Understanding PTSD and Dissociative Symptoms

What PTSD Really Is

If something overwhelming happened to you — and your mind and body have not let it go — you are not weak, and you are not broken. You are showing a recognizable pattern that medicine has named, studied, and learned how to treat. That pattern is post-traumatic stress disorder, or PTSD.

PTSD is the brain and body’s protective response to an event that pushed past what a person could process in the moment. The same alarm systems that kept you alive — the ones that flooded your body with adrenaline, narrowed your attention, and made certain memories burn in vividly — sometimes stay switched on long after the danger has passed. The result is a set of symptoms that feel like the past is still happening, even when the calendar says otherwise. Those symptoms take many shapes, and the site’s essay on the many faces of PTSD describes how varied they can be.

A few things are worth saying out loud, because they matter.

• PTSD is a real medical condition with a clear diagnosis, a clear neurobiology, and well-tested treatments.
• PTSD is not evidence that you are too sensitive, too dramatic, or too weak. Trauma changes the way the nervous system reads safety. Smart, strong, capable people develop PTSD.
• PTSD is treatable. With the right care, most people who complete a full course of evidence-based therapy see real, lasting reduction in symptoms.

This essay gives an honest, clinically grounded picture of what PTSD is. Just as importantly, it describes one form of PTSD that is often missed: PTSD with dissociative symptoms.

How PTSD Is Diagnosed: The DSM-5-TR

The diagnosis comes from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision — usually shortened to DSM-5-TR, published by the American Psychiatric Association in March 2022.¹ The adult criteria for PTSD did not change between the 2013 DSM-5 and the 2022 DSM-5-TR; the text revision updated surrounding material such as cultural considerations.²

To meet the diagnosis, several conditions must be present together.

Criterion A: Exposure to trauma

You were exposed to actual or threatened death, serious injury, or sexual violence, in at least one of these ways:

• It happened directly to you.
• You witnessed it happening to someone else in person.
• You learned that it happened to a close family member or close friend (in cases of death or threatened death, the event must have been violent or accidental).
• You had repeated or extreme exposure to disturbing details — for example, as a first responder, a clinician, or a professional who handles the aftermath of trauma.

This essay deliberately does not describe specific events. The point is that Criterion A is specific. PTSD is not a label for “stress” in the everyday sense. It follows a particular kind of life-threat or sexual-violence exposure.

The four symptom clusters

After that exposure, PTSD is defined by symptoms that fall into four groups:¹²

1. Intrusion. Unwanted memories, dreams, or moments where the past breaks into the present.
2. Avoidance. Steering clear of reminders — places, people, conversations, internal feelings — that pull you back toward the event.
3. Negative changes in thinking and mood. Persistent numbness, distorted self-blame or blame of others, loss of interest in things that used to matter, a sense that the world is unsafe or that you are permanently damaged.
4. Changes in arousal and reactivity. Being on guard, jumpy startle, irritability or anger, sleep disturbance, difficulty concentrating, sometimes reckless or self-destructive behavior.

Duration and impairment

These symptoms must last more than one month and cause meaningful distress or interference with your work, your relationships, or your daily life. If criteria are not met until at least six months after the event, the condition is called PTSD “with delayed expression.”¹

The Dissociative Subtype: PTSD with Dissociative Symptoms

Inside the same DSM-5-TR diagnosis, there is a specifier — a more precise label — called PTSD with dissociative symptoms.¹³ Clinicians sometimes call this PTSD-D or the dissociative subtype. This is where this essay slows down, because the dissociative subtype is often missed.

To meet criteria for this specifier, a person has full PTSD and also has persistent or recurring experiences of one or both of these:¹

• Depersonalization — feeling detached from your own body, thoughts, or feelings, as if you are watching yourself from outside, or as if the experience of being you is not quite real.
• Derealization — the world around you feeling unreal, dreamlike, foggy, distant, or as if behind glass.

In plain English: classic PTSD often looks like the alarm is too loud. Dissociative PTSD often looks like the alarm has been turned down so far that the person feels far away from their own life. Both are protective responses. Neither is a character flaw.

How common is it?

The National Center for PTSD (a program of the U.S. Department of Veterans Affairs) summarizes the research as showing that roughly 15% to 30% of people with PTSD also meet criteria for the dissociative subtype.³ A 2022 systematic review and meta-analysis by White and colleagues in Psychological Medicine — the most-cited recent estimate — found 22.8% (95% CI 14.8–32.0%) when researchers used careful statistical methods (latent class and latent profile analysis), and 38.1% (95% CI 31.5–45.0%) across all samples combined, with higher rates in samples that relied on clinical cutoffs and in children.⁴ Veteran samples sometimes run substantially higher.⁵ The honest summary is that this is not a rare presentation — it likely accounts for roughly one in five to one in three people with PTSD, and more in some populations.

A different brain pattern: over-regulation, not shutdown

Research led by Ruth Lanius and colleagues, first published in the American Journal of Psychiatry in 2010 and confirmed in multiple imaging studies since, has shown that classic PTSD and dissociative PTSD show opposite patterns in the brain when a person encounters reminders of the trauma.⁶⁷

• In classic PTSD, frontal-brain regions that normally calm the alarm system (the medial prefrontal cortex and the rostral anterior cingulate cortex) show lower activity, and the limbic alarm system (especially the amygdala) shows higher activity. The system is under-regulated — the brakes are not engaging.
• In dissociative PTSD, the same frontal regions show higher activity and the amygdala shows lower activity. The brakes are slammed on. The system is over-regulated.

That framing is deliberate. Dissociation is not the mind giving up or shutting down. It is the mind clamping down — protecting itself by muting feeling, body sensation, and a sense of being present. That is useful in a survival moment. It becomes a problem when it keeps happening long after the danger is gone.

Why it matters clinically

The dissociative subtype matters because it changes both the risks and the right pacing of treatment.

• Risk of suicidal thoughts and self-harm is higher. A 2026 study of a nationally representative U.S. veteran sample (Fogle and colleagues, Journal of Clinical Psychiatry) found that veterans with the dissociative subtype had roughly 3-fold greater odds of lifetime suicide plan and current suicidal ideation, and 5-fold greater odds of lifetime non-suicidal self-injury, compared to veterans with PTSD without dissociation.⁵ Meta-analyses (Calati and colleagues, 2017) point the same way: across psychiatric patients, those with a dissociative disorder were more likely than those without one to report past suicide attempts and non-suicidal self-injury.⁸
• Treatment has to be paced. Asking someone with prominent dissociation to dive into detailed trauma memory work without first building stabilization skills can worsen dissociation and outcomes. This is why the International Society for the Study of Trauma and Dissociation (ISSTD) recommends a phase-based approach when dissociation is prominent.⁹ The National Center for PTSD does not set out phases. It reports preliminary evidence that people with depersonalization or derealization responded better to treatments that added cognitive restructuring and skills training in emotional and interpersonal regulation than to exposure-based therapy alone.³ More on that below.

What PTSD and Dissociation Are Not

• Not weakness. PTSD is a biological response, not a personality failure.
• Not “all in your head.” PTSD changes how brain circuits regulate fear, memory, and arousal. It shows up on imaging studies and in physiology.⁶
• Not the same as a difficult memory or normal stress. PTSD requires Criterion A trauma plus a specific cluster of symptoms lasting more than a month. Grief, burnout, and ordinary stress reactions — while real and worth treating — are different conditions.
• Not the same as Dissociative Identity Disorder (DID). DID is a separate diagnosis involving distinct identity states and significant gaps in memory of everyday events. The dissociative subtype of PTSD shares some neurobiology with DID, but it is a specifier within the PTSD diagnosis, not a separate identity-fragmentation disorder.
• Not untreatable. This is the most important “not.” Several therapies have strong evidence. Many people get substantially better.

Who Gets PTSD

PTSD is common enough that almost everyone knows someone affected. According to the National Institute of Mental Health (NIMH), drawing on the National Comorbidity Survey Replication, lifetime PTSD affects an estimated 6.8% of U.S. adults, with past-year prevalence around 3.6%.¹⁰ Women are affected at roughly twice the rate of men — past-year prevalence of 5.2% in women versus 1.8% in men, and lifetime estimates of about 8% in women versus 4% in men.¹⁰ Rates are higher in populations with high trauma exposure: combat veterans, survivors of sexual assault, first responders, refugees, and people with childhood maltreatment histories.¹⁰

Within those who develop PTSD, roughly 15% to 30% also meet criteria for the dissociative subtype, with higher rates in some clinical and veteran samples.³⁴⁵

Safety First

If you are reading this and having thoughts of suicide or of hurting yourself, please reach out tonight — call or text 988 in the United States. More resources, national and local to the Inland Empire, are listed at the end of this essay.

A few principles, kept simple on purpose, because this is not a place for cleverness:

• Dissociation can increase risk, in part because feeling detached from your body can lower your awareness of danger. If you live with prominent dissociation, please tell your treatment team.
• Lethal-means safety — putting time and distance between yourself and any means you might use to harm yourself — is one of the most evidence-supported things any person at risk can do. Your clinician can help you plan this.
• This essay does not recommend coping techniques that rely on physical discomfort or sensory shock. Safer grounding strategies exist, and your therapist can teach them to you in a way that fits your body and your history.

Zoom

Evidence-Based Treatment

This is the section where hope earns its keep.

Trauma-focused psychotherapy is first-line

Across the major guidelines — the U.S. Department of Veterans Affairs / Department of Defense Clinical Practice Guideline (2023),¹¹¹² the American Psychological Association Clinical Practice Guideline (2025),¹³¹⁴ the U.K.’s NICE guideline NG116 (2018, current),¹⁵ and the World Health Organization — the strongest recommendation is the same: when PTSD is present and severe enough to treat, the most effective treatments are specific, time-limited trauma-focused psychotherapies, used over medication when possible.¹¹¹³ The site’s treatment hub walks through what works and what order to try it in.

Three therapies are most often singled out:

1. Cognitive Processing Therapy (CPT)

Developed by Patricia Resick. The standard protocol is 12 sessions (Resick, Monson & Chard, 2016). CPT helps you identify the “stuck points” — beliefs about safety, trust, power and control, self-esteem, and intimacy — that the trauma installed or reinforced, and to test those beliefs against the evidence. CPT is strongly recommended by both the 2023 VA/DoD CPG and the 2025 APA CPG.¹¹¹³¹⁴

2. Prolonged Exposure (PE)

Developed by Edna Foa. Roughly 8 to 15 sessions. PE pairs gradual, structured approach to feared but safe reminders in daily life (in vivo) with revisiting the trauma memory in a controlled therapeutic setting (imaginal). The goal is not to relive but to process — to teach the nervous system, in a safe room with a trained clinician, that the memory is a memory. PE is strongly recommended by both the 2023 VA/DoD CPG and the 2025 APA CPG.¹¹¹³¹⁴

3. Eye Movement Desensitization and Reprocessing (EMDR)

Developed by Francine Shapiro. Roughly 8 to 12 sessions. EMDR uses bilateral stimulation — usually eye movements, sometimes taps or tones — while a person briefly attends to the trauma memory and the beliefs and body sensations attached to it. EMDR has a Strong For recommendation in the 2023 VA/DoD CPG,¹¹ and the ISTSS and WHO PTSD guidelines also recommend it. NICE NG116 signals strength through its wording instead, using “offer” where evidence of benefit is clear and strong and “consider” where it is less certain. It says to offer EMDR to adults who present more than three months after a non-combat-related trauma, and to consider it between one and three months if the person prefers it; its adult EMDR recommendations are limited to non-combat-related trauma.¹⁵ The 2025 APA CPG gives EMDR a conditional (second-line) recommendation rather than its top tier.¹³ That difference is mentioned so you can ask honest questions, not because EMDR lacks evidence. Many trauma clinicians and trauma survivors find EMDR a good fit.

In head-to-head comparisons, CPT, PE, and EMDR perform similarly on average. The largest VA randomized trial to date (Schnurr and colleagues, JAMA Network Open, 2022; 916 veterans) found that PE was statistically more effective than CPT, but the difference was not clinically significant.¹⁶ Meta-analyses of trauma-focused CBT versus EMDR have likewise concluded that the two are roughly equivalent. The choice is usually driven by what is available in your area, how each fits your temperament, and your preference after an informed conversation with a trauma-trained clinician.

A short, honest note on a treatment that was downgraded: Narrative Exposure Therapy (NET) was a “Strong For” recommendation in the 2017 VA/DoD guideline and was moved to “Neither for nor against” in the 2023 update.¹¹¹² It may still be useful for some patients, but the evidence base did not hold up to the more rigorous re-review.

Phase-based treatment for the dissociative subtype

When dissociation is prominent, the structure of treatment matters. The standard framework, set out in the ISSTD 2011 adult treatment guidelines, uses three phases:⁹

1. Safety and stabilization. Grounding skills, emotion-regulation tools, sleep hygiene, lethal-means safety, building a steady working alliance with your therapist. This is not a delay; it is a foundation.
2. Trauma memory processing. CPT, PE, or EMDR, often delivered with modifications (slower pacing, more grounding, smaller doses of exposure) to keep the person inside their “window of tolerance.”
3. Integration. Reconnecting with the parts of life — relationships, work, identity, meaning — that trauma had narrowed.

The APA Professional Practice Guidelines for Working with Adults with Complex Trauma Histories, approved in August 2024 (developed jointly with ISSTD), explicitly endorse sequencing treatment in phases matched to each person’s readiness and preference, while noting that trauma-focused therapy may be given initial consideration.¹⁷ (The site’s essay on complex PTSD explains that diagnosis.) Jumping directly to exposure-based processing, without preparatory stabilization, can worsen dissociation in patients with prominent depersonalization or derealization.³

One point of context. The 2023 VA/DoD guideline sets no stabilization gate before trauma-focused therapy, and the site’s treatment hub says so plainly. That guideline also found trauma-focused therapy well tolerated and effective in studies that included people with dissociation, though its confidence in that evidence was low.¹¹ The case for a skills-first phase here is specific to prominent dissociation, and it is a matter of clinical judgment rather than a rule. It rests on the ISSTD guidance, which was written for dissociative identity disorder; on the APA guidance above, which treats sequencing as flexible and guided by readiness and preference; and on the preliminary studies the National Center for PTSD summarizes, in which treatments that added cognitive restructuring and skills training to exposure did better than exposure alone.⁹¹⁷³

Medications

Two medications are FDA-approved for PTSD: sertraline (Zoloft) and paroxetine (Paxil). Both are selective serotonin reuptake inhibitors (SSRIs).¹⁸ Venlafaxine (Effexor XR), a serotonin-norepinephrine reuptake inhibitor (SNRI), has strong evidence and is recommended off-label by the 2023 VA/DoD CPG.¹¹¹⁸

A few important medication points from current guidelines:¹¹¹⁸

• Benzodiazepines (such as alprazolam, lorazepam, diazepam, clonazepam) are strongly recommended against for PTSD by the 2023 VA/DoD CPG. The evidence shows no benefit and significant harm, including reduced response to trauma-focused psychotherapy.
• Cannabis is also strongly recommended against by the 2023 VA/DoD CPG, based on absence of high-quality evidence of benefit and known harms.
• Prazosin has mixed evidence. It is not recommended for global PTSD symptoms (weak against), but it is weakly recommended for trauma-related nightmares in the 2023 VA/DoD CPG.
• MDMA-assisted therapy is not FDA-approved. On August 8, 2024, the FDA issued a Complete Response Letter to Lykos Therapeutics (the company announced it the next day) declining approval and requesting additional Phase 3 study; the full letter was made public on September 4, 2025.¹⁹ In August 2026 the sponsor, now called Resilient Pharmaceuticals, was reported to have resubmitted the application without a new Phase 3 study; the site’s essay on the future of PTSD treatment tracks its status. The 2025 APA CPG concluded that current evidence is insufficient to recommend MDMA-assisted therapy or ketamine for PTSD.¹³¹⁴

Medication is a treatment in its own right, not only an add-on. The 2023 VA/DoD CPG strongly recommends sertraline, paroxetine, or venlafaxine for PTSD and prefers trauma-focused psychotherapy when both are available and feasible; it finds insufficient evidence for or against combining a medication with trauma-focused psychotherapy.¹¹ A combined plan is reasonable when sleep, depression, or daytime hyperarousal is interfering with engagement in therapy. For medication questions specific to depersonalization and derealization, see the site’s essay on low-dose naltrexone for dissociation.

Hospitalization

PTSD is overwhelmingly treated outpatient. Brief inpatient stays may be needed for acute safety — for example, if suicidal thoughts intensify and outpatient supports are not enough. Prolonged inpatient stays for PTSD itself are not standard and are usually not helpful.

What to Expect from Treatment

A clear-eyed, hopeful picture:

• Most trauma-focused therapies run 8 to 15 weekly sessions, sometimes longer for complex or dissociative presentations.
• A meaningful majority of people who complete a full course of CPT, PE, or EMDR experience substantial reduction in symptoms. The VA National Center for PTSD reports that, on intent-to-treat analyses, 53% of those who initiate PE no longer meet diagnostic criteria for PTSD, rising to 68% among those who complete treatment.¹⁸ CPT and EMDR show comparable response and loss-of-diagnosis figures across multiple randomized trials.¹⁶
• Recovery does not mean forgetting. Recovery means the memory becomes a memory — something you can recall when you choose to, that no longer hijacks your body or your day.
• For PTSD with prominent dissociation, treatment often takes longer because of the phase-based structure. That is not a problem to be hurried through. It is the architecture of safe, durable recovery.

Supporting Someone with PTSD

If you are a partner, parent, child, or close friend of someone with PTSD:

• Validate first; problem-solve second. “That sounds really hard” lands better than “Have you tried meditation?”
• Do not pressure them to talk about the trauma. Pressure backfires. Curiosity, patience, and steady presence work.
• Learn the difference between avoidance and pacing. Avoiding triggers for years is unhelpful; pacing oneself in early treatment is necessary.
• Encourage, do not enforce, treatment. You can offer to help find a therapist, sit in a waiting room, or attend a couples session. The decision to engage has to be theirs.
• Take care of yourself. Loving someone with PTSD is real work. You are allowed support of your own.

The site’s essay on loving someone with PTSD goes further, including boundaries.

Closing

If you read through this and recognized yourself — or recognized the person sitting next to you — a careful evaluation by a trauma-informed clinician is the right next step. The point of evaluation is not a label. The point is a plan.

When you look for a therapist, ask for the treatment by name: CPT, PE, or EMDR; eligible veterans can ask the VA Loma Linda Healthcare System for the same three. If you are already in care, tell your clinician about any depersonalization or derealization, because it can change the pacing of treatment.

Frequently Asked Questions

Do I have to talk in detail about what happened to get better? Not in the way most people imagine. CPT focuses more on the beliefs the trauma installed than on minute-by-minute retelling. EMDR uses brief attention to the memory plus bilateral stimulation. PE does include structured revisiting of the memory, but it is done gradually, with a trained clinician, in a way that is bearable. You will never be ambushed into talking about something you are not ready for.

What if I cannot remember everything? Memory gaps are common after trauma, especially when the trauma was repeated, occurred in childhood, or involved dissociation. Effective therapy does not require recovering every detail. It works with what you have.

Is PTSD a lifelong condition? For many people, no. With evidence-based treatment, the majority of those who complete care see substantial, lasting improvement.¹⁸¹⁶ Some people experience flares around anniversaries or new stressors; those flares are usually shorter and easier to manage than the original illness.

What is the difference between PTSD and just stress? PTSD requires a specific kind of exposure (Criterion A — life-threat, serious injury, or sexual violence), a specific symptom pattern in four clusters, duration longer than one month, and meaningful impairment.¹ Ordinary stress, grief, and burnout are real and deserve care, but they are different conditions.

Are dissociative symptoms dangerous? They are not inherently dangerous, but they raise some real risks — including a higher rate of suicidal thoughts and self-harm — and they shape how treatment should be paced.⁵⁸ They are very treatable. Tell your clinician about them honestly; do not assume they will figure it out without you.

Can children get PTSD? Yes. DSM-5 added a preschool subtype of PTSD for children six and under, with developmentally appropriate criteria.¹² School-age children and adolescents can also develop PTSD, sometimes with prominent dissociation. Trauma-focused therapies adapted for children, especially Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), have strong evidence.¹⁵ The site’s essay on PTSD in children and teens covers what parents can notice and do.

What if the trauma is still happening — ongoing abuse, ongoing war, ongoing harm? Safety comes first. Trauma-focused processing therapies are typically started after the active danger has ended. If you are in an ongoing unsafe situation, treatment focuses on safety planning, stabilization, and connecting you with the right resources — including domestic violence, sexual assault, and crisis services listed below. Healing the past is for after you are safe in the present.

Related reading on NP FADY

• How PTSD Is Treated Today: What Works, and What Order to Try It In
• The Many Faces of PTSD: Why It Almost Never Looks Like the Movies
• Low-Dose Naltrexone for Dissociation and Feeling Unreal: What We Know
• Complex PTSD, Explained: How It Differs From PTSD and BPD
• Loving Someone With PTSD: Support, Boundaries, and Treatment
• PTSD in Children and Teens: What Parents Can Notice and Do

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If you are in crisis right now, you deserve immediate help. These resources are free, confidential, and available 24/7 unless noted.

National

• 988 Suicide & Crisis Lifeline — call or text 988
• 988 en Español — call 988 and press 2, or text AYUDA to 988
• Veterans Crisis Line — call 988 and press 1, or text 838255
• The Trevor Project (LGBTQ youth) — 1-866-488-7386, or text START to 678-678
• Crisis Text Line — text HOME to 741741
• National Sexual Assault Hotline (RAINN) — 1-800-656-HOPE (4673)
• National Domestic Violence Hotline — 1-800-799-7233, or text START to 88788

California

• California Peer-Run Warm Line — call or text 1-855-600-WARM (9276) (non-crisis support; not a 24/7 line)

San Bernardino County

• SBC DBH ACCESS Line (24/7) — 888-743-1478
• SBC Mobile Crisis Response — call 800-398-0018 / text 909-420-0560
• Partners Against Violence (sexual assault, 24/7) — 909-885-8884
• SBC Substance Use Disorder Helpline (SUDRS) — 800-968-2636 (referrals 24/7)
• ARMC Adolescent Psychiatric ER (ages 13–17) — 909-580-1000
• Loma Linda University Children’s Hospital ER (under 13) — 909-651-6233

Riverside County

• Riverside RUHS CARES Line — 800-499-3008
• Inland SoCal Crisis Helpline — 951-686-HELP (4357)
• Riverside Area Rape Crisis Center (24/7) — 951-686-7273

For any life-threatening emergency, call 911 or go to your nearest emergency department.

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Sources

Footnotes

1. American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). Washington, DC: American Psychiatric Association Publishing. PTSD diagnostic criteria and “with dissociative symptoms” specifier, pp. 301–313. ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷

2. National Center for PTSD. PTSD and DSM-5. U.S. Department of Veterans Affairs. https://www.ptsd.va.gov/professional/treat/essentials/dsm5_ptsd.asp ↩ ↩² ↩³

3. National Center for PTSD. The Dissociative Subtype of PTSD. U.S. Department of Veterans Affairs. https://www.ptsd.va.gov/professional/treat/essentials/dissociative_subtype.asp ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶

4. White, W. F., Burgess, A., Dalgleish, T., Halligan, S., Hiller, R., Oxley, A., Smith, P., & Meiser-Stedman, R. (2022). Prevalence of the dissociative subtype of post-traumatic stress disorder: A systematic review and meta-analysis. Psychological Medicine, 52(9), 1629–1644. doi:10.1017/S0033291722001647 ↩ ↩²

5. Fogle, B. M., Fischer, I. C., Na, P. J., & Pietrzak, R. H. (2026). Dissociative subtype of posttraumatic stress disorder in US military veterans: Prevalence, correlates, and clinical characteristics. Journal of Clinical Psychiatry, 87(1). doi:10.4088/JCP.25br15977. PMID 41649329. https://www.psychiatrist.com/jcp/dissociative-subtype-of-ptsd-in-us-military-veterans/ ↩ ↩² ↩³ ↩⁴

6. Lanius, R. A., Vermetten, E., Loewenstein, R. J., Brand, B., Schmahl, C., Bremner, J. D., & Spiegel, D. (2010). Emotion modulation in PTSD: Clinical and neurobiological evidence for a dissociative subtype. American Journal of Psychiatry, 167(6), 640–647. doi:10.1176/appi.ajp.2009.09081168 ↩ ↩²

7. Nicholson, A. A., Friston, K. J., Zeidman, P., et al. (2017). Dynamic causal modeling in PTSD and its dissociative subtype: Bottom-up versus top-down processing within fear and emotion regulation circuitry. Human Brain Mapping, 38(11), 5551–5561. doi:10.1002/hbm.23748 ↩

8. Calati, R., Bensassi, I., & Courtet, P. (2017). The link between dissociation and both suicide attempts and non-suicidal self-injury: Meta-analyses. Psychiatry Research, 251, 103–114. doi:10.1016/j.psychres.2017.01.035 ↩ ↩²

9. International Society for the Study of Trauma and Dissociation. (2011). Guidelines for treating dissociative identity disorder in adults, third revision. Journal of Trauma & Dissociation, 12(2), 115–187. doi:10.1080/15299732.2011.537247 ↩ ↩² ↩³

10. National Institute of Mental Health. Post-Traumatic Stress Disorder Statistics. (Lifetime and past-year prevalence drawn from the National Comorbidity Survey Replication, Kessler et al., 2001–2002.) https://www.nimh.nih.gov/health/statistics/post-traumatic-stress-disorder-ptsd ↩ ↩² ↩³

11. U.S. Department of Veterans Affairs & U.S. Department of Defense. (2023). VA/DoD Clinical Practice Guideline for Management of Posttraumatic Stress Disorder and Acute Stress Disorder. https://www.healthquality.va.gov/guidelines/MH/ptsd/ ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷ ↩⁸ ↩⁹ ↩¹⁰

12. Lang, A. J., Hamblen, J. L., Holtzheimer, P., Kelly, U., Norman, S. B., Riggs, D., Schnurr, P. P., & Wiechers, I. (2024). A clinician’s guide to the 2023 VA/DoD Clinical Practice Guideline for Management of Posttraumatic Stress Disorder and Acute Stress Disorder. Journal of Traumatic Stress, 37(1). doi:10.1002/jts.23013 ↩ ↩²

13. American Psychological Association. (2025). APA Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults. Approved by APA Council, February 2025. https://www.apa.org/ptsd-guideline ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶

14. Pappas, S. (2025, July 1). CE Corner: PTSD and trauma: New APA guidelines highlight evidence-based treatments. Monitor on Psychology, 56(5). https://www.apa.org/monitor/2025/07-08/guidelines-treating-ptsd-trauma ↩ ↩² ↩³ ↩⁴

15. National Institute for Health and Care Excellence. (2018). Post-traumatic stress disorder (NG116). EMDR recommendations 1.6.18 to 1.6.20. https://www.nice.org.uk/guidance/ng116 ↩ ↩² ↩³

16. Schnurr, P. P., Chard, K. M., Ruzek, J. I., et al. (2022). Comparison of prolonged exposure vs cognitive processing therapy for treatment of posttraumatic stress disorder among US veterans: A randomized clinical trial. JAMA Network Open, 5(1):e2136921. doi:10.1001/jamanetworkopen.2021.36921 ↩ ↩² ↩³

17. American Psychological Association & International Society for the Study of Trauma and Dissociation. (2024). Guidelines for Working with Adults with Complex Trauma Histories. Approved August 2024. https://www.apa.org/practice/guidelines/adults-complex-trauma-histories.pdf ↩ ↩²

18. National Center for PTSD. Clinician’s Guide to Medications for PTSD. U.S. Department of Veterans Affairs. https://www.ptsd.va.gov/professional/treat/txessentials/clinician_guide_meds.asp ; Prolonged Exposure for PTSD. https://www.ptsd.va.gov/professional/treat/txessentials/prolonged_exposure_pro.asp ↩ ↩² ↩³ ↩⁴ ↩⁵

19. Lykos Therapeutics. (2024, August 9). Lykos Therapeutics announces Complete Response Letter for midomafetamine capsules for PTSD. https://www.prnewswire.com/news-releases/lykos-therapeutics-announces-complete-response-letter-for-midomafetamine-capsules-for-ptsd-302219182.html Confirmed by FDA public release of the CRL, September 4, 2025. Additional reporting: AJMC; HCPLive; Psychiatric Times (September 5, 2025). ↩