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| ===== Origin & Background ===== | ===== Origin & Background ===== | ||
| - | The concept of post-traumatic stress is not a new one. War veterans returning from battle have been reporting symptoms of flashbacks, hyper-arousal, anxiety and depression, for hundreds of years (Malia S). When Civil war veterans were first diagnosed, physicians referred to it as “Soldier’s Heart”, “Shell Shock” or “Combat Fatigue”. It wasn’t until 1980, that the American Psychiatric Association (APA) added Post-Traumatic Stress Disorder (PTSD) to the Diagnostic and Statistical Manual of Mental Disorders (DSM-III). | + | The concept of post-traumatic stress is not a new one. War veterans returning from battle have been reporting symptoms of flashbacks, hyper-arousal, anxiety and depression, for hundreds of years (Malia, 2014). When Civil war veterans were first diagnosed, physicians referred to their symptoms as “Soldier’s Heart”, “Shell Shock” or “Combat Fatigue”. It wasn’t until 1980, that the American Psychiatric Association (APA) added Post-Traumatic Stress Disorder (PTSD) to the Diagnostic and Statistical Manual of Mental Disorders (DSM-III). |
| - | PTSD is broadly characterized by an extreme reaction to trauma that changes how a person thinks, feels and behaves (Maria, S). This can present in a variety of different ways, of varying severity, and causes considerable distress to the individual, usually affecting their ability to function normally. An individual who develops PTSD hasn't necessarily gone through a traumatic event, but may experience symptoms of traumatic stress indirectly from a trauma affecting close friends or family (Nih, 2016). The proximity, duration and severity of trauma exposure can affect whether or not you develop symptoms. For example, you are more likely to develop symptoms if you personally experience chronic, severe trauma such as childhood abuse, rather than an individual who witnesses one-time experience, such as a robbery (APA, 2013). | + | PTSD is broadly characterized by an extreme reaction to trauma that changes how a person thinks, feels and behaves (Malia, 2014). This can present in a variety of different ways, of varying severity, and causes considerable distress to the individual, usually affecting their ability to function normally. An individual who develops PTSD hasn't necessarily gone through a traumatic event, but may experience symptoms of traumatic stress indirectly from a trauma affecting close friends or family (Post-Traumatic Stress Disorder, 2016). The proximity, duration and severity of trauma exposure can affect whether or not you develop symptoms. For example, you are more likely to develop symptoms if you personally experience chronic, severe trauma such as childhood abuse, rather than an individual who witnesses one-time experience, such as a robbery (American Psychiatric Association, 2013). |
| {{:ptsd.png|}} | {{:ptsd.png|}} | ||
| - | **Figure 1**: This image depicts the six main components of post-traumatic stress disorder. | + | **Figure 1**: This image depicts the six main components of post-traumatic stress disorder (Sadock & Ruiz, 2015). |
| === Normal Stress Reaction === | === Normal Stress Reaction === | ||
| - | Normally, when an individual is exposed to a threat, their sympathetic nervous system (fight or flight response) will be activated (APA, 2013). The sympathetic nervous system will release epinephrine & norepinephrine; pupils dilate, mouth dries, adrenal glands release norepinephrine, liver releases glucose, bladder inhibits urination and skin increases sweat production. The brain will release ACTH, cortisol and adrenaline, and heart rate will increase (APA, 2013). When you are no longer exposed to the threat, the parasympathetic nervous system will kick in and all of these processes will reverse. | + | Normally, when an individual is exposed to a threat, their sympathetic nervous system (fight or flight response) will be activated (American Psychiatric Association, 2013). The sympathetic nervous system will release epinephrine & norepinephrine; pupils dilate, mouth dries, adrenal glands release norepinephrine, liver releases glucose, bladder inhibits urination and skin increases sweat production. The brain will release ACTH, cortisol and adrenaline, and heart rate will increase (American Psychiatric Association, 2013). When you are no longer exposed to the threat, the parasympathetic nervous system will kick in and all of these processes will reverse. |
| === Post-Traumatic Stress Reaction === | === Post-Traumatic Stress Reaction === | ||
| - | In a chronic stress situation, the brain has a tendency to over-estimate how much danger you are in. In this case, your stress system malfunctions and your body remain on high alert with your sympathetic nervous system activated. With constant activation, your brain will continue to release stress hormones such as ACTH, cortisol, and adrenaline (APA, 2013). | + | In a chronic stress situation, the brain has a tendency to over-estimate how much danger you are in. In this case, your stress system malfunctions and your body remain on high alert with your sympathetic nervous system activated. With constant activation, your brain will continue to release stress hormones such as ACTH, cortisol, and adrenaline (American Psychiatric Association, 2013). |
| With continual hormone release, your brain will make mistakes interpreting the environment around you, and different structures will begin to respond differently (See Figure 2). | With continual hormone release, your brain will make mistakes interpreting the environment around you, and different structures will begin to respond differently (See Figure 2). | ||
| - | The symptoms of post-traumatic stress disorder are often debilitating and interfere with an individual’s ability to work, go to school, and have meaningful relationships. If left untreated, they can become so severe that an individual may attempt suicide (APA, 2013). | + | The symptoms of post-traumatic stress disorder are often debilitating and interfere with an individual’s ability to work, go to school, and have meaningful relationships. If left untreated, they can become so severe that an individual may attempt suicide (American Psychiatric Association, 2013). |
| {{:brainjt.png|}} | {{:brainjt.png|}} | ||
| - | **Figure 2**: This image shows how brain structures respond differently in an individual experience post-traumatic stress disorder. | + | **Figure 2**: This image shows how brain structures respond differently in an individual experience post-traumatic stress disorder (Sadock & Ruiz, 2015). |
| ===== Symptoms ===== | ===== Symptoms ===== | ||
| - | Post-traumatic stress disorder is characterized by four main types of symptoms: reliving the trauma through intrusive memories, emotional numbness and avoidance behaviour, negative changes in thinking and mood and changes in physical and emotional reactions. | + | {{ :ptsd-cloud.jpg?200|}} |
| - | {{::picture1.png?200|}} | + | Post-traumatic stress disorder is characterized by four main types of symptoms: reliving the trauma through intrusive memories, experiencing emotional numbness and avoidance behaviour, portraying negative changes in thinking and mood as well as changes in physical and emotional reactions (PTSD Mayo Clinic, 2017). |
| - | **1. Intrusive memories** | + | The first set of symptoms are displayed as recurrent, unpleasant and distressing memories of the traumatic event. These could occur through reliving the traumatic event as if it were happening again. Intrusive memories could take a form of distressing dreams or nightmares about the traumatic event. The individual could also experience severe emotional distress or physical reactions to something that recalls the traumatic event. Individuals suffering with PTSD could also display avoidance behaviour. This behaviour is displayed through avoidance of talking about the traumatic event as well as avoidance of activities or people that recall the traumatic event. The third set of symptoms are characterized by negative changes in thinking and mood. These symptoms might include having negative thoughts about oneself, other people or the world as well as being hopeless about the future. Individuals could also experience memory problems, including not remembering important aspects of the traumatic event. It might also be difficult to maintain close relationships and feeling detached from family and friends. PTSD patients may also lack interest in activities once enjoyed and have difficulty experiencing positive emotions. This is often described as being emotionally numb. The last set of symptoms often displayed are changes in physical and emotional reactions. Changes in physical reactions might include being easily startled or frightened, being on guard or feeling in danger most of the time as well as displaying self-destructive behaviour (e.g., excess drinking, driving too fast). Changes in emotional reactions could display as being unable to concentrate or focus, being easily irritable, displaying angry outburst or aggressive behaviour as well as displaying overwhelming guilt or shame. Children of six years of age and older could display PTSD by re-enacting the traumatic event or aspects of the traumatic event through play. They could also experience frightening dreams that may or may not include aspects of the traumatic event (PTSD Mayo Clinic, 2017). |
| - | * Recurrent, unpleasant and distressing memories of the traumatic event | + | |
| - | * Reliving the traumatic event as if it were happening today | + | |
| - | * Having distressing dreams or nightmares about the traumatic event | + | |
| - | * Experiencing severe emotional distress or physical reactions to something that recalls the traumatic event | + | |
| - | **2. Avoidance** | + | ===== Diagnosis ===== |
| - | * Avoiding thinking or talking about the traumatic event | + | |
| - | * Avoiding places, activities or people that recall the traumatic event | + | |
| - | **3. Negative changes in thinking and mood** | + | {{ :dsm-5_3d.jpg?100|}} |
| - | * Having negative thoughts about oneself, other people or the world | + | DSM5 is the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013). It is used by clinicians and researchers to diagnose and classify mental disorders. The aim of this diagnostic tool is to provide concise and explicit criteria to facilitate objective assessments of symptom presentations in a variety of clinical settings. The settings may include inpatient, outpatient, consultation, clinical, private practice and primary care (American Psychiatric Association, 2013). The diagnostic criteria for Post-Traumatic Stress Disorder, as listed in the DSM-5, is provided below: |
| - | * Being hopelessness about the future | + | |
| - | * Experiencing memory problems (e.g., forgetting important aspects of the traumatic event) | + | |
| - | * Having difficulty maintaining close relationships | + | |
| - | * Feeling detached from family and friends | + | |
| - | * Lacking interest in activities once enjoyed | + | |
| - | * Having difficulty experiencing positive emotions | + | |
| - | * Feeling emotionally numb | + | |
| - | + | ||
| - | **4. Changes in physical and emotional reactions** | + | |
| - | * Being easily startled or frightened | + | |
| - | * Being on guard or feeling in danger most of the time | + | |
| - | * Displaying self-destructive behaviour (e.g., as drinking too much or driving too fast) | + | |
| - | * Being unable to concentrate or focus | + | |
| - | * Being easily irritable, displaying angry outbursts or aggressive behaviour | + | |
| - | * Displaying overwhelming guilt or shame | + | |
| - | * Children 6 and older: | + | |
| - | * Re-enacting the traumatic event or aspects of the traumatic event through play | + | |
| - | * Having frightening dreams that may or may not include aspects of the traumatic event | + | |
| - | + | ||
| - | + | ||
| - | ===== Diagnosis ===== | + | |
| - | DSM5 is the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders. It is used by clinicians and researchers to diagnose and classify mental disorders. The aim of this diagnostic tool is to provide concise and explicit criteria to facilitate objective assessments of symptom presentations in a variety of clinical settings. The settings may include inpatient, outpatient, consultation, clinical, private practice and primary care. The diagnostic criteria for Post-Traumatic Stress Disorder, as listed in the DSM-5, is provided below: | ||
| - | {{:dsm-5_3d.jpg?200|}} | ||
| - | **Figure 2**: An image of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition. | + | **Figure 2**: An image of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (American Psychiatric Association, 2013). |
| **Criterion A (one required)**: The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, in the following way(s): | **Criterion A (one required)**: The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, in the following way(s): | ||
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| ===== Etiology ===== | ===== Etiology ===== | ||
| - | PTSD can develop in war veterans, children, and victims of natural disasters, sexual or physical abuse, family violence, and torture (The National Institute of Mental Health, 2016). If a person directly experiences the traumatic event and there is bodily harm involved, the risk of PTSD is significantly higher (Ford et al., 2015). If a person witnesses the traumatic event taking place, and the event is on a large scale like instances of war and genocide, this can lead to a greater likelihood of developing PTSD. Repeated exposure to traumatic stressors, known as “retraumatization”, has proven to increase PTSD risk in individuals. This is still being debated as the criteria for what should be considered retraumatization has not been defined. PTSD is not triggered exclusively by traumatic experiences. Approximately 80-90% of people exposed to traumatic events do not develop PTSD. If the traumatic event occurs during one’s developmental years, the risk of developing PTSD is greater by 75% or more (Ford et al., 2015). | + | PTSD can develop in war veterans, children, and victims of natural disasters, sexual or physical abuse, family violence, and torture (National Institute of Mental Health, 2016). If a person directly experiences the traumatic event and there is bodily harm involved, the risk of PTSD is significantly higher (Ford et al., 2015). If a person witnesses the traumatic event taking place, and the event is on a large scale like instances of war and genocide, this can lead to a greater likelihood of developing PTSD. Repeated exposure to traumatic stressors, known as “retraumatization”, has proven to increase PTSD risk in individuals. This is still being debated as the criteria for what should be considered retraumatization has not been defined. PTSD is not triggered exclusively by traumatic experiences. Approximately 80-90% of people exposed to traumatic events do not develop PTSD. If the traumatic event occurs during one’s developmental years, the risk of developing PTSD is greater by 75% or more (Ford et al., 2015). |
| - | PTSD can develop at any age however, adolescents and young to midlife adults have a greater risk compared to children and elderly populations(Ford et al., 2015). Females and ethnic-racial minorities are also more susceptible to developing PTSD, the latter being a result of social and economic factors like racial stigma, discrimination, and poverty (Ford et al., 2015). Additional determinants that increase one’s likelihood of developing PTSD are childhood trauma, poverty, living through dangerous events, dealing with physical injuries and having a history of mental illness or substance abuse (The National Institute of Mental Health, 2016). The type of response that follow these traumatic events are also risk factors, known as “peritraumatic” risk factors (Ford et al., 2015). Some of the main peritraumatic risk factors include high levels of initial distress characterized by increases in blood pressure, as well as dissociation and disorientation (Ford et al., 2015). | + | PTSD can develop at any age however, adolescents and young to midlife adults have a greater risk compared to children and elderly populations(Ford et al., 2015). Females and ethnic-racial minorities are also more susceptible to developing PTSD, the latter being a result of social and economic factors like racial stigma, discrimination, and poverty (Ford et al., 2015). Additional determinants that increase one’s likelihood of developing PTSD are childhood trauma, poverty, living through dangerous events, dealing with physical injuries and having a history of mental illness or substance abuse (National Institute of Mental Health, 2016). The type of response that follow these traumatic events are also risk factors, known as “peritraumatic” risk factors (Ford et al., 2015). Some of the main peritraumatic risk factors include high levels of initial distress characterized by increases in blood pressure, as well as dissociation and disorientation (Ford et al., 2015). |
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| ===== Genetics ===== | ===== Genetics ===== | ||
| - | Few research studies have been conducted on the genetics of PTSD and findings have generally produced inconclusive results (Sareen, 2017). A study analyzing the stress-related gene FKBP5 found that the presence of one of four polymorphisms on the gene was linked to an increased risk of PTSD in patients who had suffered child abuse. Patients without a history of child abuse did not show an increased risk (Sareen, 2017). | + | Few research studies have been conducted on the genetics of PTSD and findings have generally produced inconclusive results (Sareen, 2017). A study analyzing the stress-related gene FKBP5 found that the presence of one of four polymorphisms on the gene was linked to an increased risk of PTSD in patients who had suffered child abuse. Patients without a history of child abuse did not show an increased risk (Sareen, 2017). Additionally, the FKBP5 genotype was found to be linked with peritraumatic dissociation a strong determinant for PTSD development (Wilker et al., 2014). |
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| === Neuroanatomy === | === Neuroanatomy === | ||
| - | The amygdala is responsible for stimulating the hippocampus to allow the brain to learn and create memories pertaining to specific threats (Vieweg, 2006). The initial reaction to a traumatic stressor is triggered by the amygdala. The prefrontal cortex is responsible for maintaining a cognitive understanding of the stimulus, including the event itself and the biopsychosocial responses of the traumatic event in the short and long-term (Vieweg, 2006). A study comparing a PTSD population and a control population found that individuals with PTSD showed reduced volume of the hippocampus, left amygdala, and anterior cingulate cortex compared to matched controls (Sareen, 2017). Other research has shown decreased functioning of the left hemisphere, which may explain the confusion experience in PTSD individuals when recalling the timeline of traumatic events. Other findings have shown increased central norepinephrine levels with down-regulation of central adrenergic receptors. Reduced glucocorticoid levels and up-regulation of receptors have also been observed in PTSD groups(Sareen, 2017). | + | The amygdala is responsible for stimulating the hippocampus to allow the brain to learn and create memories pertaining to specific threats (Vieweg, 2006). The initial reaction to a traumatic stressor is triggered by the amygdala. The prefrontal cortex is responsible for maintaining a cognitive understanding of the stimulus, including the event itself and the biopsychosocial responses of the traumatic event in the short and long-term (Vieweg, 2006). A study comparing a PTSD population and a control population found that individuals with PTSD showed reduced volume of the hippocampus, left amygdala, and anterior cingulate cortex compared to matched controls (Sareen, 2017). Other research has shown decreased functioning of the left hemisphere, which may explain the confusion experience in PTSD individuals when recalling the timeline of traumatic events. Some findings have shown increased central norepinephrine levels with down-regulation of central adrenergic receptors. Reduced glucocorticoid levels and up-regulation of receptors have also been observed in PTSD groups (Sareen, 2017). |
| === Provocation studies === | === Provocation studies === | ||
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| === Cognitive activation studies === | === Cognitive activation studies === | ||
| - | Cognitive activation studies have shown increased amygdalar activity and decreased medial prefrontal cortical responses to threat in PTSD groups (Taber and Hurley, 2009). Reduced responses in the rostral anterior cingulate cortex to emotional stimuli have also been observed(Taber and Hurley, 2009). | + | Cognitive activation studies have shown increased amygdalar activity and decreased medial prefrontal cortical responses to threat in PTSD groups (Taber and Hurley, 2009). Reduced responses in the rostral anterior cingulate cortex to emotional stimuli have also been observed (Taber and Hurley, 2009). |
| === Morphometric studies === | === Morphometric studies === | ||
| Morphometric studies have demonstrated reduced volume in several limbic areas,including the hippocampus, rostral anterior cingulate, dorsal anterior cingulate, and subcallosal cortices linked to PTSD (Taber and Hurley, 2009). | Morphometric studies have demonstrated reduced volume in several limbic areas,including the hippocampus, rostral anterior cingulate, dorsal anterior cingulate, and subcallosal cortices linked to PTSD (Taber and Hurley, 2009). | ||
| - | Figure. 4 | ||
| === Research === | === Research === | ||
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| - | Figure 5. Analysis of functional neuroimaging studies where regions of hyperactivation in PTSD are indicated in yellow and regions of hypoactivation in PTSD are indicated in blue (Hayes et al., 2012). | + | Figure 4. Analysis of functional neuroimaging studies where regions of hyperactivation in PTSD are indicated in yellow and regions of hypoactivation in PTSD are indicated in blue (Hayes et al., 2012). |
| === Neurobiology of Serotonin === | === Neurobiology of Serotonin === | ||
| - | In the brain, specifically in the brainstem medical and dorsal raphe nuclei, serotonin cell bodies (5-HT) regulate important functions (Kelmendi et al., 2016). Some vital roles that the 5-HT regulates include sleep, motor function, cognition and aggression (Sherin & Nemeroff, 2011). Previous research indicated that 5-HT is involved in stress response in patients with PTSD since the 5-HT neurons mediate anxiety producing effects on individuals through the 5-HT2 receptors (Sherin & Nemeroff, 2011). On the other hand, the 5-HT1A receptors regulate anti-anxiety producing effects from the median raphe. The5-HT1A and 5-HT1B receptors have been associated with disorders including PTSD (Bailey et al., 2013). Any changes in the functional 5-HT pathway may contribute to intrusive memories and impulsivity that is associated with PTSD symptoms PTSD (Bailey et al., 2013). Furthermore, Sari identifies the 5-HT1B receptor to be associated with PTSD. In the study, when there was a reduced amount of 5-HT1B receptor in the brain, the animals showed anxiety like behaviour (Sari, 2004). | + | In the brain, specifically in the brainstem medical and dorsal raphe nuclei, serotonin cell bodies (5-HT) regulate important functions (Kelmendi et al., 2016). Some vital roles that the 5-HT regulates include sleep, motor function, cognition and aggression (Sherin & Nemeroff, 2011). Previous research indicated that 5-HT is involved in stress response in patients with PTSD since the 5-HT neurons mediate anxiety producing effects on individuals through the 5-HT2 receptors (Sherin & Nemeroff, 2011). On the other hand, the 5-HT1A receptors regulate anti-anxiety producing effects from the median raphe. The 5-HT1A and 5-HT1B receptors have been associated with disorders including PTSD (Bailey et al., 2013). Any changes in the functional 5-HT pathway may contribute to intrusive memories and impulsivity that is associated with PTSD symptoms(Bailey et al., 2013). Furthermore, Sari identified that the 5-HT1B receptor to be associated with PTSD, when there was a reduced amount of 5-HT1B receptor, the animals showed anxiety like behaviour (Sari, 2004). |
| {{ :serotonin_melatonin_2017_.jpg?300 |}} | {{ :serotonin_melatonin_2017_.jpg?300 |}} | ||
| - | Figure 6: The image represents the pathway of 5-HT1B receptors on Serotonin neurons and how it can affect behaviour in animals (Melatonin, 2017). | + | Figure 5: The image represents the pathway of 5-HT1B receptors on Serotonin neurons and how it can affect behaviour in animals (Melatonin, 2017). |
| ===== Treatments ===== | ===== Treatments ===== | ||
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| {{:ptsd_association_of_canada.jpeg?200|}}{{:veterans_transition_network.png?200|}}{{:cmha_logo_.jpg?300|}}{{:camh_logo.jpg?200|}} {{:casp-blue-logo.png?100|}} | {{:ptsd_association_of_canada.jpeg?200|}}{{:veterans_transition_network.png?200|}}{{:cmha_logo_.jpg?300|}}{{:camh_logo.jpg?200|}} {{:casp-blue-logo.png?100|}} | ||
| - | These are a lot of mental health resources that are related to people struggling with PTSD. Although some of these organizations don’t specialize specifically in PTSD, there are treatments or programs that they may provide. A lot of these organizations work together as opposed to separate and different organizations may handle different illnesses depending on the community that they are located in. If some can’t find what they are looking for at one of these organizations they will have connections to others that do. These five organizations are not the only five that deal with PTSD. There are a variety of them out there, the common ones were selected that were located in Canada. | + | There are a lot of mental health resources that are related to people struggling with PTSD. Although some of these organizations don’t specialize specifically in PTSD, there are treatments or programs that they may provide. A lot of these organizations work together as opposed to separate and different organizations may handle different illnesses depending on the community that they are located in. If some can’t find what they are looking for at one of these organizations they will have connections to others that do. These five organizations are not the only five that deal with PTSD. There are a variety of them out there, the common ones were selected that were located in Canada. |
| ==Post-traumatic Stress Disorder Association of Canada (PTSDAC)== | ==Post-traumatic Stress Disorder Association of Canada (PTSDAC)== | ||
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| + | ===== PTSD Powerpoint Presentation ===== | ||
| + | {{:group_4_ptsd_slides.pptx|}} | ||
| ===== References ===== | ===== References ===== | ||
| - | 1. Shubina, I. (2015). Cognitive-behavioral Therapy of Patients with Ptsd: Literature Review. Procedia - Social And Behavioral Sciences, 165, 208-216. http://dx.doi.org/10.1016/j.sbspro.2014.12.624 | + | 1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. |
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| + | 2. Asnis, G., Kohn, S., Henderson, M., & Brown, N. (2004). SSRIs versus Non-SSRIs in Post-traumatic Stress Disorder. Drugs, 64(4), 383-404. http://dx.doi.org/10.2165/00003495-200464040-00004 | ||
| - | 2. Cognitive Behavioral Therapy (CBT) for Treatment of PTSD. (2017). http://www.apa.org. Retrieved 16 September 2017, from http://www.apa.org/ptsd-guideline/treatments/cognitive-behavioral-therapy.aspx | + | 3. Bailey, C. R., Cordell, E., Sobin, S. M., & Neumeister, A. (2013). Recent progress in understanding the pathophysiology of post-traumatic stress disorder. CNS drugs, 27(3), 221-232. |
| - | 3. Post-traumatic stress disorder (PTSD) - Treatment - NHS Choices. (2015). Nhs.uk. Retrieved 26 September 2017, from http://www.nhs.uk/Conditions/Post-traumatic-stress-disorder/Pages/Treatment.aspx | + | 4. Brady, K., Pearlstein, T., Asnis, G., Baker, D., Rothbaum, B., Sikes, C., & Farfel, G. (2000). Efficacy and Safety of Sertraline Treatment of Posttraumatic Stress Disorder. JAMA, 283(14), 1837. http://dx.doi.org/10.1001/jama.283.14.1837 |
| - | 4. Eye Movement Desensitization and Reprocessing Therapy | Psychology Today. (2017). Psychologytoday.com. Retrieved 27 September 2017, from https://www.psychologytoday.com/therapy-types/eye-movement-desensitization-and-reprocessing-therapy | + | 5. Canadian Association for Suicide Prevention. (2016). Need Help?: CASP . Retrieved September 22, 2017, from CASP Web site: https://suicideprevention.ca/need-help/ |
| - | 5. Wilson, K. (2012). Equine- Assisted Psychotherapy as an Effective Therapy in Comparison to or in Conjunction with Traditional Therapies (Undergraduate). University of Central Florida. | + | 6. Canadian Mental Health Association. (2017). Mental Health: CMHA Ontario. Retrieved September 22, 2017, from CMHA Ontario Web site: http://ontario.cmha.ca/ |
| - | 6.Masters, N. (2010). Equine Assisted Psychotherapy for Combat Veterans with PTSD (Masters of Nursing). WASHINGTON STATE UNIVERSITY. | + | 7. Centre for Addiction and Mental Health. (2012). Who We Are: CAMH. Retrieved September 22, 2017, from CAMH Web site: http://www.camh.ca/en/hospital/about_camh/who_we_are/Pages/who_we_are.aspx |
| - | 7. Equine Therapy for (PTSD) Post Traumatic Stress Disorder. (2017). Calico Junction New Beginnings Ranch, Inc.. Retrieved 26 September 2017, from http://www.calicojunctionnewbeginningsranch.org/ptsd.html | + | 8. Cognitive Behavioral Therapy (CBT) for Treatment of PTSD. (2017). http://www.apa.org. Retrieved 16 September 2017, from http://www.apa.org/ptsd-guideline/treatments/cognitive-behavioral-therapy.aspx |
| - | 8. Pharmacogenetics And Genomics, 19(11), 907-909. http://dx.doi.org/10.1097/fpc.0b013e32833132cb | + | 9. Davidson, J., Pearlstein, T., Londborg, P., Brady, K., Rothbaum, B., & Bell, J. et al. (2003). Efficacy of Sertraline in Preventing Relapse of Posttraumatic Stress Disorder. FOCUS, 1(3), 273-281. http://dx.doi.org/10.1176/foc.1.3.273 |
| - | 9. Asnis, G., Kohn, S., Henderson, M., & Brown, N. (2004). SSRIs versus Non-SSRIs in Post-traumatic Stress Disorder. Drugs, 64(4), 383-404. http://dx.doi.org/10.2165/00003495-200464040-00004 | + | 10. Dryden-Edwards, M. R. (n.d.). Posttraumatic Stress Disorder: Read Up on PTSD Symptoms. Retrieved September 27, 2017, from http://www.medicinenet.com/posttraumatic_stress_disorder/article.htm |
| - | 10. Brady, K., Pearlstein, T., Asnis, G., Baker, D., Rothbaum, B., Sikes, C., & Farfel, G. (2000). Efficacy and Safety of Sertraline Treatment of Posttraumatic Stress Disorder. JAMA, 283(14), 1837. http://dx.doi.org/10.1001/jama.283.14.1837 | + | 11. Eye Movement Desensitization and Reprocessing Therapy | Psychology Today. (2017). Psychologytoday.com. Retrieved 27 September 2017, from https://www.psychologytoday.com/therapy-types/eye-movement-desensitization-and-reprocessing-therapy |
| - | 11. Davidson, J., Pearlstein, T., Londborg, P., Brady, K., Rothbaum, B., & Bell, J. et al. (2003). Efficacy of Sertraline in Preventing Relapse of Posttraumatic Stress Disorder. FOCUS, 1(3), 273-281. http://dx.doi.org/10.1176/foc.1.3.273 | + | 12. Equine Therapy for (PTSD) Post Traumatic Stress Disorder. (2017). Calico Junction New Beginnings Ranch, Inc. Retrieved 26 September 2017, from http://www.calicojunctionnewbeginningsranch.org/ptsd.html |
| - | 12. Three Types of Medications Used to Treat PTSD – DH Information. (2011). Dhinfo.org. Retrieved 25 September 2017, from https://www.dhinfo.org/2011/02/three-types-of-medications-used-to-treat-ptsd/ | + | 13. Ford, J. D., Grasso, D. J., Elhai, J. D., & Courtois, C. A. (2015). Posttraumatic stress disorder: scientific and professional dimensions. Amsterdam: Academic Press. Retrieved September 23, 2017, from http://scitechconnect.elsevier.com/wp-content/uploads/2016/05/PTSD.pdf |
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| - | 14. Southwick, S. M., Yehuda, R., Giller Jr, E. L., & Charney, D. S. (1994). Use of tricyclics and monoamine oxidase inhibitors in the treatment of PTSD: a quantitative review. Catecholamine function in post-traumatic stress disorder: Emerging concepts, 293-305.) | + | 15. Hayes, J. P., VanElzakker, M. B., & Shin, L. M. (2012). Emotion and cognition interactions in PTSD: a review of neurocognitive and neuroimaging studies. Frontiers in Integrative Neuroscience. Retrieved September 27, 2017, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3466464/ |
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