You may have heard of posttraumatic stress disorder (PTSD). It is used quite often in the media and it is worthwhile understanding a bit more about the diagnosis and the objectives in treating PTSD. I am referring to “ordinary” PTSD in this article. There is considerable evidence that people exposed to traumatic events over a long period (such as in extremely violent, abusive families, torture, war and so on) can present with more diffuse symptoms. This diagnosis is not made immediately following a traumatic event as most people will be affected in some of these ways following severe trauma. The diagnosis is therefore only made if symptoms persist a month after the event. If you are concerned that you or someone you care about may have PTSD please see a psychologist or psychiatrist yourself or encourage your friend or relative to do it. Quite a bit can be done; it is not necessary to live with these symptoms.
What is PTSD?
PTSD is not a new condition; it has been described in various writings through out the ages. There is some indication that Homer’s Iliad refers to the development of PTSD. Essentially PTSD can develop following extreme traumatic, often life-threatening events. It is therefore one of the very few psychiatric diagnoses which is attributable to a specific event. Various groups of symptoms arise in PTSD. I am going to discuss them briefly as they make it easier to understand the experience of PTSD. The symptom groups I am going to discuss are the reliving of the traumatic event, avoidance of reminders of the event, numbing and increased arousal.
Reliving the event
Our natural way of coming to terms with things is by replaying what has happened in our minds. You can see it easily in yourself, by observing your reactions when you have had an argument with someone. You replay it over and over until you have made some sort of sense of it. You may decide you have to apologise as you were wrong, or decided that your friend was just in a bad mood and that she’ll get over it in time and you can leave it. Once you have the solution, you can leave it alone. However, when exposed to extremely traumatic events, your ability to make sense of them is overwhelmed. They often shatter our assumptions of the world. Things we took for granted, we can no longer take for granted. Where we may have thought we were safe, we now know we are not safe. We all assume that we will arrive safely at our destination, even though we know the roads are dangerous. After a serious accident, we can never again make that assumption. We assume we are safe in our homes, even though we know that robberies happen. After an armed robbery at home, the assumption of safety in our homes cannot be recovered – we know that we could be robbed again.
Another difficulty which arises in the replaying of extremely traumatic events is the nature of the memories. It feels very different to normal memory in which we are aware of our surroundings, we know that what we are thinking of happened in the past and is not currently part of our reality, beyond our recollections. When we experience flashbacks it is as though the traumatic event is happening, again, now. We are experiencing it without the sense that it happened in the past. With a bit of imagination you can understand how debilitating this can be. Let us take an example: If a woman has been raped and she experiences a flashback during her and her husband’s lovemaking, she may see, smell and feel the rapist again.
The person who has severe PTSD is never free of the trauma. He or she will often fear going to bed, as they often wake from severe nightmares in which they relive the trauma or something related to the trauma. Again, consider the implications: If you get into bed at night (every night) knowing that despite your intense desire to have it different that you will wake in the middle of a nightmare, with heart racing, struggling for breath, skin clammy and totally disorientated, it becomes frightening to go to sleep. You may try and avoid it to the point of exhaustion, but when you fall asleep you will again experience the horror of the nightmare. Often, after awakening, they find it impossible to sleep again. Sleep deprivation becomes part of the problem. Often, especially if the trauma happened at night, people start to switch day and night, finding they can sleep in the day and not at night which they associate with danger. If you have to be at work early the next morning, this becomes an enormous problem.
Reminders of the trauma are everywhere. Generally traumatic events happen while we are living our lives and our normal experiences can lead to debilitating symptoms. If someone you love died in a car accident, you will be reminded of what happened where ever you go. Newspaper stories report on crime on every page.
The recognition that a traumatic experience can lead to avoidant behaviours is part of folk-wisdom. Hence the directive that if you fall off a horse to get back on again as soon as possible. People with PTSD avoid reminders of what has happened to them. So if someone has been hijacked, they might find themselves avoiding driving in the area in which they were hijacked, or not driving the time of day that they were hijacked. They may also avoid conversations and activities (such as reading newspapers) which remind them of what has happened. As you will realise, this can become quite debilitating, especially if it involves your own home or generalises to all shopping malls and so on.
Numbing and some other unpleasant symptoms
People with severe PTSD may sometimes find that they cannot remember an important part of the trauma. It is not forgetfulness, it is the awareness that something important happened and I do not remember it. The thought of eventually remembering can be extremely threatening.
People who have PTSD often lose interest in things they normally enjoyed. Other aspects of their experience of life are often affected. They may find that they cannot experience emotions which they normally experienced. If you struggle to express love to the people who are close to you it starts to affect the relationships you have with them. People often feel as though they are detached or estranged from the world. When you have experienced horrors others have not, it is very hard to believe anyone can understand or relate to the experience. In actual fact people who have not experienced severe trauma do not understand the experience.
Every time you have intrusive images your body responds to them as though you have just been exposed to the trauma. Your body responds by releasing stress hormones. This eventually leads to a state of increased arousal where you are constantly in a physiological state of responding to the traumatic event. You experience difficulties in falling or staying asleep – not only as a result of the nightmares. People frighten easily, finding that they are much more reactive to sounds or sudden movements than they normally are. This is paired with constantly being on the lookout for danger. They may become irritable or have aggressive outbursts. When we consider the problems in relating to others already caused by difficulties in experiencing emotions and by a sense of detachment it is easy to see why aggressive outbursts or irritability can compound relationship difficulties. People also find their ability to concentrate is badly affected.
Treatment of PTSD
There are a few principles that are important in the treatment of PTSD. Medication is often useful and sufferers may be referred to a psychiatrist for medication. However, psychotherapy is generally necessary in managing the symptoms of PTSD. Let us look at the logic of treatment. All psychotherapeutic interventions which have proven to be effective are exposure-based (mainly prolonged exposure and Eye Movement Desensitisation and Reprocessing). Effective treatments all entail revisiting the traumatic event. In the beginning this entails the visualisation of what has happened and telling the story. Later the revisiting can include going to the actual places and so on where the trauma occurred. Why is this necessary? By revisiting the events we are mimicking the natural process of coming to terms with events. We also, by revisiting the trauma, are helping people to desensitise to the event – to no longer have the intense physiological response they initially had. If the traumatised person then experiences reminders or images relating to the trauma, he or she no longer has the strong physiological response to the trauma. They have a sense of mastery over the traumatic event and no longer have to avoid it. It also means that the symptoms of increased arousal abate.
Traumatised people are generally taught some skills before starting desensitisation. These entail managing flashbacks and skills which ameliorate the worst of the anxiety and discomfort associated with the increased arousal and physiological response to exposure to reminders of the traumatic event.
An intrinsic part of coming to terms with trauma is to reconstruct our lives. As discussed, people who have been been exposed to severe trauma experience that their lives and much that they have built their lives on has been shattered. This has to be reconstructed in a way which the person finds meaningful. Often this process also entails coming to terms with how we have responded before, during and after the event. People often experience guilt around trauma which has to be resolved.
As I mentioned in the beginning of this article, it is possible to treat PTSD effectively. Many people find that their symptoms abate completely with treatment, others find that their symptoms are more manageable following treatment.