Post-traumatic Stress Disorder
About this leaflet
This leaflet is for anyone who has been through a harrowing
experience, who has been abused or tortured, or who knows someone
to whom this has happened.
In our everyday lives, any of us can have an
experience that is overwhelming, frightening, and beyond our
control. We could find ourselves in a car crash, be the victim of
an assault, or see an accident. Police, fire brigade or
ambulance workers are more likely to have such experiences – they
often have to deal with horrifying scenes. Soldiers may be shot or
blown up, and see friends killed or injured.
Most people, in time, get over experiences
like this without needing help. In some people, though, traumatic
experiences set off a reaction that can last for many months or
years. This is called Post-traumatic Stress Disorder, or PTSD for
People who have repeatedly experienced:
- severe neglect or abuse as an adult or as a child
- severe repeated violence or abuse as an adult, such as torture
or abusive imprisonment
can have a similar set of reactions. This is
called 'complex PTSD' and is described later on in this
How does PTSD start?
PTSD can start after any traumatic event. A
traumatic event is one where you see that you are in
danger, your life is threatened, or where you see other people
dying or being injured. Typical traumatic events would
- serious accidents
- military combat
- violent personal assault (sexual assault, physical attack,
abuse, robbery, mugging)
- being taken hostage
- terrorist attack
- being a prisoner-of-war
- natural or man-made disasters
- being diagnosed with a life-threatening illness.
Even hearing about the unexpected injury or
violent death of a family member or close friend can start
When does PTSD start?
The symptoms of PTSD can start immediately or
after a delay of weeks or months, but usually within 6 months of
the traumatic event.
What does PTSD feel like?
Many people feel grief-stricken, depressed,
anxious, guilty and angry after a traumatic experience. As well as
these understandable emotional reactions, there are three main
types of symptoms:
Flashbacks & nightmares
You find yourself re-living the event, again
and again. This can happen both as a 'flashback' in the day and as
nightmares when you are asleep. These can be so realistic that it
feels as though you are living through the experience all over
again. You see it in your mind, but may also feel the
emotions and physical sensations of what happened - fear, sweating,
smells, sounds, pain.
Ordinary things can trigger off flashbacks.
For instance, if you had a car crash in the rain, a rainy day might
start a flashback.
Avoidance & numbing
It can be just too upsetting to re-live your
experience over and over again. So you distract yourself. You
keep your mind busy by losing yourself in a hobby, working very
hard, or spending your time absorbed in crosswords or jigsaw
puzzles. You avoid places and people that remind you of the
trauma, and try not to talk about it.
You may deal with the pain of your feelings by
trying to feel nothing at all – by becoming emotionally numb. You
communicate less with other people who then find it hard to live or
work with you.
You find that you stay alert all the time, as
if you are looking out for danger. You can’t relax. This is called
'hypervigilance'. You feel anxious and find it hard to sleep.
Other people will notice that you are jumpy and irritable.
- muscle aches and pains
- irregular heartbeats
- feelings of panic and fear
- drinking too much alcohol
- using drugs (including painkillers).
Why are traumatic events so shocking?
They undermine our sense that life is fair,
that it is reasonably safe and that we are secure. A traumatic
experience makes it very clear that we can die at any time.
The symptoms of PTSD are part of a normal reaction to
Does everyone get PTSD after a traumatic
No. But nearly everyone will have the symptoms
of post-traumatic stress for the first month or so. This is because
they can help to keep you going, and help you to understand the
experience you have been through. This is an 'acute stress
reaction'. Over a few weeks, most people slowly come to
terms with what has happened, and their stress symptoms start to
Not everyone is so lucky. About 1
in 3 people will find that their symptoms just carry on and
that they can’t come to terms with what has happened. It is as
though the process has got stuck. The symptoms of post-traumatic
stress, although normal in themselves, become a problem – or
Post-traumatic Stress Disorder – when they go on for too long.
What makes PTSD worse?
The more disturbing the experience, the more
likely you are to develop PTSD. The most traumatic events:
- are sudden and unexpected
- go on for a long time
- are when you are trapped and can’t get away
- are man-made
- cause many deaths
- cause mutilation and loss of arms or legs
- involve children.
If you continue to be exposed to stress
and uncertainty, this will make it difficult or impossible for your
PTSD symptoms to improve.
What about ordinary 'stress'?
Everybody feels stressed from time to time.
Unfortunately, the word 'stress' is used to mean two rather
- our inner sense of worry, feeling tense or feeling
- the problems in our life that are giving us these feelings.
This could be work, relationships, maybe just trying to get by
without much money.
Unlike PTSD, these things are with us, day in
and day out. They are part of normal, everyday life, but can
produce anxiety, depression, tiredness, and headaches. They can
also make some physical problems worse, such as stomach ulcers and
skin problems. These are certainly troublesome, but they are not
the same as PTSD.
Why does PTSD happen?
We don’t know for certain. There are a several
possible explanations for why PTSD occurs.
- When we are frightened, we remember things
very clearly. Although it can be distressing to remember these
things, it can help us to understand what happened and, in the long
run, help us to survive.
- The flashbacks can be seen as replays of what
happened. They force us to think about what has happened so we
might be better-prepared if it were to happen again.
- It is tiring and distressing to remember a trauma.
Avoidance and numbing keep the
number of replays down to a manageable level.
- Being 'on guard' means that we can react
quickly if another crisis happens. We sometimes see this happening
with survivors of an earthquake, when there may be second or third
shocks. It can also give us the energy for the work that’s needed
after an accident or crisis.
But we don’t want to spend the rest of our
life going over it. We only want to think about it when we have to
- if we find ourselves in a similar situation.
- Adrenaline is a hormone our
bodies produce when we are under stress. It 'pumps up' the body to
prepare it for action. When the stress disappears, the level of
adrenaline should go back to normal. In PTSD, it may be that the
vivid memories of the trauma keep the levels of adrenaline high.
This will make a person tense, irritable, and unable to relax or
- The hippocampus is a part of the brain that
processes memories. High levels of stress hormones, like
adrenaline, can stop it from working properly – like 'blowing a
fuse'. This means that flashbacks and nightmares continue
because the memories of the trauma can’t be processed. If the
stress goes away, and the adrenaline levels get back to normal, the
brain is able to repair the damage itself, like other natural
healing processes in the body. The disturbing memories can then be
processed and the flashbacks and nightmares will slowly
How do I know when I’ve got over a traumatic
When you can:
- think about it without becoming distressed
- not feel constantly under threat
- not think about it at inappropriate times.
Why is PTSD often not recognised?
- None of us like to talk about upsetting
events and feelings.
- We may not want to admit to having symptoms
because we don't want to be thought of as weak or mentally
- Doctors and other professionals are human.
They may feel uncomfortable if we try to talk about gruesome or
- People with PTSD often find it easier to talk
about the other problems that go along with it - headache, sleep
problems, irritability, depression, tension, substance abuse,
family or work-related problems.
How can I tell if I have PTSD?
Have you experienced a traumatic event of the
sort described at the start of this leaflet? If you have, do
- have vivid memories, flashbacks or
- avoid things that remind you of the event?
- feel emotionally numb at times?
- feel irritable and constantly on edge, but can’t see why?
- eat more than usual, or use more drink or drugs than
- feel out of control of your mood?
- find it more difficult to get on with other people?
- have to keep very busy to cope?
- feel depressed or exhausted?
If it is less than 6 weeks
since the traumatic event and these experiences are slowly
improving, they may be part of the normal process of
If it is more than 6 weeks
since the event, and these experiences don’t seem to be getting
better, it is worth talking it over with your doctor.
Children and PTSD
PTSD can develop at any age. Younger
children may have upsetting dreams of the actual trauma, which then
change into nightmares of monsters. They often re-live the trauma
in their play. For example, a child involved in a serious road
traffic accident might re-enact the crash with toy cars, over and
They may lose interest in things they used to
enjoy. They may find it hard to believe that they will live long
enough to grow up.
They often complain of stomach aches and
How can PTSD be helped?
- keep life as normal as possible
- get back to your usual routine
- talk about what happened to someone you
- try relaxation exercises
- go back to work
- eat and exercise regularly
- go back to where the traumatic event
- take time to be with family and friends
- be careful when driving – your concentration
may be poor
- be more careful generally – accidents are
more likely at this time
- speak to a doctor
- expect to get better.
- beat yourself up about it - PTSD symptoms are
not a sign of weakness. They are a normal reaction of a normal
person to terrifying experiences.
- bottle up your feelings. If you have
developed PTSD symptoms, don’t keep it to yourself because
treatment is usually very successful.
- avoid talking about it
- expect the memories to go away immediately;
they may be with you for quite some time
- expect too much of yourself. Cut yourself a
bit of slack while you adjust to what has happened.
- stay away from other people
- drink lots of alcohol or coffee or smoke
- get overtired
- miss meals
- take holidays on your own.
What can interfere with getting better?
You may find that other people
- not let you talk about it
- avoid you
- be angry with you
- think of you as weak
- blame you.
These are all ways in which other people
protect themselves from thinking about gruesome or horrifying
events. It won’t help you because it doesn’t give you the chance to
talk over what has happened to you. And it is hard to talk about
A traumatic event can put you into a
trance-like state which makes the situation seem unreal or
bewildering. It is harder to deal with if you can’t remember what
happened, can’t put it into words, or can’t make sense of it.
Just as there are both psychological and
physical aspects to PTSD, so there are both psychological and
physical treatments for it.
All the effective psychotherapies for PTSD
focus on the traumatic experience – or experiences - rather than
your past life. You cannot change or forget what has happened. You
can learn to think differently about it, about the world, and about
You need to be able to remember what happened,
as fully as possible, without being overwhelmed by fear and
distress. These therapies help you to put your experiences into
words. By remembering the event, going over it and making sense of
it, your mind can do its normal job of storing the memories away,
and moving on to other things.
When you start to feel safer, and more in
control of your feelings, you won’t need to avoid the memories as
much. You will be able to only think about them when you want to,
rather than having them burst into your mind out of the
All these treatments should all be given by
PTSD specialists. The sessions should be at least weekly, with the
same therapist, for 8-12 weeks. Although sessions will
usually last around an hour, they can sometimes last up to 90
Therapy (CBT) is a talking treatment which
can help us to understand how 'habits of thinking' can make the
PTSD worse - or even cause it. CBT can help you change these
'extreme' ways of thinking, which can also help you to feel better
and to behave differently.
EMDR (Eye Movement Desensitisation &
This is a technique which uses eye movements
to help the brain to process flashbacks and to make sense of the
traumatic experience. It may sound odd, but it has been shown
This involves meeting with a group of other
people who have been through the same, or a similar traumatic
event. It can be easier to talk about what happened if you are with
other people who have been through a similar experience.
SSRI antidepressant tablets may help to reduce
the strength of PTSD symptoms and relieve any depression that is
also present. They will need to be prescribed by a doctor.
This type of medication should not make you
sleepy, although they all have some side-effects in some
people. They may also produce unpleasant symptoms if stopped
too quickly, so the dose should usually be reduced gradually. If
they are helpful, you should carry on taking them for around 12
months. Soon after starting an antidepressant, some people may find
that they feel more:
These feeling usually pass in a few days, but you
should see a doctor regularly.
If these don't work for you, tricyclic and MAOI antidepressants
may still be helpful. For further information, see our
Occasionally, if someone is so distressed that
they cannot sleep or think clearly, anxiety-reducing medication may
be necessary. These tablets should usually not be prescribed
for more than 10 days or so.
These don't help PTSD directly, but can help
to control your distress and hyperarousal, the feeling of
being 'on guard' all the time. These include physiotherapy and
osteopathy, but also complementary therapies such as massage,
acupuncture, reflexology, yoga, meditation and tai chi. They
can help you to develop ways of relaxing and managing
What works best?
At present, there is evidence that EMDR,
Cognitive Behavioural Therapy, behaviour therapy and
antidepressants are all effective. There is not enough information
for us to show that one of these treatments is better than another.
There is not yet any evidence that other forms of psychotherapy or
counselling are helpful for PTSD.
Which treatment first?
Guidelines from the National Institute for Health and Care
Excellence (NICE) suggest that trauma-focussed psychological
therapies (CBT or EMDR) should be offered before medication,
For friends, relatives & colleagues
- watch out for any changes in behaviour –
poor performance at work, lateness, taking sick leave, minor
- watch for anger, irritability, depression,
lack of interest, lack of concentration
- take time to allow a trauma survivor to
tell their story
- ask general questions
- let them talk, don’t interrupt the
flow or come back with your own experiences.
- tell a survivor you know how they feel –
- tell a survivor they’re lucky to be alive –
it doesn't feel like that to them
- minimise their experience – “it’s not that
bad, surely …”
- suggest that they just need to "pull
This can start weeks or months after the
traumatic event, but may take years to be recognised.
Trauma affects a child's development - the
earlier the trauma, the more harm it does. Some children cope by
being defensive or aggressive. Others cut themselves off from what
is going on around them, and grow up with a sense of shame and
guilt rather than feeling confident and good about themselves.
Adults who have been abused or tortured over a
period of time develop a similar sense of separation from others,
and a lack of trust in the world and other people.
As well as many of the symptoms of PTSD
described above, you may find that you:
- feel shame and guilt
- have a sense of numbness, a lack of feelings in your body
- can't enjoy anything
- control your emotions by using street drugs, alcohol, or by
- cut yourself off from what is going on around you
- have physical symptoms caused by your distress
- find that you can't put your emotions into words
- want to kill yourself
- take risks and do things on the 'spur of the moment'.
It is worse if:
- it happens at an early age – the earlier the age, the worse the
- it is caused by a parent or other care giver
- the trauma is severe
- the trauma goes on for a long time
- you are isolated
- you are still in touch with the abuser and/or threats to your
Try to start doing the normal things of life
that have nothing to do with your past experiences of
trauma. This could include finding friends, getting a job,
doing regular exercise, learning relaxation techniques, developing
a hobby or having pets. This helps you slowly to trust the world
Lack of trust in other people – and the world
in general – is central to complex PTSD. Treatment often needs to
be longer to allow you to develop a secure relationship with a
therapist – to experience that it is possible to trust
someone in this world without being hurt or abused. The work will
often happen in 3 stages:
- learn how to understand and control your distress and emotional
cutting-off, or 'dissociation'. This can involve 'grounding'
techniques to help you to stay in the present – concentrating on
ordinary physical feelings to remind you that you are living in the
present, not the abusive and traumatic past.
- start to 'disconnect' your physical symptoms of fear and
anxiety from the memories and emotions that produce them, making
them less frightening.
- start to be able to tolerate day-to-day life without
experiencing anxiety or flashbacks.
This may sometimes be the only help that is needed.
EMDR or Cognitive Behavioural
Therapy can help you to remember
your traumatic experiences with less distress and more control.
Other psychotherapies, including psychodynamic psychotherapy, can
also be helpful. Care needs to be taken in complex PTSD because
these treatments can make the situation worse if not used
You begin to develop a new life for
yourself. You become able to use your skills or learn new ones, and
to make satisfying relationships in the real world.
Medication can be used if you feel too
distressed or unsafe, or if psychotherapy is not possible. It can
include both antidepressants and antipsychotic medication – but not
usually tranquillisers or sleeping tablets.
Psychological Trauma Society (formerly UK Trauma
Group): clinical network of UK Traumatic Stress Services.
PILOTS database of the National Center for PTSD (USA):
published international literature on PTSD.
David Baldwin’s Trauma
Pages website: up-to-date comprehensive information
about trauma including leading articles.
– non-military links.
- Post-traumatic Stress Disorder – The
Invisible Injury ( 2002). David Kinchin.
- Effective Treatments for PTSD: Practice
Guidelines from the International Society of Traumatic Stress
Studies (2nd edition) (2010). Eds. Foa E, Keane T, Friedman M &
- Treating Trauma: Survivors with PTSD (2002).
Ed. Yehuda, R. Washington DC. American Publishing.
- Adshead G and Ferris S. Treatment of victims
of trauma. Advances in Psychiatric Treatment (September
- Bisson JI, Pharmacological treatment of post-traumatic stress
disorder. Advances in Psychiatric Treatment (March 2007)
- Coetzee RH and Regel S, Eye movement desensitisation and
reprocessing: an update. Advances in Psychiatric Treatment
(March 2005) 11:347-354.
- Hull, A.M., Alexander, D.A. & Klein, S.
Survivors of the Piper Alpha oil platform disaster: long-term
follow-up study (2002). Br. J. Psychiatry, 181: 433 – 438
- NICE guidelines (update 2012):
Post-traumatic stress disorder: the management of PTSD in adults
and children in primary and secondary care.
- Lab, D., Santos, I. & de Zulueta,
F.Treating post-traumatic stress disorder in the ‘real world’:
evaluation of a specialist trauma service and adaptations to
standard treatment approaches (2008). Psychiatric
Bulletin, 32: 8-12.
- Frueh BC, Grubaugh AL, Yeager
DE and Magruder KM. Delayed-onset post-traumatic stress
disorder among war veterans in primary care clinics (2009).
The British Journal of Psychiatry, 194, 515–520.
This leaflet was produced by the Royal College
of Psychiatrists Public Education Committee Editorial
Series Editor: Dr Philip Timms
Expert : Dr Gordon Turnbull
Illustration: Lo Cole: www.locole.co.uk
This leaflet reflects the best available evidence at the
time of writing.
© April 2013. Due for review: April 2015. Royal College of
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