UNDERSTANDING POST TRAUMATIC STRESS DISORDER

 INTRODUCTION

Many of us will experience trauma at some point in our lives. With time, most people recover from their experiences without needing professional help. However, for a significant proportion of people the effects of trauma last for much longer, and they develop a condition called post-traumatic stress disorder (PTSD). It is thought that between 3 and 5 people out of every 100 will experience PTSD every year. Fortunately, there are a range of excellent psychological therapies for PTSD.

A traumatic experience is one which is overwhelming, threatening, frightening, or out of our control.

Common traumas include:

• Being in an accident or witnessing an accident
• Being in a life threatening situation like a natural disaster or medical emergency
• Being a victim to violence like physical or sexual assault, imprisoned, kidnapped, tortured or bullied
• Witnessing violence towards another person or death

Some traumas are isolated one-off events that are unexpected and happen ‘out of the blue’. Other traumas are frightening in different ways: they are expected, anticipated, and dreaded. Some people’s jobs expose them to trauma, for example military or emergency service personnel often experience or witness distressing events.

Children experience trauma too – and the effects can be even more profound and permanent if the people who were supposed to care for them were responsible for causing harm.

DEFINITION

Some people develop post-traumatic stress disorder (PTSD) after experiencing a shocking, scary, or dangerous event. It is natural to feel afraid during and after a traumatic situation. Fear is a part of the body’s normal “fight-or-flight” response, which helps us avoid or respond to potential danger. People may experience a range of reactions after trauma, and most will recover from their symptoms over time. Those who continue to experience symptoms may be diagnosed with PTSD.

It is normal to be affected by traumatic experiences. If you have been through a trauma you might feel shocked, scared, guilty, ashamed, angry, vulnerable, or numb. With time most people recover from their experiences, or find a way to live with them, without needing professional help. However, for many people the effects of trauma last for much longer and may develop into posttraumatic stress disorder (PTSD).

Symptoms of PTSD can be split into groups:

• Hyperarousal and Hypervigilance
• Re-experiencing what happened
• Negative thoughts and moods
• Avoidance of reminders

Re-experiencing symptoms

Re-experiencing the trauma means that memories of the event play over and over in your mind. These memories can come back as ‘flashbacks’ during the day, or as nightmares at night. The memories can be re-experienced in any of your five senses – you might see images of what happened, or experience sounds, smells, tastes, or body sensations associated with the trauma. Emotions from the trauma can also be re-experienced and many trauma survivors say that it can feel as though the events are happening over and again.

Reexperiencing symptoms include:

• Upsetting memories of the event intruding into your mind.
• Having nightmares about the event.
• Feeling physical reactions in your body when you are reminded of the event.
• Dissociation and feeling disconnected from the present moment.

Arousal symptoms

It is common to be ‘on edge’ or ‘on guard’ following a trauma. For people who have PTSD these feelings tend to persist for even longer than normal. You might find it very difficult to relax, or find that your sleep is affected.

Arousal symptoms include:

• Always looking out for danger. Psychologists call this ‘hypervigilance’.
• Feeling ‘on edge’ or easily startled.
• Having difficulty falling or staying asleep.
• Having difficulty concentrating.

Avoidance symptoms

A normal human way of dealing with physical or emotional pain is to avoid it, or to distract ourselves. When you have PTSD you might try to avoid any people, places, or any other reminders of your trauma. You might try very hard to distract yourself in order to avoid thinking about what happened.

Avoidance symptoms include:

• Avoiding reminders of the trauma.
• Trying not to talk or think about what happened.
• Feeling ‘numb’ or like you have no feelings.

Negative thoughts and mood.

Trauma has a powerful effect on how we think. Many people with PTSD blame themselves for what happened, even when it was not their fault. Or you might replay parts of the trauma and think “what if …?” or “if only …”. Many people with PTSD also experience depression.

Negative thoughts and mood about the trauma might include:

• Thinking negatively about yourself.
• Feeling guilty or ashamed about what happened.
• Feeling depressed or withdrawn.
• Feeling that no-one can be trusted.

We can separate the effects of PTSD into things that affect your mind (thoughts, images and memories), feelings, and behaviours.

What goes through your mind

• Intrusive and unwanted memories of the trauma (flashbacks).
• Images in your mind of what has happened, or what might happen.
• Thoughts that the trauma is happening again right now.
• Thoughts that what happened was your fault or that you could have prevented it.
• Thoughts that you are going mad.

How you may feel

Any emotions that you experienced at the time of the trauma, including:

• Fear
• Anger
• Humiliation
• Shame
• Disgust
• Dissociated (feeling separate or detached from what is happening).
• Feelings in your body that are the same as those you experienced during the trauma.

How you might act

• Avoid people or places that remind you of the trauma.
• Avoid thinking or talking about what happened.
• Try to push memories away, or forget the traumatic event.
• Avoid going to sleep for fear of nightmares.
• Use alcohol or drugs to numb yourself.
• Keep yourself busy.

COMPLEX TRAUMA

People who have experienced a lot of trauma, have experienced trauma early in their lives, or have experienced trauma as a result of things that were done by their parents or caregivers often have extra symptoms in addition to PTSD.

• How much trauma a person has experienced. A bigger ‘dose’ of trauma tends to result in more complex symptoms.
• The type of trauma. Interpersonal trauma – trauma deliberately inflicted by another human being – tends to have more complicated effects than trauma that occurs as the result of accidents.
• When it happened in a person’s life. Trauma that is experienced earlier in your life can have significant effects upon what happens to you later.
• Severe problems in managing your emotions. Psychologists call this a problem of ‘affect regulation’ or ‘emotion regulation’.
• Strong beliefs about yourself as diminished, defeated, or worthless. These might be accompanied by deep feelings of shame, guilt, or failure related to your traumatic experiences.
• Difficulties in sustaining relationships and in feeling close to others. This makes sense if you have experienced trauma at the hands of others.

When people experience these symptoms as well as PTSD, mental health professionals  might label it Complex PTSD. You can think of it as ‘PTSD Plus’. Research indicates that many of the treatments that are effective for PTSD are also effective for people with Complex PTSD.

What is it like to have PTSD?

People with PTSD experience strong unwanted memories of their trauma, to the point where it can feel as though the trauma is happening again right now in the present moment. As a result, people with PTSD often feel on-edge and on the lookout for danger. Some people find that reading about other people’s trauma can be upsetting, so feel free to skip this section until a time comes when you feel more able. Remember, though, that learning about trauma cannot harm you – it is the first step in overcoming PTSD.

EXAMPLE

TIM’S GUILT

I was driving some friends home after spending a day at the lake. As I pulled out from a side road we were hit by another car whose driver we later found out was using his phone. I saw the other car coming towards us but couldn’t get out of the way. My friend, who was sitting in the passenger seat, was killed in the accident. Six months after the accident I couldn’t get it out of my mind. I had nightmares where the crash happened over and over again, and I would wake up covered in sweat. Even though I tried to keep my mind occupied during the day, I would keep seeing the crash in my mind and would see pictures of my friend in the hospital morgue. I blamed myself for what happened, and kept thinking to myself “What if I’d chosen to go another way?”, “My friend would be alive now”. I didn’t go to my friend’s funeral because I couldn’t face seeing his parents. I stopped driving because cars made me so anxious, and I couldn’t bear to go anywhere or do anything that reminded me of the accident. I was convinced that other people thought I was a bad person, so I cut myself off from the friends I used to hang out with.

What causes PTSD?

The main cause of PTSD and Complex PTSD is being exposed to traumatic, life-threatening, or frightening events. Not everybody who experiences a trauma goes on to develop PTSD and it is not your fault if you suffer from it. Some of the things that make people more likely to develop PTSD after a traumatic experience include:

• How much social support you have.

Psychologists have found that people with higher levels of social support are less likely to develop PTSD following a trauma. If you have people to talk to, with whom you can make sense of a trauma, it can act as a ‘protective shield’ from the effects of what happened.

• The way your brain processes memories of your trauma.

Memories in PTSD are different from ‘normal’ memories: they are much more vivid and intense; and have the ability to ‘trick’ you into thinking that the trauma is happening again – even many years after the trauma is over. Scientists think that there are differences in the way that your brain encodes, stores, and retrieves trauma memories which mean that some people are more likely to develop PTSD.

• Genetic and biological factors.

There is some evidence that genetic and biological factors can influence who develops PTSD following a trauma. For example, some psychologists argue that the size of a part of the brain called the hippocampus is thought to influence whether memories of your trauma cause you to develop PTSD.

What keeps PTSD going?

Cognitive Behavioural Therapy (CBT) is a popular evidence-based psychological therapy. It is always very interested in what keeps a problem going. This is because by working out what keeps a problem going, we can treat the problem by breaking the cycle.

The three big reasons:

• Unprocessed memories.
• Feeling like they are happening right now in the present moment. Psychologists sometimes call this ‘nowness’.
• They are intrusive and involuntary. They pop into your mind unexpectedly and are unwanted. They are easily triggered by things around you.
• They are especially detailed and vivid. You might re-experience trauma memories in any of your senses: sight, sound, touch, smell, taste.
• They are often fragmented. You might only remember parts of the trauma, or even just an image or a feeling.
• Psychologists think that trauma memories have these special properties because your brain did not have a chance to ‘process’ and store them properly at the time.Until your brain has completed the job of ‘processing’ your trauma memories you might continue to suffer from re-experiencing symptoms.
• Beliefs about trauma and its consequences.
• Cognitive behavioural therapy (CBT) says that the way we think and act affects the way we feel. Strong events – like traumas – can produce equally strong beliefs, which result in strong feelings.
• Beliefs at the start of therapy. I’m in danger now. What happened was my fault. People would think I’m a terrible person if they knew. Psychologists believe that one of the most important jobs of trauma therapy is working with the meaning that you made of your trauma.
• Some examples are given below of the meanings of their trauma expressed by some people at the start and end of their therapy:
• Beliefs at the end of therapy. The accident happened in the past. I survived and I am safe. The abuse was not my fault. I was only 8 years old. Nobody else would judge me as harshly as I judge myself. The abuse was the fault of the person who hurt me. I deserved what happened to me. For a long time I believed that what happened was my fault and carried a lot of guilt Nobody deserves that. My abuser wanted me to believe I deserved it, but that is not the truth.\
• Coping strategies, including avoidance.

Avoidance is a natural response to things that we find anxiety provoking and upsetting, but that doesn’t mean that it is helpful. People with PTSD tend to avoid things such as:

• Avoiding your memories of the trauma (which means they stay ‘unprocessed’).
• Avoiding reminders of the trauma.
• Using alcohol or other substances to block out memories or feelings.
• Not talking about what happened. Unfortunately, avoidance has some unhelpful effects on PTSD symptoms. Although it can feel helpful in the short-term, it means that your trauma memories don’t get a chance to be ‘processed’, and your negative beliefs about your trauma don’t tend to change.

How is PTSD treated?

It is important for anyone with PTSD symptoms to work with a mental health professional who has experience treating PTSD. The main treatments are psychotherapy, medications, or both. An experienced mental health professional can help people find the treatment plan that meets their symptoms and needs. Some people with PTSD may be living through an ongoing trauma, such as being in an abusive relationship. In these cases, treatment is usually most effective when it addresses both the traumatic situation and the symptoms. People who have PTSD or who are exposed to trauma also may experience panic disorder, depression, substance use, or suicidal thoughts. Treatment for these conditions can help with recovery after trauma. Research shows that support from family and friends also can be an important part of recovery.

Cognitive Behavioural Therapy (CBT) / Trauma-focused CBT

• Eye Movement Desensitisation and Reprocessing (EMDR)
• Cognitive Processing Therapy (CPT)
• Prolonged Exposure (PE)
• Narrative Exposure Therapy (NET) Although the mechanics of these therapies all differ slightly, they all contain some common ‘ingredients’:
• Exposure to memories. Trauma therapists sometimes call this ‘trauma memory processing’. Almost all evidence-based treatments for PTSD include at least some talking about (or facing) what happened to you, although they can differ a bit in terms of how this is done. Psychologists think that exposure may allow “aspects of the trauma to become clearer, new pieces of the puzzle may emerge, and new perspectives may be gained” .
• Work to change meanings. This means examining how you made sense of what happened to you and seeing whether these perspectives are fair or helpful. There is emerging evidence that the way these therapies work is by changing the way we think about the trauma and its aftermath. Research into trauma-focused therapies show that if we can change the meaning of the trauma we can change how you feel.
• Reduction of unhelpful coping strategies. Reducing avoidance helps you to challenge unhelpful beliefs and begin reclaiming your life.
• Cognitive restructuring helps people make sense of the traumatic event. Sometimes people remember the event differently than how it happened, or they may feel guilt or shame about something that is not their fault. Cognitive restructuring can help people with PTSD think about what happened in a realistic way.

Medications

The most studied type of medication for treating PTSD is a type of antidepressant medication called selective serotonin reuptake inhibitors (SSRIs). SSRIs may help control PTSD symptoms such as sadness, worry, anger, and feeling emotionally numb. SSRIs and other medications may be prescribed along with psychotherapy. Other medications may help address specific PTSD symptoms, such as sleep problems and nightmares. Health care providers and patients can work together to find the best medication or combination of medications, as well as the right dose. Check the U.S. Food and Drug Administration website (www.fda.gov) for the latest information on patient medication guides, warnings, or newly approved medications.

ADDENDUM A

PTSD DEFINITION AND DSM-5 DIAGNOSTIC CRITERIA

Posttraumatic Stress Disorder (PTSD) will be included in a new chapter in DSM-5 on Trauma- and Stressor-Related Disorders. This move from DSM-IV, which addressed PTSD as an anxiety disorder, is among several changes approved for this condition that is increasingly at the center of public as well as professional discussion.  The diagnostic criteria for the manual’s next edition identify the trigger to PTSD as exposure to actual or threatened death, serious injury or sexual violation.

The exposure must result from one or more of the following scenarios, in which the individual: •directly experiences the traumatic event;

• witnesses the traumatic event in person;
• learns that the traumatic event occurred to a close family member or close friend (with the actual or threatened death being either violent or accidental); or
• experiences first-hand repeated or extreme exposure to aversive details of the traumatic event (not through media, pictures, television or movies unless work-related).

The disturbance, regardless of its trigger, causes clinically significant distress or impairment in the individual’s social interactions, capacity to work or other important areas of functioning. It is not the physiological result of another medical condition, medication, drugs or alcohol.

Changes in PTSD Criteria Compared to DSM-IV, the diagnostic criteria for DSM-5 draw a clearer line when detailing what constitutes a traumatic event. Sexual assault is specifically included, for example, as is a recurring exposure that could apply to police officers or first responders. DSM-5 pays more attention to the behavioral symptoms that accompany PTSD and proposes four distinct diagnostic clusters instead of three. They are described as re-experiencing, avoidance, negative cognitions and mood, and arousal. Re-experiencing covers spontaneous memories of the traumatic event, recurrent dreams related to it, flashbacks or other intense or prolonged psychological distress. Avoidance refers to distressing memories, thoughts, feelings or external reminders of the event. Negative cognitions and mood represents myriad feelings, from a persistent and distorted sense of blame of self or others, to estrangement from others or markedly diminished interest in activities, to an inability to remember key aspects of the event. Finally, arousal is marked by aggressive, reckless or self-destructive behavior, sleep disturbances, hypervigilance or related problems. The current manual emphasizes the “flight” aspect associated with PTSD; the criteria of DSM-5 also account for the “fight” reaction often seen.

• Posttraumatic Stress Disorder The number of symptoms that must be identified depends on the cluster. DSM-5 would only require that a disturbance continue for more than a month and would eliminate the distinction between acute and chronic phases of PTSD.

SYMPTOMS

Symptoms of PTSD usually begin within 3 months of the traumatic incident, but they sometimes emerge later. To meet the criteria for PTSD, symptoms must last longer than 1 month, and they must be severe enough to interfere with aspects of daily life, such as relationships or work. The symptoms also must be unrelated to medication, substance use, or other illness. The course of the illness varies: Although some people recover within 6 months, others have symptoms that last for a year or longer. People with PTSD often have co-occurring conditions, such as depression, substance use, or one or more anxiety disorders. After a dangerous event, it is natural to have some symptoms or even to feel detached from the experience, as though you are observing things rather than experiencing them. A health care provider—such as a psychiatrist, psychologist, or clinical social worker—who has experience helping people with mental illnesses can determine whether symptoms meet the criteria for PTSD.

What can I do to help myself?

It is important to know that, although it may take some time, you can get better with treatment. Here are some things you can do to help yourself: ⊲ Talk with your health care provider about treatment options, and follow your treatment plan. ⊲ Engage in exercise, mindfulness, or other activities that help reduce stress. ⊲ Try to maintain routines for meals, exercise, and sleep. ⊲ Set realistic goals and do what you can as you are able. ⊲ Spend time with trusted friends or relatives, and tell them about things that may trigger symptoms. ⊲ Expect your symptoms to improve gradually, not immediately. ⊲ Avoid use of alcohol or drugs.

How can I help a friend or relative who has PTSD?

If you know someone who may be experiencing PTSD, the most important thing you can do is to help that person get the right diagnosis and treatment. Some people may need help making an appointment with their health care provider; others may benefit from having someone accompany them to their health care visits. If a close friend or relative is diagnosed with PTSD, you can encourage them to follow their treatment plan. If their symptoms do not get better after 6 to 8 weeks, you can encourage them to talk to their health care provider. You also can: ⊲ Offer emotional support, understanding, patience, and encouragement. ⊲ Learn about PTSD so you can understand what your friend is experiencing. ⊲ Listen carefully. Pay attention to the person’s feelings and the situations that may trigger PTSD symptoms. ⊲ Share positive distractions, such as walks, outings, and other activities.

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