N Engl J Med, Vol. 346, No. 2
January 10, 2002
The New England Journal of Medicine
From the Division of Traumatic Stress Studies and Department of Psy-
chiatry, Mount Sinai School of Medicine and Bronx Veterans Affairs Med-
ical Center, New York. Address reprint requests to Dr. Yehuda at Bronx
Veterans Affairs Medical Center, 130 Kingsbridge Rd., Bronx, NY 10468,
or at firstname.lastname@example.org.
HE terrorist attacks on the World Trade Cen-
ter and the Pentagon on September 11, 2001,
represented an amalgam of interpersonal vio-
lence, loss, and disaster. Tens of thousands of people
ran for their lives in fear, were exposed to graphic
scenes of death, or lost loved ones. It is estimated
that well over 100,000 people directly witnessed the
events, and many people around the world were also
exposed to these horrifying scenes through the me-
The attacks were followed by the imminent threat
of subsequent attacks, the prospect of war, and bio-
terrorism. These events have influenced and will con-
tinue to influence the clinical presentation of pa-
tients seeking health care services, and post-traumatic
stress disorder (PTSD) will develop in a substantial
number of people. On the basis of data obtained after
the 1995 bombing of the Murrah Federal Building in
Oklahoma City, which was previously the deadliest
act of terrorism in America, one could predict PTSD
will develop in approximately 35 percent of those
who were directly exposed to the September 11 at-
In addition, many persons with prior expo-
sure to traumatic events may have a recrudescence of
PTSD symptoms triggered by news of catastrophic
events and their distressing effects. Since traumatized
persons with PTSD are far more likely to visit primary
care physicians for their symptoms than mental health
professionals, primary care practitioners will play an
important part in identifying and treating this disorder.
DEFINITION OF PTSD
The defining characteristic of a traumatic event is
its capacity to provoke fear, helplessness, or horror
in response to the threat of injury or death.
who are exposed to such events are at increased risk
for PTSD as well as for major depression, panic dis-
order, generalized anxiety disorder, and substance
abuse, as compared with those who have not experi-
enced traumatic events. They may also have somatic
symptoms and physical illnesses, particularly hyper-
tension, asthma, and chronic pain syndromes.
To be given a diagnosis of PTSD, a person has to
have been exposed to an extreme stressor or trau-
matic event to which he or she responded with fear,
helplessness, or horror and to have three distinct types
of symptoms consisting of reexperiencing of the event,
avoidance of reminders of the event, and hyperarous-
al for at least one month (Table 1).
of the event refers to unwanted recollections of the
incident in the form of distressing images, nightmares,
or flashbacks. Symptoms of avoidance consist of at-
tempts to avoid reminders of the event, including
persons, places, or even thoughts associated with the
incident. Symptoms of hyperarousal refer to physio-
logical manifestations, such as insomnia, irritability,
impaired concentration, hypervigilance, and increased
Within the first month after a traumatic experience,
traumatized persons may meet the diagnostic criteria
for acute stress disorder. Although acute stress disor-
der is not always followed by PTSD, it is associated
with an increased risk of PTSD.
The symptoms of PTSD are readily identifiable by
a primary care physician. Because there is substantial
overlap between the symptoms of PTSD and those
of depression and other anxiety disorders, however,
the diagnosis is easily missed unless specific inquiries
are made about the occurrence of a traumatic event.
Often practitioners are reluctant to ask their patients
about events that might be distressing or that might
involve shame or secrecy, and patients will not usually
mention such topics without prompting. By provid-
ing patients with the opportunity to disclose such
events, practitioners break down an important barrier
to treatment by legitimizing the event as a valid expla-
nation for symptoms. Exposure to a traumatic event
can often explain the presence of nonspecific symp-
toms such as palpitations, shortness of breath, tremor,
nausea, insomnia, unexplained pain, and mood swings,
as well as a reluctance to undergo certain types of
examinations (e.g., rape victims may feel uncomfort-
able undergoing a gynecologic examination) and be-
havior such as nonadherence to treatment, which
may be a manifestation of avoidance.
wise unexplained physical symptoms or behavior may
prompt clinicians to question patients about the pos-
sibility of traumatic experiences and the specific symp-
toms of PTSD.
114 · N Engl J Med, Vol. 346, No. 2 · January 10, 2002 · www.nejm.org
The New England Journal of Medicine
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