Introduction
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, 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 short.
This leaflet is for anyone who has been through traumatic
experiences, or who knows someone to whom this has happened.
People who have repeatedly experienced:
- severe neglect or abuse as an adult or as a child
- severe repeated violence of abuse as an adult, e.g. torture,
abusive imprisonment
can have a similar set of reactions. This is called
'complex PTSD' and is described later on in this leaflet.
How does PTSD start?
PTSD can start after any traumatic event. A traumatic event is
one where we can see that we are in danger, our life is threatened,
or where we see other people dying or being injured. Some typical
traumatic events would be:
- serious road accidents
- military combat
- violent personal assault (sexual assault, rape, 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 an the unexpected injury or violent death
of a family member or close friend can start PTSD.
When does PTSD start?
The symptoms of PTSD can start after a delay of weeks, or even
months. They usually appear within 6 months of a 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
produced by such an experience:
1. 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.
2. 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 crossword 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.
3. Being "On Guard"
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.
Other Symptoms
Emotional reactions to stress are often accompanied by:
- muscle aches and pains
- diarrhoea
- irregular heartbeats
- headaches
- feelings of panic and fear
- depression
- drinking too much alcohol
- using drugs (including painkillers).
Why are traumatic events so shocking?
They undermine our sense that life is fair, 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 narrowly avoided death.
Does everyone get PTSD after a traumatic experience?
No. But nearly everyone will have the symptoms of post traumatic
stress for the first month or so. This is because they 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 disappear.
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
- 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 are in a situation where 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 different things:
- our inner sense of worry, feeling tense or feeling
burdened.
or
- 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.
Psychological
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, or replays, force us to think about what has
happened. We can decide what to do if it happens again. After a
while, we learn to think about it without becoming upset.
- 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.
Physical
- 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 sleep well.
- 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 disappear.
How do I know when I've got over a traumatic experience?
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 unstable.
- Doctors and other professionals are human. They may feel
uncomfortable if we try to talk about gruesome or horrifying
events.
- 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 have experienced a traumatic event of the sort
described at the start of this leaflet?
If you have, do you:
- have vivid memories, flashbacks or nightmares?
- 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
usual?
- 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 that 6 weeks since the traumatic event, and
these experiences are slowly improving, they may be part of the
normal process of adjustment.
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 over again.
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 headaches.
How can PTSD be helped?
Helping yourself
Do .........
- keep life as normal as possible
- get back to your usual routine
- talk about what happened to someone you trust
- try relaxation exercises
- go back to work
- eat and exercise regularly
- go back to where the traumatic event happened
- take time to be with family and friends
- drive with care - your concentration may be poor
- be more careful generally - accidents are more likely at this
time
- speak to a doctor
- expect to get better.
Don't ........
- beat yourself up about it - PTSD symptoms are not a sign of
weakness. They are a normal reaction, of normal people, 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 more.
- get overtired.
- miss meals.
- take holidays on your own.
What can interfere with getting better?
You may find that other people will:
- 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.
You may not be able to talk easily about it. 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.
Treatment
Just as there are both physical and psychological aspects to
PTSD, so there are both physical and psychological treatments for
it.
Psychotherapy
All the effective psychotherapies for PTSD focus on the traumatic
experiences that have produced your symptoms 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 your
life.
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 words to the traumatic experiences that
you have had. 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.
If you can start to feel safe again and in control of your
feelings, you won't need to avoid the memories as much. Indeed, you
can gain more control over your memories so that you only think
about them when you want to, rather than having them erupt into
your mind spontaneously.
All these treatments should all be given by specialists in the
treatment of PTSD. The sessions should be at least weekly, every
week, with the same therapist, and should usually continue for 8-12
weeks. Although sessions will usually last around an hour, they may
sometimes last up to 90 minutes.
Cognitive Behavioural Therapy (CBT)
is a way of helping you to think differently about your memories,
so that they become less distressing and more manageable. It will
usually also involve some relaxation work to help you tolerate the
discomfort of thinking about the traumatic events. For further
information, see our factsheet on CBT.
EMDR (Eye Movement Desensitisation & Reprocessing) 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 to work.
Group therapy involves meeting with a group of other people
who have been through the same, or a similar traumatic event. The
fact that other people in the group do have some idea of what you
have been through can make it much easier to talk about what has
happened.
Medication
SSRI antidepressant tablets will both 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 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
antidepressany, some people may find that they feel more:
- anxious
- restless
- suicidal
These feelings usually pass in a few days, but you should see your
doctor regularly.
If these don't work for you, tricyclic or MAOI antidepressant
tablets may still be helpful. For more information, see our
factsheet on antidepressants.
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.
Body-focussed Therapies
These can help to control the distress of PTSD. They can also
reduce hyperarousal, or the feeling of being "on guard" all the
time. These therapies include physiotherapy and osteopathy, but
also complementary therapies such as massage, acupuncture,
reflexology, yoga, meditation and tai chi. They all help you to
develop ways of relaxing and managing stress.
Effectiveness of Treatments
At present, there is evidence that EMDR, cognitive behavioural
therapy and antidepressants are all effective. There is not enough
information for us to say that one of these treatments is better
than another. There is no evidence that other forms of
psychotherapy or counselling are helpful to PTSD.
Which treatments first?
The National Institute for Clinical Excellence (NICE) guidelines
suggest that trauma-focussed psychological therapies (CBT or EMDR)
should be offered before medication, wherever possible.
Complex PTSD
This can start weeks or months after the traumatic event, but
may take years to be recognised for what they are. As well as the
symptoms of PTSD described above, you may:
- feel shame and guilt
- have a sense of numbness, a lack of feelings in your body
- be unable to enjoy anything
- control your emotions by using street drugs, alcohol, or by
harming yourself
- cut yourself off from what is going on around you
(dissociation)
- 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'.
What makes PTSD worse?
If:
- it happens at an early stage - the earlier the age, the worse
the trauma
- 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
safety.
How does it come about?
The earlier the trauma happens, the more it affects
psychological development. Some children cope by being
defensive or aggressive, while others cut themselves off from what
is going on around them. They tend to grow up with a sense of shame
and guilt rather than feeling confident and good about
themselves.
Getting better
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 around you.
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 - if
you like, to experience that it is possible to trust someone in
this world without being abused. The work will often happen in 3
stages:
Stabilisation
You learn how to understand and control your distress and
emotional cutting off, or 'dissociation'. This can involve
'grounding' techniques to help you stay in the present -
concentrating on ordinary physical feelings that remind you that
you are not still living in the traumatic past.
You may also be able to 'disconnect' your physical symptoms of
fear and anxiety from the memories and emotions that produce them,
making them less frightening.
You start to be able to tolerate day to day life without
experiencing anxiety and flashbacks. This may sometimes be
the only help that is needed.
Trauma-focused Therapy
EMDR or CBT (see above) can help you 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 properly.
Reintegration
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 antipsychotioc medication - but not usually
tranquillisers or sleeping tablets.
For friends, relatives and colleagues
Do .......
- watch out for any changes in behaviour - poor performance at
work, lateness, taking sick leave, minor accidents
- 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.
Don't .......
- tell a survivor you know how they feel - you don't
- tell a survivor they're lucky to be alive - they'll get
angry
- minimise their experience - "it's not that bad, surely
..."
- suggest that they just need to 'pull themselves together'.
References
"Traumatic Stress: The Effects of Overwhelming Experience on
Mind, Body, and Society". (1996). Eds. van der Kolk BA, McFarlane
AC, & Weisaeth L. Guildford Press. New York, London.
"Psychological Trauma: A Developmental Approach". (1997). Eds.
Black D, Newman M, Harris-Hendriks J, & Mezey G. London;
Gaskell:The Royal College of Psychiatrists.
"Effective Treatments for PTSD: Guidelines from the
International Society of Traumatic Stress Studies" (2000). Eds. Foa
E, Keane T, & Friedman M. Guildford Press. New York,
London.
"Treating Trauma: Survivors with PTSD".(2002). Ed. Yehuda, R.
Washington DC. American Publishing.
Adshead, G. Psychological therapies for Post-traumatic Stress
Disorder. British Journal of Psychiatry, Aug 2000; 177: 144 -
148
Hull, A.M., Alexander, D.A. & Klein, S. Survivors of the
Piper Alpha Oil Platform Disaster: Long-term Follow-up Study.
British Journal of Psychiatry, Nov 2002; 181: 433 - 438
Lab D, Santos I, de Zulueta F (2008) Treating post-traumatic
stress disorder in the 'real world': evaluation of a specialist
trauma service and adaptations to standard treatment approaches.
Psychiatric Bulletin 32: 8-12.
Further information
"Post-Traumatic Stress Disorder - The Invisible Injury" (2002).
David Kinchin. Successunlimited.
www.successunlimited.co.uk/books/ptsympt.htm
Internet resources
UK Trauma Group has links to a selection of materials which
helpful information for the general public and for health
professionals about Post Traumatic Stress Reactions.
www.uktrauma.org.uk
David Baldwin's Trauma Pages website: up-to-date comprehensive
information about trauma including leading articles
www.trauma-pages.comFurther help
Assist
(Assistance Support and Self-Help in Surviving Trauma)
Helpline: 01788 560800. A support organisation for people suffering
from PTSD.
This leaflet was produced by the Royal College of
Psychiatrists' Public Education Editorial Board.
Series Editor: Dr Philip Timms
Expert review: Dr Gordon Turnbull
Editorial Board: Dr Ros Ramsay, Dr Martin Briscoe, Deborah
Hart
User & Carer input: Special Committee of Patients and
Carers
This leaflet recieved a commendation in the 2005 BMA
book awards.
The Royal College of Psychiatrists produces:
A range of materials for carers of people with mental health
problems has also been produced by the 'Partners in Care' campaign.
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