A guide to post-traumatic stress disorder (PTSD)

The term post-traumatic stress disorder (PTSD) describes a range of symptoms someone can develop in response to experiencing a traumatic event. Depending on the person, it can sometimes take weeks, months or even years for the symptoms to appear.

There is increasing evidence to demonstrate the impact of trauma on an employee's well-being. Trauma is often related to the impact of a single or series of incidents which have threatened the individual's experience of the world as a safe and secure place.

Examples of traumatic events may include being attacked or threatened in some way, being violated or subjected to a situation that feels outwith personal control, being in an accident (e.g. falling off a ladder) or witnessing a circumstance that has involved another persons distress, harm or death (e.g a death at work).

Although many people manage recent or historic traumatic events in a productive and functional way, some people find it difficult to cope. They develop a range of psychological symptoms that, over time, evolve into post-traumatic stress disorder (PTSD). Common symptoms of trauma may include flashbacks to the traumatic event, heightened anxiety/panic in particular circumstances, avoidance of contexts or people associated with the traumatic event, difficulties relaxing and feeling calm, low mood, and problems in relationships.

Introduction - What is PTSD and what causes it?

PTSD can sometimes develop in response to a person experiencing a traumatic event. Depending on the person, PTSD can take between a few weeks and a few years to develop.

A traumatic event is one where we know we are in danger and feel that our life is threatened. It is often accompanied by feelings of fear and helplessness. It can be a single event or a series of events taking place over a period of time. Some typical traumatic events that can lead to PTSD are:

Violent crimes: stabbing, beating, kidnapping, rape and sexual violence, torture, domestic violence, sexual and physical abuse, being taken hostage, assault, robbery, mugging, witnessing violent death, terrorist attacks

Accidents: witnessing/being in a car/train accident, plane crashes, work accidents

Witnessing natural disasters: flooding, earthquakes, hurricanes

traumatic health issues: traumatic childbirth, surgery, being diagnosed with a life-threatening illness

Military combat

Sudden death of a loved one

Childhood neglect

Even if you have not been directly involved in a traumatic event, you may still experience symptoms of distress comparable to those who were involved.

How common is PTSD and who is more likely to develop it?

It is estimated that up to 1 in 10 people may develop PTSD at some stage in life, and up to a third of people who experience trauma will have PTSD. While it is impossible to predict who will develop PTSD in response to trauma, there are certain risk factors that increase your vulnerability.

You are more likely to get PTSD when:

You were directly involved in the event
You lost someone you were close to
The trauma was intense and lasted for a long time
You were injured
You remained conscious during the experience
You had a strong reaction to the trauma
You didn't feel in control of events
You didn't get enough help and support after the event
You blamed yourself for what happened

The more disturbing the experience, the more likely you are to develop PTSD.

Groups most at risk of developing PTSD after a distressing event:

Females
Teenagers and children
Fire-fighters and other people working in traumatic environments
People suffering from mental health problems
People with recent and stressful life changes
People with prior traumatic experiences

The difference between PTSD and a normal response to trauma

Common stress reactions after a traumatic experience: Following a traumatic event, almost everyone experiences symptoms of PTSD. These normal reactions to abnormal events help to keep you going and help you to understand the experience you have been through.

Common reactions after a traumatic experience are:

Fear or anxiety: You may feel tense or afraid, feel on alert and be jumpy.
Sadness or depression: You may lose interest in things you used to enjoy, feel tired, empty and numb, want to be alone all the time or have crying spells
Guilt and shame: You may feel responsible for what happened, feel guilty because others were injured or killed and you survived.
Anger and irritability: You may overreact to small misunderstandings, have less patience, and lash out at close friends and relatives
Behaviour changes: You may drink, use drugs or smoke too much, drive aggressively, and avoid certain people or situations

This acute stress reaction usually lasts for a few days or weeks, but declines afterwards and symptoms start to disappear. If your reactions don't go away after some time and they cause you severe distress and disrupt your life, your body and mind remain in psychological shock. You may have developed PTSD and should seek help.

What are the symptoms and signs of PTSD?

PTSD is characterised by four main symptoms:
Re-experiencing (reliving the event): Memories of the traumatic event can come back at any time in the form of: vivid flashbacks; nightmares; intrusive thoughts and images; intense distress at real or symbolic reminders of the trauma. These memories can be so realistic that they make you feel like you are living through the experience again. Ordinary things can bring back memories of the traumatic event, for example: a sound, a place or seeing someone who reminds you of the trauma.

Avoidance (avoiding memories): You may try to avoid thoughts, situations, conversations, places, people, activities or anything that triggers memories of the trauma, because it is too upsetting to re-live the experience over and over again. You distract yourself by, for example, working very hard or by losing yourself in a hobby.

Numbness You may deal with the pain of your feelings associated with the trauma by becoming emotionally numb and therefore:

feel detached and cut off from others
find it hard to express your feelings or to have loving and positive feelings towards others
not be interested in activities you used to enjoy
communicate less with other people
not talk and remember parts of the trauma
not engage in relationships.

Hyperarousal ("being on guard") You may experience increased arousal, which you did not have before the trauma. This may include: difficulties in going to sleep or staying asleep; difficulties concentrating; being jumpy; being irritable, which may include sudden anger; being alert and looking out for danger; feeling anxious.

Other symptoms There are a variety of other symptoms that people with PTSD can experience including:

depression and hopelessness
feelings of panic and fear
feelings of mistrust and betrayal
feeling alienated and alone
guilt, shame or self-blame
physical aches and pains (headaches, muscle aches and pains)
irregular heartbeats
diarrhoea
substance abuse (alcohol, painkillers, drugs)
suicidal thoughts and feelings.

You may have PTSD if these symptoms last for over a month and have chronic PTSD if they persist for more than three months.

Symptoms of PTSD in adolescents and children

Children show different symptoms and additional symptoms to PTSD than adults.

Young children (aged 1-5) often re-live the trauma in their play (for example, a child involved in a road traffic accident might re-enact the crash with toy cars over and over again), stories or drawings and have upsetting dreams of the actual trauma. They are scared of being separated from their parents and may develop new phobias and anxieties that seem unrelated to the trauma (for example, a fear of monsters). They can also lose previously-acquired skills, such as toilet training, and often complain about aches and pains with no apparent cause.

School-aged children (5-12) may not have flashbacks or problems remembering the trauma, but might put the events of the trauma in the wrong order. They can also think there were signs that the trauma was going to happen and pay attention to these signs, in order to avoid future traumas. They keep re-living the trauma in the play and might fit parts of the trauma into their daily lives.

Teenagers (aged 12-18) show some of the PTSD symptoms of adults, but are more likely than younger children and adults to show impulsive and aggressive behaviours. They might not be able to trust others, they might feel alone and worried, feel as if people are looking down on them and have low self-esteem. They might engage in self-harm and substance abuse.

Complex PTSD and its symptoms

When a traumatic situation is continuous and repeats itself for months or years, people experience chronic trauma. These people often report additional symptoms alongside PTSD symptoms. Long-term trauma can be caused by:

concentration camps
prisoner of War camps
prostitution brothels
long-term domestic violence
long-term child physical, and/or sexual abuse
organised child exploitation rings.

The victim is generally held in a state of captivity and unable to get away from the danger. Survivors of chronic trauma might have different thoughts and show different behaviour in the following areas:

Emotional regulation: persistent sadness, suicidal thoughts, explosive or inhibited anger

Consciousness: forgetting traumatic events, reliving traumatic events, having episodes in which one feels detached from one's mental processes or body (dissociation)

Self-perception: shame, guilt, a sense of being completely different from other human beings

Distorted perceptions of the perpetrator: attributing total power to the perpetrator, becoming preoccupied with the relationship to the perpetrator, or becoming preoccupied with revenge

Relationships: isolation, distrust, repeated search for a rescuer

One's system of meanings: loss of sustaining faith, hopelessness, despair

Coping with PTSD - Seeking help

Recovery from PTSD is a gradual and ongoing process and will not make you forget the trauma. Recovery will help you cope with its symptoms and increase your quality of life. There are many different treatment methods for PTSD, which will be described in detail below.

Self-Help

Self-help is characterised by active coping, which means to accept the impact of trauma on your life and to take action to improve things. Active coping will make you feel stronger and can help you reduce distressing symptoms.

Self-help tip 1: Learn about trauma and PTSD
Find out about natural reactions to trauma and about the signs of needing help from others. You will realise that you are not weak, alone or crazy, which is the first step in understanding your response to trauma.

Self-help tip 2: Reach out to others for support
Support from people who care about you is important for your recovery, so it is important to stay connected to life and these people. Ask your close friends and relatives for help and explain to them what you need. You can:

confide in a person you trust
spend time with positive people
join a support group for survivors of trauma (if you can't find a group in your area, you may consider online support groups). It is also important to talk to a doctor and/or a counsellor when your symptoms persist.

Self-help tip 3: Practice relaxation techniques
Relaxation might increase distress at first in a few people, because your attention is focused on disturbing physical sensations and you reduce contact with the outside world. It is therefore important to continue practicing relaxation methods in small amounts you can handle, because they will help to reduce negative feelings and symptoms over time. A few examples of relaxation techniques are:

muscle relaxation exercises
breathing exercises
meditation
prayer
swimming, stretching, yoga
listening to quiet music
spending time in nature

Self-help tip 4: distract yourself
Positive activities can help you to distract yourself from memories and reactions. They also improve your mood, limit the harm caused by PTSD and help you rebuild your life. Take care of yourself by using the resources around you and don't expect too much of yourself. It takes time to heal and adjust to what has happened.

Psychological Treatment

Mindfulness practice: Mindfulness is a way of thinking and focusing that can help you become more aware of your present experiences. It consists of: paying attention to and being aware of the present moment and Accepting or being willing to experience your thoughts and feelings without judging them. This technique might increase your ability to cope with emotions that have arisen from trauma, by noticing them and letting them go, without acting on them. Mindfulness can prepare you for treatment by giving you skills and confidence so that you can handle your feelings and thoughts.

Anxiety management: This technique involves learning skills that will help you cope better with PTSD and is used to reduce the intensity of symptoms and distress they create. It is important to practice anxiety management repeatedly until it can be employed automatically. It includes: relaxation; Breathing training - This method helps against anxiety and fear that provoke hyperventilation; assertiveness training - You learn to express your feelings, needs and opinions in a direct and honest way, without threatening another person; positive thinking - The goal is to replace negative and destructive thoughts with positive thoughts; thought stopping - You learn to stop thinking distressing thoughts.

EMDR (Eye movement desensitisation and reprocessing): EMDR is a technique that integrates many different approaches, such as psychodynamic, cognitive behavioural, interpersonal, experiential and body-centred therapies to maximise treatment effect. It uses eye movements to help the brain to process flashbacks and distressing memories, and to make sense of the traumatic experience. During this treatment a therapist will ask you to think of aspects of the trauma. Whilst you are thinking about it, you will follow the movement of the therapists moving fingers with your eyes. It usually takes 4 to 12 sessions to change your reactions towards trauma.

CBT (Cognitive behavioural therapy): Cognitive behavioural therapy is the most effective treatment for PTSD and aims to help you work through the trauma and gain control of your fear and distress. It is based on the assumption that most unwanted thinking patterns and emotional behavioural reactions are learned over a long period of time. CBT involves identifying irrational, distorted and upsetting thoughts about the traumatic event and replacing them with more realistic and positive ones. You will also learn to expose yourself to your feelings, thoughts and situations that remind you of the trauma. You will be treated for around 8 to 12 weekly sessions, although fewer may be needed if you start treatment within one month of the traumatic event.

CPT (Cognitive processing therapy): This type of CBT focuses on examining and challenging thoughts about the trauma and replacing them with positive thoughts. You will:

Learn about your symptoms and how treatment can help you
Become aware of your thoughts and feelings
Learn skills to challenge your thoughts and feelings (cognitive restructuring)
Understand the common changes in beliefs that occur after a trauma
PE (Prolonged exposure therapy) - This type of CBT helps you identify the thoughts, feelings, and situations you have been avoiding and you will be confronted with them until your distress decreases. You will:
- Learn about your symptoms and how treatment can help you
- Practice breathing training to help you relax and manage distress
- Be repeatedly confronted with the situation, thoughts and feelings you have been avoiding (in-vivo exposure)
- Talk through the trauma to get control of your thoughts and feelings (imaginal exposure)

Family therapy: Family therapy can be especially productive, because PTSD affects not only the person that suffers from it, but also their relatives and friends. It can help other people understand what you're going through and increase communication within your family and entourage.

Rewind technique: During this treatment the therapist will help you move to a state of deep relaxation. Afterwards he/she will ask you to imagine you are watching yourself watching a film of the traumatic event. This helps you to distance yourself from the memory. You then rewind and replay it as many times as you need to. By replaying the traumatic event it gets stored in your "back memory", rather than in your conscious memory, where it affects your everyday life. One advantage of this method is that you don't need to talk about the traumatic event.

Group therapy: Group therapy provides an ideal therapeutic setting, because trauma survivors are able to risk sharing traumatic experiences. At first it is often much easier to accept confrontation from a fellow sufferer than from a therapist and confidence as well as trust can be established. By telling your story in a group setting (trauma narrative) you will directly face grief, anxiety and guilt related to your traumatic experience, which will enable you to go on with your life.

Brief psychodynamic therapy: Brief psychodynamic therapy focuses on the emotional conflicts caused by the traumatic event. Through retelling your experience you will achieve a greater sense of self-esteem, develop effective ways of thinking and coping, and deal with the intense emotions that emerge during therapy. Your therapist will also help you identify current life situations that set off traumatic memories.

Treatment for children

When it comes to treating children with PTSD some factors should be included:

Treatment has to be adapted to suit the child's age, circumstances and level of development.
Treatment should be regular and continuous
Treatment should be delivered by the same practitioner
The family should also be involved in the treatment plan

EMDR and CBT are effective treatment methods for children. Some therapists use play therapy to treat young children, who are not able to deal with the trauma more directly. The therapist uses games, drawings and other methods to help children process their traumatic memories.

Psychological first aid (PFA) is a method that provides comfort and support, lets children know their reactions are normal and teaches calming and problem solving skills. Medication should notnbe offered to children with PTSD, because there is no supporting evidence that this treatment method contributes to their recovery.

Medication

Medication can help to treat adults with PTSD, but for most people it is not as helpful as traumafocused psychological treatment. Healthcare professionals should usually offer you psychological treatment before medication but may offer you medication if:

you prefer not to have psychological treatment
you can't start psychological treatment due to a high risk of further trauma
you have severe depression or hypersensitivity that affects your ability to benefit from psychological treatment
psychological treatment has not helped you

Antidepressants are usually offered for people with PTSD, because they may relieve some of the symptoms and help people to get the best from their psychological treatments. Most commonly used antidepressants for PTSD are SSRI antidepressants (selective serotonin reuptake inhibitors), which include Paroxetine (Paxil) and Sertraline (Zoloft).How do they work? They raise the level of serotonin in your brain, which can make you feel better. It takes 2 to 4 weeks before the effect of antidepressants builds up and a full build up can take up to three months. If you are responding to medication, you should be encouraged with the treatment for at least 12 months. Afterwards antidepressants can be gradually reduced over 4 weeks and then stopped. Antidepressants should be used with caution and with full knowledge of their possible side effects, because they can be difficult to come off.

A guide for friends, relatives and colleagues

How can family and friends support someone who has PTSD? In order to provide practical and emotional support to your loved one, you first need to take care of yourself. Try and not give up your outside life, don't feel guilty and don't feel bad if things change slowly. Here are some guidelines how you can help your loved one

Learn as much as you can about PTSD, because it will help you understand what your family member is going through and keep things in perspective.
Tell your loved one you are there when they want to talk and listen to them without being judgmental
Support your family member by offering to go with them to the doctor
Plan family activities together and encourage contact with family and close friends

Keep in mind that your family member may not want your help and that this withdrawal can be a symptom of PTSD. If this happens, give your loved one space and let them know that you are there for them. If your family is having a lot of trouble, you might consider trying family therapy (see above).

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