Post-Traumatic Stress Disorder
What is post-traumatic stress disorder (PTSD)?Post-traumatic stress disorder (PTSD) is a reoccurring stress response that follows the exposure to a traumatic event. PTSD can be acquired when: • You directly experienced the trauma (e.g. you believed you were in danger or your life was threatened). Or you have been involved in managing the traumatic incident (e.g. you helped the person in danger and/or interacted with an attacker in some way). • You witnessed a trauma in close proximity “with your own eyes”, but without direct involvement e.g. you saw someone else in danger, being injured, or actually die. • You learned about the trauma from family or close friends who were involved in the incident. • You were informed about the trauma from external sources e.g. the media such as television news or factual documentaries. External sources are likely to affect you if you are highly sensitive to viewing distressing scenes. They can also re-activate your PTSD symptoms if you have suffered a previously related trauma.
Does everyone get post-traumatic stress disorder following a trauma?Post-traumatic stress disorder is a distressing reactive revisit to a past traumatic event, but most people do not develop PTSD following the trauma. It is common to have an ‘acute stress response’ within the first month where your mind is coming to terms with the traumatic events. Your understanding of the trauma and the emotional connection that you have made with it is being processed and released. But for about 30% of those who have suffered a trauma, you can find that your symptoms persist for longer than a month. When you have Post-traumatic stress disorder, you are unable to come to terms with the traumatic events and the “normal processing” of the trauma is obstructed. The post-traumatic stress symptoms become the new problem; a series of “aftershocks”, creating the disorder (PTSD) in the long term.
Post-traumatic stress disorder risk factorsA group of people can be exposed to the same trauma, but only some people in that group will suffer with Post-traumatic stress disorder. So why are some people more likely than others to get PTSD following an exposure to a trauma? Research suggests that genetics can increase your susceptibility to PTSD. So if you are exposed to any traumatic events, what you have inherited from your family genes will dictate how you manage the trauma. Certain subcultures and biological groups can also be vulnerable to Post-traumatic stress disorder. They include those with learning difficulties, mental illness, children and adolescents, females and certain minority groups. It is considered that some of these groups have a heightened sensitivity to trauma, or can have a different biological pathway that affects the brain’s response to trauma. Some risk factors are more situational. They include:
- Frequency of traumatic events – You have dealt with a number of traumas in your life either due to your occupation, lifestyle or by circumstance. This accumulation of different traumas has compounded your symptoms.
- Duration of traumas – One or several of your traumas have been experienced over a period of time increasing your feeling of helplessness. You may have been trapped in your traumatic situation for a long period.
- Suddenness of traumas – When the trauma is unexpected, the degree of alertness is intensified. Sudden shocks prevent any preparation or rehearsed coping strategies.
- Severity of trauma – This can be subjective depending on your sensitivity and connection with the trauma (some young children have reported being traumatised by horror films). But those traumas in which you are personally involved in (rather than being told about it after the event), have a higher death rate, involve children and involve the mutilation of body parts will increase your risk of Post-traumatic stress disorder. Man-made (rather than natural) traumas are also considered to increase the risk of PTSD possibly because they destroy trust in other human beings.
- You work in a high risk occupation – This can include the military, police, medical and rescue services.
- You are a refugee or asylum seeker – Being forced to leave your home, family and friends under harrowing circumstances and then face the uncertainty of rebuilding your life in a new country can be a cause of Post-traumatic stress disorder
- Presence of a prior psychological condition – Having another condition prior to exposure to your trauma e.g. depression, anxiety disorder and high stress levels from a non-related issue may increase the effect of a trauma. It is important to remember that some conditions may not have been diagnosed prior to the trauma. If you have a negative emotional trait e.g. prone to feeling guilt, the negative emotion can influence your negative processing of the incident. Thus if you have survived the trauma and other family members died, excessive guilt would become part of your PTSD symptoms.
- A lack of support following the trauma – Dealing with the trauma in isolation may mean that you suppress or repress the effects of the trauma. By refusing to accept help or deny that there is an issue, you may be reinforcing your negative interpretation of the trauma e.g. blaming yourself for the trauma or your mistaken handling of the trauma.
- Violence in the home – Parental violence in the home can have the same traumatising effect on children as combat has on soldiers. It is thought that those children who have been exposed to violence in the home adapt their brains in the long term to be hyper-aware of external danger, increasing the risk of Post-traumatic stress disorder. Even with domestic violence inflicted on partners, the same adaptive responses can happen in the long-term abused partner. This is because your partner (who you would expect to be trustworthy and nurturing) ends up betraying you. This can cause you to feel abandoned, ashamed and helpless. The traumatising effects accumulate because the abuser often denies the abused person any medical or psychological support. In a family situation, feelings of hopelessness suppress the courage needed to escape with your children to a safe place. Even when you have managed to flee the domestic situation, the “aftershocks” (or PTSD as the condition) continue to haunt you.
What traumas cause Post-Traumatic Stress Disorder?Post-traumatic stress disorder symptoms can begin following any traumatic event, but usually involve those traumas with intense fear, horror or helplessness. Here are some examples:
- Personal violent attacks including mugging, robbery, sexual assault and physical abuse.
- Severe domestic neglect or abuse as a child (or adult).
- Having a traumatic childbirth as the mother or witnessing partner.
- Being diagnosed with a life-threatening illness.
- Serious accidents including road accidents and fires.
- Military combat including being a prisoner of war.
- Acts of terrorism including being held hostage.
- Natural disasters such as earthquakes, tsunamis or major flooding.
- Witnessing violent injuries or deaths.
- Losing a partner, member of the family or close friend in distressing circumstances.
What are Post-Traumatic Stress Disorder symptoms?There are many Post-traumatic stress disorder symptoms, but they tend to fall into 4 categories: 1. Re-living aspects of the trauma These are associations that draw you back to the trauma and can be caused internally (in your own mind) or by some external event or situation. • Flashbacks – Flashbacks are intense memories replaying in your mind and feel like you are experiencing the emotions of the trauma over again. Flashbacks can be in the form of images, sounds, smells, feelings and physical sensations (see below). Flashbacks indicate that your mind is struggling to cope and is overwhelmed by the emotion of the trauma. • Nightmares – You can sustain vivid dreams of the actual trauma, disturbing “distorted” dreamed accounts of the trauma (usually emphasising your negative emotions) and unrelated yet adrenaline-filled dreams with night sweats. • Physical responses – You can experience distressing physical symptoms when you are reminded of the trauma e.g. when watching the news or a movie, hearing a sound or seeing images that symbolised the trauma (such as hearing explosions or seeing an object used in the attack). The physical responses can be similar to those experienced in a panic attack. 2. Avoidance behaviour When you experience a trauma, it is common to exhibit avoidance patterns of behaviour to protect you from the reactions outlined in 1 (above). • Changing routines – At first, subtle changes are made to your routines to try and cope with the associations you have made with your traumatic experience. But the associations grow, making it more difficult to function on a daily basis as more situations, objects, people and events are met with avoidance. • Social isolation – You don’t want people to see your stress reactions, so you avoid certain people or larger groups. But the importance of “having” to go to formal events e.g. a wedding, builds up the anticipatory anxiety, making the situation harder to cope with when the event arrives. • Withdrawal – As you become more aware of your stress reactions in different situations, you lose interest in what you used to enjoy. You withdraw from hobbies, locations, people and events as a way coping with the effects of the trauma. Even when you are with people, you feel tense and self-absorbed because you are confused about where the next anxiety attack will come from. • Depression – Your life feels increasingly out of control since it is dominated by anxiety and other negative emotions (guilt, distrust, self-blame and shame). This situation becomes more hopeless because you ultimately lose the enthusiasm for those things that you once enjoyed. Some trauma survivors feel suicidal. • Emotionally numb – You suppress your emotions to get through each event; it feels like each day is a survival task. You may abuse certain substances e.g. alcohol or drugs. • Amnesia of the traumatic event – Conscious and unconscious “blanking” of the traumatic event is part of your survival method to protect you from re-awakening those distressing emotions. 3. Hyper-alertness This is where you remain on a state of constant hyper-vigilance causing you to feel tense and irritable. • You are easily startled – Your senses are over-attentive causing you to feel “jumpy” when they are stimulated e.g. loud noises overwhelm you. • Daily functioning is affected – you struggle to concentrate, relax, eat food (due to nausea), and sleep. You develop a variety of stress-related symptoms e.g. migraines, aches and pains. • Impending doom – You are on the continuous “red alert” waiting for something disastrous to happen. 4. Detachment This is where your mind disengages from reality to keep you safe from further harm. Due to the extreme states of hyper-attentiveness (see 3. above), the constant fatigue can also cause you feel emotionally absent. • You feel disconnected – It’s as if something in your sub-consciousness is constantly drawing your attention, demanding to be dealt with when you are trying to relax. • General amnesia – In addition to forgetting the traumatic event, you struggle to remember recent events and things that need to be done. • Confused identity – You may be questioning who you are and how you ought to behave in situations following your traumatic encounter. • Hallucinations – Depending on the nature of your trauma, you may imagine that the trauma is happening to you again (when in reality nothing is happening). Or you imagine that it is happening to people around you, or affecting certain objects or situations. Images can be distorted, leaving you confused about whether you are really seeing these distortions or are just imagining them.
Children’s PTSD symptomsOlder children (teenagers) tend to show Post-traumatic stress disorder symptoms that are very similar to adults, but they can also be more externally aggressive and disrespectful as a way of coping with the trauma. PTSD Symptoms in children, particularly in the very young, can be different to those experienced by adults. Young children can experience:
- Insecurity – They worry that something traumatic will happen to you. They feel more anxious when you are about to leave them or are away from them for extended periods. They can be unusually clingy in your presence and seek reassurance that you are not in any danger.
- Re-living the trauma – A tendency to express the negative emotions of the trauma in art, role-play and stories.
- Disturbed sleep – Restless nightmares (with sleep walking) directly related to the trauma, or anxious sleep patterns with unidentifiable content.
- Loss of functional habits – Young children can be become incontinent and suffer with enuresis (bedwetting). Speech patterns can also become inhibited.
- New fears and phobias – Fears become exaggerated for very young children e.g. fear of the dark, ghosts and monsters.
- More anxiety-related symptoms – These can include loss of appetite, aches and pains, nausea etc.
- Aggression – As with older children, younger children can also display anger directly or in the form of tantrums/mood swings.
Why does Post-Traumatic Stress Disorder happen?By understanding the difference between normal memory storage and traumatic memory storage, you can appreciate why certain symptoms are experienced following a traumatic incident. Normal memory storage – In basic terms, the brain is like an ever-changing wardrobe full of clothes that has been neatly arranged according to many factors e.g. your beliefs and values. Your brain (wardrobe) prefers that clothes are processed (washed, ironed and labelled) before being placed into the wardrobe. This makes it easy for the retrieval and selection for the clothes in different situations. When you have an experience, you are given some items of clothing to store away in the right place. You may put it on the temporary holding rail if they are “dirty” or doesn’t have a category yet (you haven’t made sense of them) or you may need to “compress” some of the clothes in a category when a section has become full. But the experiences (clothing) need processing before they can be stored comprehensively in the wardrobe. Once stored, the clothing then becomes a memory. When it has been stored in the right place, it can be accessed easily and worn to suit the right occasion. So under normal conditions (low to moderate stress), the storage and retrieval of your clothing (experiences and memories) is an organised and coordinated system (we won’t go into fancy dress parties just yet!) Traumatic memory storage – In traumatic memory storage however (and using the analogy), the processing of the clothing (traumatic experience) is suspended. The traumatic experience increases the load by a few hundred items and because of the stressful nature of the experience, the clothing is heavily soiled. So clothing is randomly stuffed into the wardrobe without being processed, causing the wardrobe doors to bulge in places. The soiled clothing contaminates the other clothes (causing internal conflicts e.g. panic attacks). Feeling overloaded and about to burst open, clothing is expelled back into the processing area (into your consciousness as flashbacks), demanding to be sorted. You end up wearing the wrong clothes to different situations causing your to feel out of place (detached). You can keep throwing the clothes back into the wardrobe unprocessed (as avoidance), but the wardrobe will keep rejecting them until they have been processed properly. Each time that you go back into the wardrobe to access an individual item of clothing (memory), random or traumatic clothes (memories) are forced up into your consciousness. Summary of why Post-traumatic stress disorder happens - During a traumatic experience, high levels of adrenaline are released to help you deal with the trauma. The need to survive is the priority, so the mind interrupts and fragments the processing and storage of the traumatic event until the perceived danger has passed. During this continued red alert period, the “events”, emotions and sensations of the trauma can become distorted. Some memories are “forgotten” and others are re-presented for storage causing the individual to have disturbing flashbacks. Distressing emotions that were experienced at the time of the trauma can also be re-experienced at random moments. This can cause feelings of extreme helplessness and fear because acute anxiety is felt when there is an absence of any external danger. The processing of sensations (e.g. sounds) experienced during the trauma can also be “misfiled” when being presented for memory storage. Hypersensitivity to the sounds heard during the trauma can be increased with Post-traumatic stress disorder and you can suffer hallucinations i.e. believe that you are hearing sounds of gun fire when there are none. The processing and storage abilities in the mind can be restored when the system has been stabilised (i.e. stress and anxiety have been reduced). Repairs to the processing and storage of the traumatic experience can then be completed in gradual stages, re-analysing the experience in manageable “chunks”.
Common Treatments for Post-Traumatic Stress DisorderTreatment for Post-traumatic stress disorder will aim to reduce the effect that the acute stress is having on your body. It will also help you deal with the trauma in stages to reduce the symptoms you are experiencing. Medication – In consultation with your doctor or consultant, medication can be prescribed to increase serotonin levels. This can reduce your anxiety and depression and any other symptoms associated with your PTSD. Medication may be chosen as the main treatment when the threat of the trauma is recurrent (e.g. with domestic abuse). It may also be used if other treatments have not been beneficial for you or you prefer not to be treated with trauma focused psychological therapy. Psychological therapy – There are various types of trauma focused therapy (psychotherapy) including
- Cognitive behavioural therapy (CBT) – CBT can help you challenge your irrational (or distorted) thoughts and feelings associated with the trauma.
- Exposure therapy – This therapy helps you to gradually deal with the traumatic events in small steps. As you go through the desensitisation process, you relearn how to control your fearful responses to the trauma.
- Eye-Movement Desensitisation and Reprocessing (EMDR) – This therapy incorporates CBT with eye movements, sounds or tapping movements with the hand. As with the other therapies, it aims to reprogram your reactions to the traumatic memories.