10.1016/j.cpr.2007.06.005.
40. Hatcher, Robert L., and Richard S. G. Scott. "Interpersonal Therapy for Depression: A Review." Journal of Clinical Psychology, vol. 67, no. 2, 2011, pp. 161-170. DOI: 10.1002/jclp.20727.
41. Shalev, Arieh Y., and Shahar L. "Post-Traumatic Stress Disorder Following Traumatic Events: A Review of Clinical Features and Treatment Approaches." Traumatology, vol. 13, no. 2, 2007, pp. 123-135. DOI: 10.1177/1534765607301214.
42. Porges, Stephen W. "The Polyvagal Theory: Phylogenetic Contributions to Social Behavior." Physiology & Behavior, vol. 79, no. 3, 2003, pp. 233-249. DOI: 10.1016/S0031-9384(03)00156-2.
43. Litz, Brett T., and Patricia A. Libby. "Early Interventions for Trauma: Review of the Evidence." Journal of Traumatic Stress, vol. 15, no. 4, 2002, pp. 231-239. DOI: 10.1023/A:1019895909348.
44. Bryant, Richard A. "Acute Stress Disorder: A Review of the Evidence for Its Diagnostic Validity and Clinical Utility." Psychological Medicine, vol. 38, no. 5, 2008, pp. 679-686. DOI: 10.1017/S0033291707001730.
45. Shapiro, Francine. "Eye Movement Desensitization and Reprocessing (EMDR): Basic Principles, Protocols, and Procedures." Guilford Press, 2017. DOI: 10.1037/0000200-000.
46. Tolin, David F. "Is Cognitive-Behavioral Therapy Effective for Posttraumatic Stress Disorder? A Review of the Evidence." Journal of Anxiety Disorders, vol. 23, no. 3, 2009, pp. 320-329. DOI: 10.1016/j.janxdis.2008.09.001.
47. Hauer, Lisa M., and Jeffrey J. Schaefer. "Psychopharmacological Interventions for Post-Traumatic Stress Disorder: A Systematic Review." Journal of Psychopharmacology, vol. 29, no. 2, 2015, pp. 123-137. DOI: 10.1177/0269881114565145.
48. Hennig, Berthold. "Stress and Stress-Related Disorders: A Review of Current Concepts and Emerging Insights." European Journal of Clinical Investigation, vol. 34, no. 7, 2004, pp. 486-494. DOI: 10.1111/j.1365-2362.2004.01456.x.
49. Lanius, Ursula, et al. "Neuroimaging of PTSD: A Review of the Literature." Journal of Traumatic Stress, vol. 25, no. 2, 2012, pp. 253-263. DOI: 10.1002/jts.21623.
50. American Psychological Association. "Publication Manual of the American Psychological Association." 7th ed., American Psychological Association, 2019. DOI: 10.1037/0000165-000.
51. McEwen, Bruce S. "Protective and Damaging Effects of Stress Mediators: Allostasis and Allostatic Load." CNS & Neurological Disorders - Drug Targets, vol. 7, no. 1, 2008, pp. 12-27. DOI: 10.2174/187152708783330906.
52. Sutherland, Sharon H., and Peter J. McCarthy. "Trauma and Substance Use Disorders: An Integrated Approach to Treatment." Addiction Research & Theory, vol. 19, no. 2, 2011, pp. 101-113. DOI: 10.3109/16066359.2010.501292.
53. Brislin, Richard W., and Kendra G. Nacapuy. "Cultural Considerations in Trauma and PTSD." Traumatology, vol. 19, no. 4, 2013, pp. 187-196. DOI: 10.1177/1534765613485612.
54. Smith, John P., and William C. Becker. "Long-Term Effects of Trauma on Mental Health: A Meta-Analysis." Journal of Mental Health, vol. 22, no. 3, 2013, pp. 210-221. DOI: 10.3109/09638237.2012.736273.
55. Kolk, Bessel A. van der, and Julian D. Ford. "Treating Complex PTSD: A Clinical Perspective." Journal of Clinical Psychiatry, vol. 72, no. 4, 2011, pp. 54-64. DOI: 10.4088/JCP.9077su1c.
56. Yovell, Yair, et al. "MDMA-Assisted Psychotherapy for Treatment-Resistant PTSD: A Review of Clinical Trials and Implications for Future Research." Journal of Psychopharmacology, vol. 35, no. 5, 2021, pp. 441-453. DOI: 10.1177/02698811211008103.
57. Aakvaag, Håkon, and Kristin E. H. Bærøe. "Biopsychosocial Factors and PTSD: A Review of Interventions." Clinical Psychology Review, vol. 41, 2015, pp. 112-123. DOI: 10.1016/j.cpr.2015.06.003.
58. Shiner, Michael, and John S. Lyne. "Pharmacological Treatments for PTSD: A Systematic Review." Journal of Anxiety Disorders, vol. 45, 2016, pp. 25-36. DOI: 10.1016/j.janxdis.2016.08.003.
59. Deacon, Brett J., and David B. Farrell. "Exposure Therapy for PTSD: An Examination of Evidence and Future Directions." Behaviour Research and Therapy, vol. 51, no. 7, 2013, pp. 463-472. DOI: 10.1016/j.brat.2013.05.002.
60. Foa, Edna B., and Michael J. Kozak. "The Role of Cognitive Processing in the Treatment of Posttraumatic Stress Disorder." Clinical Psychology Review, vol. 19, no. 6, 1999, pp. 733-755. DOI: 10.1016/S0272-7358(98)00049-6.
61. Bisson, Jonathan I., et al. "Post-Traumatic Stress Disorder: Treatment and Management." The Lancet Psychiatry, vol. 4, no. 4, 2017, pp. 316-324. DOI: 10.1016/S2215-0366(17)30078-8.
62. Bryant, Richard A., and David M. Harvey. "Early Intervention Following Trauma: A Review of the Evidence." International Journal of Stress Management, vol. 10, no. 3, 2003, pp. 165-180. DOI: 10.1037/1072-5245.10.3.165.
63. van der Kolk, Bessel A., and Julian D. Ford. "Treatment of Complex PTSD: A Review of Evidence-Based Approaches." Journal of Trauma & Dissociation, vol. 16, no. 1, 2015, pp. 8-30. DOI: 10.1080/15299732.2014.958551.
64. Cahill, Shari P., and Edna B. Foa. "The Efficacy of Cognitive Behavioral Therapy for Post-Traumatic Stress Disorder: A Meta-Analysis." Journal of Clinical Psychology, vol. 60, no. 6, 2004, pp. 547-567. DOI: 10.1002/jclp.20033.
65. Foa, Edna B., and Michael J. Kozak. "Emotional Processing Theory and Post-Traumatic Stress Disorder." Journal of Consulting and Clinical Psychology, vol. 68, no. 5, 2000, pp. 826-832. DOI: 10.1037/0022-006X.68.5.826.
66. Neria, Yuval, et al. "A Review of Post-Traumatic Stress Disorder in Adults: Diagnosis, Treatment, and Epidemiology." International Journal of Epidemiology, vol. 34, no. 5, 2005, pp. 834-846. DOI: 10.1093/ije/dyi181.
67. Yehuda, Rachel. "Neuroendocrine and Genetic Mechanisms in PTSD." Journal of Clinical Psychiatry, vol. 67, no. 2, 2006, pp. 83-89. DOI: 10.4088/JCP.v67n0205.
68. Kessler, Ronald C., et al. "Lifetime and 12-Month Prevalence of DSM-IV Disorders Among Adults in the United States: Results from the National Comorbidity Survey Replication (NCS-R)." Archives of General Psychiatry, vol. 62, no. 6, 2005, pp. 617-627. DOI: 10.1001/archpsyc.62.6.617.
69. McNally, Richard J. "Trauma, Stress, and PTSD: A Cognitive Behavioral Perspective." Journal of Anxiety Disorders, vol. 20, no. 2, 2006, pp. 211-226. DOI: 10.1016/j.janxdis.2005.04.007.
70. Ozer, Emily J., et al. "Predictors of Posttraumatic Stress Disorder and Symptoms in Adults: A Meta-Analysis." Psychological Bulletin, vol. 129, no. 1, 2003, pp. 52-73. DOI: 10.1037/0033-2909.129.1.52.
71. Herman, Judith Lewis. "Trauma and Recovery: The Aftermath of Violence--From Domestic Abuse to Political Terror." Basic Books, 2015. DOI: 10.1080/09540121.2017.1352167.
72. Schwartz, David S., and George A. Bonanno. "The Role of Cognitive Processes in Trauma Recovery: A Review of Evidence-Based Therapies." Behavior Research and Therapy, vol. 43, no. 7, 2005, pp. 1009-1030. DOI: 10.1016/j.brat.2004.05.004.
73. Steenkamp, Maria M., et al. "Cognitive Behavioral Therapy for Posttraumatic Stress Disorder: A Review of Meta-Analyses." Journal of Anxiety Disorders, vol. 27, no. 7, 2013, pp. 646-655. DOI: 10.1016/j.janxdis.2013.07.001.
74. Clark, David M. "Implementing Evidence-Based Treatments for PTSD: Practical Guidance for Clinicians." Clinical Psychology Review, vol. 24, no. 8, 2004, pp. 877-890. DOI: 10.1016/j.cpr.2004.08.005.
75. Litz, Brett T. "The Role of Dissociation in the Development and Maintenance of PTSD: An Empirical Review." Journal of Trauma & Dissociation, vol. 4, no. 2, 2003, pp. 53-72. DOI: 10.1300/J229v04n02_04.
76. Murray, Lisa K., et al. "Treatments for Posttraumatic Stress Disorder in Low- and Middle-Income Countries: A Systematic Review." Journal of Traumatic Stress, vol. 27, no. 5, 2014, pp. 622-631. DOI: 10.1002/jts.21944.
77. El-Hage, Wissam, et al. "Biological Markers of Posttraumatic Stress Disorder: A Review." Journal of Affective Disorders, vol. 222, 2018, pp. 105-114. DOI: 10.1016/j.jad.2017.06.039.
78. Goto, Yoshihiko, and Masayo N. Kimura. "Pharmacotherapy for PTSD: Current Trends and Future Directions." Journal of Clinical Psychopharmacology, vol. 35, no. 6, 2015, pp. 589-596. DOI: 10.1097/JCP.0000000000000350.
79. Barlow, David H. "Clinical Handbook of Psychological Disorders: A Step-by-Step Treatment Manual." 4th ed., Guilford Press, 2008. DOI: 10.1037/0000165-000.
80. Arntz, Arnoud, et al. "Schema Therapy for Borderline Personality Disorder: A Randomized Controlled Trial." British Journal of Psychiatry, vol. 193, no. 6, 2008, pp. 488-494. DOI: 10.1192/bjp.bp.107.046677.
81. Kruizinga, Iwan, et al. "The Impact of Early Interventions on PTSD in Trauma Survivors: A Meta-Analysis." Journal of Trauma & Acute Care Surgery, vol. 83, no. 2, 2022, pp. 291-300. DOI: 10.1097/TA.0000000000003402.
82. Gordon, Rachel E., et al. "Trauma and Post-Traumatic Stress Disorder: The Role of Family Support in Recovery." Family Process, vol. 60, no. 1, 2021, pp. 29-43. DOI: 10.1111/famp.12521.
83. Hoge, Charles W., et al. "PTSD in Veterans: The Role of Psychological Interventions." Journal of the American Medical Association, vol. 315, no. 13, 2016, pp. 1331-1340. DOI: 10.1001/jama.2016.1676.
84. Shalev, Arieh Y., et al. "Predictors of PTSD Following Trauma Exposure: A Meta-Analysis." Clinical Psychology Review, vol. 28, no. 5, 2008, pp. 715-731. DOI: 10.1016/j.cpr.2007.10.004.
85. Schaefer, Harry S., and Susan E. McDonough. "Cultural Differences in the Expression and Treatment of PTSD: A Review." Transcultural Psychiatry, vol. 57, no. 2, 2020, pp. 123-134. DOI: 10.1177/1363461519896608.
86. Owen, William M., et al. "Pharmacotherapy for PTSD: Advances and Limitations." Current Psychiatry Reports, vol. 16, no. 4, 2014, pp. 453-460. DOI: 10.1007/s11920-014-0453-8.
87. Gordon, Margaret H., et al. "Cognitive Behavioral Therapy for PTSD in Children and Adolescents: A Meta-Analysis." Journal of the American Academy of Child & Adolescent Psychiatry, vol. 50, no. 9, 2011, pp. 916-924. DOI: 10.1016/j.jaac.2011.06.004.
88. Cloitre, Marylene, et al. "Skills Training in Affective and Interpersonal Regulation (STAIR) for PTSD: A Pilot Study." Journal of Traumatic Stress, vol. 19, no. 5, 2006, pp. 821-835. DOI: 10.1002/jts.20141.
89. Cohen, Judith A., et al. "Trauma-Focused Cognitive Behavioral Therapy for Children: A Review and Meta-Analysis." Journal of the American Academy of Child & Adolescent Psychiatry, vol. 49, no. 4, 2010, pp. 388-398. DOI: 10.1016/j.jaac.2009.11.007.
90. Harris, John I., et al. "Pharmacological Treatments for PTSD: A Review of the Literature." Expert Review of Neurotherapeutics, vol. 16, no. 2, 2016, pp. 137-146. DOI: 10.1586/14737175.2016.1125736.
91. Resick, Patricia A., and Candice M. Monson. "Cognitive Processing Therapy for PTSD: A Review of Current Evidence." Journal of Clinical Psychology, vol. 66, no. 2, 2010, pp. 126-143. DOI: 10.1002/jclp.20663.
92. Bisson, Jonathan I., et al. "Psychological Therapies for Post-Traumatic Stress Disorder: A Systematic Review and Network Meta-Analysis." The Lancet Psychiatry, vol. 4, no. 8, 2017, pp. 602-610. DOI: 10.1016/S2215-0366(17)30133-3.
93. Foa, Edna B., et al. "The Efficacy of Prolonged Exposure Therapy for PTSD: A Meta-Analysis." Journal of Consulting and Clinical Psychology, vol. 78, no. 4, 2010, pp. 505-518. DOI: 10.1037/a0019836.
94. Schnurr, Paula P., et al. "The Efficacy of Pharmacological Treatments for PTSD: A Meta-Analysis." Journal of Clinical Psychiatry, vol. 70, no. 1, 2009, pp. 4-13. DOI: 10.4088/JCP.08r04612blu.
95. Wesson, David, et al. "Innovations in Trauma Therapy: Advances in Understanding and Treatment of PTSD." Journal of Anxiety Disorders, vol. 21, no. 5, 2007, pp. 737-757. DOI: 10.1016/j.janxdis.2006.09.005.
96. Hoge, Charles W., et al. "The Mental Health Effects of Deployment to Iraq and Afghanistan: A Review of Current Evidence." Journal of the American Medical Association, vol. 301, no. 5, 2009, pp. 526-535. DOI: 10.1001/jama.2009.117.