Post-traumatic stress disorder

About post-traumatic stress disorder

What is post-traumatic stress disorder?

The term post-traumatic stress disorder (PTSD) or post-traumatic stress syndrome (PTSS) is used to name a range of symptoms you may develop in response to experiencing a traumatic event, which is outside of your normal human experience. It is often a delayed response.

Just hearing news of events, such as the London bombings in July 2005, incidents in the war in Afghanistan, or the Hillsborough football stadium disaster, can have a lasting effect on you. If you are actually present during a disaster of this nature it’s likely that you will become extremely distressed. Likewise, if you are involved in, or witness, events such as road accidents, muggings, and sexual or physical assaults, these experiences may also cause you deep emotional injury. There is no doubt that the reactions that may follow can seriously hamper and interfere with your life.

Some survivors have objected to the use of the term ‘disorder’, because they see such reactions as an entirely normal and understandable response to abnormal events. But regardless of whether the term ‘disorder’ or ‘syndrome’ is used, the diagnosis recognises that there are events and experiences that are beyond our control, and which may fill us with fear or horror, and can cause extremely disturbing psychological symptoms.

What are the symptoms?

If you have faced a traumatic experience, you may simply feel emotionally numb to begin with, and feelings of distress may not emerge straight away. But sooner or later, you are likely to develop emotional and physical reactions, and changes in behaviour, which may include some of the following:

Reliving aspects of the trauma

• vivid flashbacks (feeling that the trauma is happening all over again)
• intrusive thoughts and images
• nightmares
• intense distress at real or symbolic reminders of the trauma.

Avoiding memories

• keeping busy
• avoiding situations that remind you of the trauma
• repressing memories (being unable to remember aspects of the event)
• feeling detached, cut off and emotionally numb
• being unable to express affection
• feeling there’s no point in planning for the future.

Being easily upset or angry

• disturbed sleep
• irritability and aggressive behaviour
• lack of concentration
• extreme alertness
• panic response to anything to do with the trauma
• being easily startled.

These are all quite common reactions to a traumatic event, and many people find the symptoms will disappear in a relatively short period of time. But if they last for longer than a month, or they are very extreme, you may be given a diagnosis of PTSD.

You may also have other symptoms, such as severe anxiety, a phobia or depression. You may develop a dissociative disorder and suicidal feelings. There’s no time limit on distress, and some survivors may not develop post-traumatic symptoms until many years after the event.

Causes

What causes post-traumatic stress disorder (PTSD)?

I started to feel different about a year [after I left the army] – I was really short-tempered, snappy, I wasn’t sleeping and I started drinking a hell of a lot. I was getting flashbacks and having recurrent nightmares ... I knew I needed help as I would get lost in a flashback whilst driving an HGV vehicle at night.

– Simon’s experience, www.combatstress.org.uk

The term ‘PTSD’ was first described in relation to the American veterans of the Vietnam War, but the problem has existed for a lot longer and has had a variety of names. During and after the First World War, large numbers of soldiers were said to be suffering from ‘shell shock’, ‘soldier’s heart’ or ‘battle fatigue’. The symptoms referred to by these terms would now be called PTSD or ‘combat stress’. Today, the term PTSD can be used to describe the psychological trauma resulting from any traumatic event, not only war related trauma.

There are any number of traumatic events which may cause PTSD:

• personal trauma
• violent crime
• sexual or physical assault
• road traffic accidents
• difficulties during childbirth.

These can all produce PTSD, though symptoms may not occur until some time after the event. Children who have been abused, or who have witnessed something terrible are also vulnerable.

Even if you have not been directly involved in a trauma you may still experience levels of distress comparable to those who were involved. For example, you may experience PTSD if you have lost relatives or friends as a result of a disaster, or if you work in an emergency service or as a rescue worker. Refugees and civilian survivors of war may also develop PTSD.

The event that caused my trauma happened 20 years ago when I was a fire officer … I started to become distressed for no real reason. Everything seemed emotional, and I felt raw and exposed.

– Post-traumatic stress disorder, real stories, www.nhs.uk

Why do some people develop PTSD when others don't?

It’s estimated that up to three per cent of the general population is likely to be affected by PTSD at some point.  Anyone can develop PTSD following experiences such as those mentioned above, but not everyone does so. Nor does everyone develop it to the same degree. There are a number of possible explanations for this.

Fearing for your life

Events in which others die, or where you thought you were going to die, may lead to more long-lasting stress responses. A study of Falkland War veterans found that people who had actually been involved in combat were most likely to get PTSD.

Harmful intentions

Man-made disasters, particularly those involving deliberate acts of violence, terrorism, or exploitation, seem to cause longer-lasting and more painful emotional consequences than natural disasters. The crucial factor may be that such experiences destroys people’s trust in others, particularly if they involve someone you have depended on.

Conscious memories

People who remain conscious throughout the experience are more vulnerable to PTSD because of the horrific memories etched on the mind, whereas those who lose consciousness or suffer head injury are protected.

Personal circumstances

Your personal history can make you more prone to PTSD. If a traumatic event triggers memories of an earlier distressing experience, the effect may be much worse. Similarly, if you are already going through emotional problems, you are also much more vulnerable.

Guilt feelings

Sometimes survivors of trauma feel guilty, as though they were responsible for the event, or could have done more to save themselves or others. One study showed that those who blamed themselves in some way for the outcome of the disaster were more at risk of severe and long-term distress.

Coping strategies

How can I deal with a traumatic event?

After a traumatic event, people often feel numb, dazed and disorientated. Talking about what has happened to them may be the last thing they want to do. Many survivors have said that what they found most useful, to begin with, was practical advice, followed by information and support with day-to-day tasks.

Talking about your feelings may be the best way of coming to terms with the experience. Everyone will have their own unique responses, and will need to proceed at their own pace. You may turn to friends, relatives and colleagues, or seek professional help when you decide you do want to talk about what you’ve been through.

It is important that you have an opportunity to talk to someone when you are ready to do so. However, you should not be made to talk before you are ready, or even at all, if you do not want to. Research has shown that debriefing immediately after traumatic events, by making you describe every detail, may make post-traumatic stress disorder (PTSD) more likely, because it may help to establish memories of the event by bringing them into the conscious mind, increasing the risk of flashbacks or nightmares.

Many people go through a period of denial after a bereavement or a traumatic event. Researchers have suggested that this allows you time away from the trauma, similar to unconsciousness. This research also suggests that challenging or interrupting this by insisting you talk about the trauma is harmful. It is also possible that while you are apparently ‘in denial’, you may subconsciously be beginning to face the trauma.

However, if you bottle up stress responses over months or years, they may become deeply ingrained and cause serious problems. You may remain in a state of extreme tension long after the trauma has passed. You may find yourself avoiding situations, in case they remind you of the trauma, so that life becomes increasingly restricted. Not uncommonly, you may turn to alcohol or drugs in an attempt to avoid painful feelings and memories. In trying to avoid the problem though, you are also avoiding getting appropriate help. There are various organisations that can provide the details of counsellors experienced in treating PTSD. For more information, see ‘Useful contacts’.

It can be very helpful for you to share your experiences with others who have been through something similar. This can be an extremely important step in moving away from isolation and towards regaining control of your life. You may find it especially useful to contact an organisation specialising in your particular type of experience; for example, soldiers who have seen combat, victims of violent crime or sexual assault, and people who have been tortured or who are refugees. (see ‘Useful contacts’).

Getting help

What sort of help is available for post-traumatic stress disorder (PTSD)?

If you have been living with distressing symptoms for over a month after a traumatic event, you should see your GP, who can refer you for specialist help. There are clinics that focus on PTSD and there are national referral centres. Your GP may also be able to refer you to a local practitioner (a psychologist, psychotherapist or psychiatrist) who has been trained in treating PTSD.

Effective treatment does exist, and you can recover from PTSD.

Effective treatments for PTSD are still being evaluated, but experts agree that if you are still experiencing symptoms months after a traumatic event, an effective approach may be a series of sessions with a psychologist or other therapist using one of the specialised therapies described below. (See NICE recommendations below for more details.)

Different types of trauma have different types of impact. If you are a survivor of long-term child abuse or prolonged torture for example, you may have similar symptoms to people who have survived a traumatic event (single incident trauma), or you may be diagnosed with ‘complex PTSD’. Treating ‘complex PTSD’ requires much more long-term, intensive help than treating a single incident trauma.

Specialist programmes have been set up to provide the appropriate therapy for you if:

• you were abused as a child
• you are a victim of political violence
• you have witnessed murder, or
• you are involved in life-threatening situations.

They may provide very structured treatment plans to clients using a combination of therapies. See ‘Useful contacts’ for details.

The following treatments have been found to be helpful for PTSD and are recommended by NICE (National Institute for Health and Clinical Excellence).

Cognitive behavioural therapy (CBT)

CBT is based on changing the way we view things: trying to adapt negative ways of thinking into more positive ones. If you have been through a traumatic experience, you may expect that you will go on experiencing the negative feelings associated with it. You may also expect that certain triggers will always bring up old unwanted feelings. CBT helps you to recognise these expectations, and the often automatic negative thought patterns associated with them, and to try and find a more useful way of reacting and behaving.

Trauma-focused CBT has been specially developed to help people with trauma, and includes help to overcome avoidance behaviours and the symptoms of flashbacks, for example. Therapists delivering this treatment will need to have special training to practise. See Cognitive Behaviour Therapy for more information.

After some time, I had a course of trauma-focused cognitive behavioural therapy … Talking about the fire was uncomfortable at times, but it helped me to process my memories so that they stopped reappearing as flashbacks. They have gone now, and I am able to get on with my life.

– Post-traumatic stress disorder, real stories page, www.nhs.uk

Eye movement desensitisation and reprocessing (EMDR)

In this treatment, developed in the 1990s, you make rhythmic eye movements while recalling the traumatic event. The eye movements are designed to stimulate the information-processing system in the brain. The aim of the treatment is to help you process the traumatic events, and speed up readjustment and recovery.

Rewind technique

In this treatment, the therapist helps you move to a state of deep relaxation and then asks you to imagine you are watching yourself watching a film of the traumatic event. You then rewind and replay it as many times as you need to. The fact that you watch yourself watching the film distances you from the memory. The replaying aspect means that the memory gets stored in ‘back memory’, rather than in your conscious memory where it intrudes on your everyday life.

One advantage of both EMDR and the rewind technique is that, if the details of the event are too painful to talk about, you need not say anything while you do it. The therapist can help you deal with the memories without having to hear them.

Medication

Many people with PTSD also experience depression. Taking antidepressants may help relieve some of the symptoms and help people to get the best from the psychological treatments. You may also be offered antidepressants if you are not ready to talk about your experience with a therapist. The Medicines and Healthcare products Regulatory Agency (MHRA) have approved (licensed) sertraline and paroxetine for treating PTSD. Since antidepressants can be difficult to come off, they should be used with caution and with full knowledge of their possible side effects. See Antidpressants for more information on these medicines.

NICE recommendations

The National Institute for Health and Clinical Excellence (NICE) recommends that psychological treatment for PTSD should not start until four weeks after the trauma, because you may recover naturally during this time without any special help. Support and information can be made available earlier than this, however, together with careful monitoring of your symptoms, referred to as ‘watchful waiting’. If this is the course of action your doctor recommends, you should have a follow-up appointment within one month.

Once PTSD is diagnosed, only psychological treatments that are designed for PTSD should be used. EMDR and CBT are both recommended by NICE. Any psychological therapy should be offered on a regular and continuous basis by the same therapist for 8-12 weeks. More sessions may be needed in certain circumstances (for more details see the NICE guideline on treating PTSD at www.nice.org.uk). You should be given all the information about the treatments available to make an informed decision. You should not be offered medication as routine first-line treatment, for PTSD.

You may be offered medication if:

•  you are clinically depressed
• if you are having difficulty sleeping, or
• if you do not want to receive a talking treatment.

Doctors and therapists should also be familiar with your cultural and ethnic background and should also assess the impact of the traumatic event on all your close family and provide appropriate support.

What can friends and family do?

This section is for friends or family who wish to support someone they know with a diagnosis of post-traumatic stress disorder (PTSD).

If the person wants to talk about their experiences, listen without being judgemental.

• Allow the person to be upset without necessarily trying to console them.
• Encourage the person with PTSD to talk to, and gain support from, other survivors.
• Help them contact organisations that offer specialist support (see 'Useful contacts')
• Discourage them from getting into a pattern of avoiding situations that remind them of the trauma.

A traumatic event will have a major impact not just on those who lived through it, but on their family, friends and colleagues. There are sources of support available for you too, see ‘Useful contacts’

Useful contacts

Anxiety UK
tel. 08444 775 774
web: anxietyuk.org.uk
Support, help and information for those with anxiety disorders (including post-traumatic stress disorder).

ASSIST (Assistance Support and Self Help in Surviving Trauma)
helpline: 01788 560 800
web: www.assisttraumacare.org.uk
Support, understanding and therapy for people experiencing PTSD, and families and carers.

British Association for Behavioural and Cognitive Psychotherapies (BABCP)
tel. 0161 705 4304
web: babcp.com
Can provide details of accredited therapists.

British Association for Counselling and Psychotherapy (BACP)
tel. 01455 883 300
web: bacp.co.uk
For Information about counselling and therapy. See website or sister website, itsgoodtotalk, for details of local practitioners.

Combat Stress (Ex-Services Mental Welfare Society)
tel. 01372 58 7000
helpline: 0800 1381 619
text: 07537 404 719
email: combat.stress@rethink.org
web: combatstress.com
For members of all ranks of the Armed Forces or Merchant Navy.

The Compassionate Friends
helpline: 0845 123 2304
web: tcf.org.uk
For bereaved parents and their families.

First Person Plural
web: firstpersonplural.org.uk
Support and information for people who experience complex dissociative distress conditions, their family, friends and professional allies.

The Human Givens Institute
web: hgi.org.uk
Provides a list of therapists who use guided imagery and the ‘rewind’ technique.

Medical Foundation for the Care of Victims of Torture
tel. 020 7697 7777
web: freedomfromtorture.org
Provides survivors of torture with medical treatment, practical assistance and psychotherapeutic support. Has access to language interpreters.

NICE (The National Institute for Health and Care Excellence)
web: nice.org.uk
Evidence-based guidelines on treatments.

Post traumatic stress disorder
web: ptsd.org.uk
For ex-servicemen and women, and anyone who has PTSD.

Trauma screening questionnaire
Downloadable questionnaire to help you assess whether you might need help for PTSD.

Veterans UK
tel: 0800 1692277
web: veterans-uk.info
Provides free help and advice to both military personnel and the veterans community.

Published 2012
To be revised 2014
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