Post-traumatic stress disorder (PTSD)

PTSD can affect anyone, and is caused when someone is exposed to actual or threatened:

• death
• serious injury
• sexual violence

They may be exposed in one of the following ways:

• Directly – it happened to them
• Witnessing – they saw it happen to someone else
• Learning – they found out that it had happened to someone very close to them
• Repeated exposure – they have been repeatedly exposed to traumatic incidents themselves or to repeated traumatic events affecting other people. We also know that some people who are exposed to traumatic events through electronic media, television, movies or pictures at work may experience mental health difficulties.

Examples of traumatic events can include:

• witnessing a violent death
• serious accidents, e.g. a car crash
• physical or sexual assault
• serious health problems or being in intensive care
• complicated childbirth experiences
• being diagnosed with a life-threatening illness
• war and conflict
• terrorist attacks
• natural or man-made disasters, e.g. tsunamis or fires

It’s important to remember that there are a huge number of events not covered here that could cause PTSD. If your experience is not covered here, that does not mean you shouldn’t seek help and support.

Traumatic events are shocking because we cannot make sense of them. They don’t fit with our sense of what the world should be like.

Traumatic events often appear to be ‘random’ or don’t have a clear cause. They do not fit in with our views about how the world should be, which can make it difficult for us to understand the meaning behind them.

Traumatic experiences also show us that bad things can happen to us and the people we care about at any time. This can lead to us feeling unsafe and threatened which is understandably frightening. Sometimes traumatic events can make us question who we are, which can be distressing too.

Many people will experience traumatic events throughout their lives. About one third of adults in England report having experienced at least one traumatic event. However, not everyone who experiences a traumatic event will go on to develop PTSD.

Many people can experience grief, sadness, anxiety, guilt and anger after a traumatic experience. This does not necessarily mean that someone has PTSD. People who have PTSD often have many of the following symptoms. These can start immediately, or they might take some weeks or even months to begin.

With PTSD, these symptoms will interfere with your day-to-day activities and/or cause you to feel extremely distressed. If you have any of these symptoms immediately after a traumatic event, this does not necessarily mean that you will develop PTSD.

Re-experiencing symptoms

• Memories – Having unwanted memories of the event, known as intrusive thoughts, that are very overwhelming and distressing.
• Dreams – Having distressing dreams or nightmares about the event.
• Dissociative reactions – Feeling or acting as if the traumatic event is happening again (known as flashbacks). In extreme situations, you might stop being aware of what is happening around you.
• Physical and psychological distress – Feeling very distressed and physically aroused (e.g. fast breathing, rapid pulse) when exposed to things that remind you in some way of the event.

Avoidance symptoms

• Dissociative amnesia – Being unable to remember parts of the traumatic event.
• Detachment – Feeling detached or no longer close to people you previously felt close to.
• Avoiding talking and thinking - Not wanting to speak or think about the traumatic event(s).
• Avoiding associations – Avoiding memories, thoughts, feelings, things, people and places associated with the traumatic event. This might include avoiding TV or other media about the event, especially if doing so causes you distress.

Mood symptoms

• Negative beliefs and expectations – Thinking negatively about yourself, others or the world.
• Blame – Blaming yourself or other people for the traumatic event happening or its consequences.
• Negative emotions – Persistently experiencing fear, horror, anger, guilt or shame.
• Loss of interest in activities – Not taking part in or being interested in activities that you used to enjoy or be able to do regularly.
• Unable to feel positive emotions – Not able to experience happiness, satisfaction or loving feelings.

Alertness and reactivity symptoms

• Hypervigilance – Being overly aware of what’s going on around you and being unable to relax.
• Being startled easily – Overreacting to noises or movements that remind you of the traumatic event.
• Difficulty concentrating – Finding it hard to focus on tasks that you were able to focus on before.
• Difficulty sleeping – Finding it difficult to fall asleep and stay asleep. When you do fall asleep your sleep might be poor and you might have nightmares.
• Irritability – Having outbursts where you are verbally or physically aggressive towards people or things. These outbursts might be caused by experiencing something that reminds you of the traumatic event.
• Recklessness – Doing dangerous or self-destructive things.

There are several possible explanations for what causes PTSD.

Psychological

The psychological symptoms of PTSD are deeply unpleasant and distressing. However, these symptoms can make sense when we think about how our minds might work to protect us after a traumatic event.

• Memory – After experiencing a traumatic event we might be unable or unwilling to remember it. Although it can be distressing to remember what has happened, doing so can help us to make sense of the event. This can be helpful for our mental health.
• Intrusive thoughts or flashbacks – These can be seen as replays of what happened. They might force us to think about what has happened so we might be better prepared if it were to happen again. However, in PTSD these thoughts just cause us to feel distressed.
• Avoidance and numbing – It is tiring and distressing to remember a trauma. Avoidance and numbing can help you to stop thinking about what happened. However, they also stop you from making sense of your experiences.
• Hypervigilance – If we are ‘on guard’, we might feel prepared to react quickly if another crisis happens. It can also give us the energy for the work that’s needed after an accident or crisis. However, it can also be exhausting and prevent us from doing things we used to enjoy.

Physical

Some of the physical symptoms that occur with PTSD occur because our bodies are trying to incorrectly process trauma.

• Adrenaline – This is a hormone our bodies produce when we are under stress. It helps to prepare our bodies for activities that need a lot of energy, for example, running or fighting someone off. When the stress disappears, the level of adrenaline should go back to normal. In PTSD, vivid memories of the stressful event can keep the levels of adrenaline high. High levels of adrenaline can make you tense, irritable and unable to relax or sleep well.
• The hippocampus – This is a part of the brain that processes memories. High levels of stress hormones, like adrenaline, can stop it from working properly. This means that memories of the traumatic event aren’t processed. This can cause you to remember the event as though the risk is still present, rather than seeing it as something that happened in the past. 

Anyone can get PTSD if they have experienced a traumatic event. However, some people have jobs that mean they are more likely to experience traumatic events. This means that the risk of them developing PTSD is higher than in other careers. These jobs can include:

• Emergency service workers (e.g. police, fire brigade or ambulance staff)
• Social workers
• Intensive care staff
• Military personnel and other people working in war zones

The symptoms of PTSD can start immediately after a traumatic event, or even weeks or months afterwards. Usually, symptoms start within 6 months of the event. Sometimes symptoms will start after 6 months, though this is less common. Unfortunately, many people will not ask for help when their symptoms first start.

PTSD cannot be diagnosed in the first month after a traumatic event. If you experience trauma symptoms straight away, and these are severe and prevent you from functioning, you might be experiencing an 'acute stress disorder'.

After a traumatic experience, many people will have some trauma symptoms for the first month or so. Many of these symptoms are normal reactions to experiencing real or perceived danger. You can think about them as your brain’s way of protecting you from harm.

However, most people will process what has happened after a few weeks, or sometimes a little longer, and their stress symptoms will start to disappear.

Research shows that certain groups of people are at increased risk of developing PTSD. The risk of developing PTSD is decreased if someone can:

• access social support and
• recover from the traumatic event in a ‘low stress environment’.

Any traumatic event can cause PTSD, although the more disturbing the experience, the more likely you are to develop PTSD. For example, you might be more likely to develop PTSD if the event:

• is sudden and unexpected
• goes on for a long time
• happens when you are trapped and can’t get away
• is man-made
• causes many deaths
• causes mutilation
• involves children.

If you continue to be exposed to stress and uncertainty, this will make it more difficult for your PTSD symptoms to improve.

You may have got over a traumatic event if you can:

• think about it without becoming overly distressed
• not feel constantly under threat
• not think about it at inappropriate times.

There are a number of reasons why someone with PTSD might not be diagnosed.

Stigma and misunderstanding

People with PTSD will often avoid talking about how they are feeling so they don’t have to think about the traumatic event.

Some people feel that the symptoms they are experiencing (for example, avoidance and numbing) are helping them to cope, and don’t realise that they are caused by PTSD.

When someone is very unwell, they can find it hard to believe that they will return to how they felt before the traumatic event. This can put them off getting help.

There is also a common misunderstanding that only people in the armed forces get PTSD. In fact, PTSD can happen to anyone, and every experience of PTSD is valid.

Incorrect diagnosis

Some people who have PTSD might be incorrectly diagnosed with conditions like anxiety or depression. Some people will have other psychological or physical health problems that mean their PTSD goes unnoticed.

They might also have ‘medically unexplained physical symptoms’ such as:

• gastrointestinal difficulties
• pain syndromes
• headaches

These symptoms can mean that their PTSD is identified as something else.

Other challenges

Some people with PTSD might also have other challenges, such as relationship difficulties or dependence on alcohol or drugs. These might be caused by their PTSD, but can be more obvious than the PTSD itself.

PTSD can develop at any age. As well as the symptoms of PTSD experienced in adults, children can also experience:

• Frightening dreams – In children, these dreams may or may not reflect the actual traumatic event.
• Repetitive play – Some children will act out the traumatic event when they are playing. For example, a child involved in a serious road traffic accident might re-enact the crash with toy cars. 
• Physical symptoms – They might complain of stomach aches and headaches.
• Fear that their life will end soon – They may find it hard to believe that they will live long enough to grow up.

There are a number of different treatments for PTSD, including trauma-focused cognitive behavioural therapy (TF-CBT), Eye Movement Desensitisation & Reprocessing (EMDR) and medications.

Psychotherapy

Psychotherapies for PTSD will focus on the traumatic experience, rather than your past life. They will help you with the following things:

• Acceptance – Learning to accept that though you can’t change what has happened, you can think differently about the event, the world and your life.
• Remembering the event – Remembering what happened without being overwhelmed by fear and distress. You will be able to think about what happened when you want to, rather than through intrusive thoughts or flashbacks.
• Putting your experiences into words – Talking about what happened so that your mind can store the memories away, and move on to other things.
• Feeling safer – Helping you to feel more in control of your feelings. This can help you to feel safer, so you won’t need to avoid the memories as much.

Any psychotherapy should be given by a someone who is properly trained and accredited. Sessions are usually at least weekly, with the same therapist, and often last for at least 8-12 weeks.

Although sessions will usually last around an hour, they can sometimes last up to 90 minutes.

Therapies for PTSD include:

Trauma-focused cognitive behavioural therapy (TF-CBT)

This is a talking therapy that can help you change your ways of thinking. In time this can help you to feel better and to behave differently. This is usually delivered one-to-one although there is some evidence that TF-CBT can be delivered in groups too.

EMDR (Eye Movement Desensitisation & Reprocessing)

This is a technique that uses eye movements to help the brain to process traumatic memories.

You will be asked to recall the traumatic event and how it makes you think and feel. While you do this, you will be asked to perform eye movements or receive some kind of ‘bilateral stimulation’ such as hand tapping. This has been shown to lower the intensity of the emotions you experience around a traumatic memory, helping to resolve the trauma.

EMDR should be delivered by a trained practitioner. EMDR is usually delivered over 8-12 sessions that last from 60-90 minutes.

Some other forms of talking therapies may be helpful to target specific symptoms (e.g. poor sleep) for people who do not respond well to EMDR or TF-CBT.

Medication

If you have tried other therapies to treat your PTSD and find these are not working, your doctor may prescribe you antidepressants.

Selective serotonin reuptake inhibitors (SSRIs) are antidepressants that can help to reduce PTSD symptoms. If you are also experiencing depression, antidepressants can help with this.

If SSRIs don't work for you, you may be offered other medication, but this should usually be on the advice of a mental health specialist.

There is evidence that TF-CBT and EMDR are the best first-line therapies. Medication can be helpful for those who do not want talking therapies or who cannot access them easily.

Trauma-focused psychological therapies (TF-CBT or EMDR) should be offered before medication, wherever possible. This is according to guidelines from the National Institute for Health and Care Excellence (NICE).

There are some things that you can do to support your recovery if you have PTSD. Your therapist will help to support you with these things and make sure you do them at the right time:

• Keeping to your routine – If possible, try to get back to or stay in your usual routine. Keeping your life as normal as possible can give you a sense of grounding
• Talk to someone you trust – While you shouldn’t feel like you have to talk about what happened with just anyone, talking to someone you trust can help you to process your feelings in a safe space. It might also help to speak to someone who experienced the same thing that you did, or who has experienced a similar event before, if doing so is not too distressing.
• Try relaxation exercises – Try self-led meditation and other exercises to relax. Relaxing with PTSD can be challenging, so speak to your therapist about exercises or activities that might work for you.
• Go back to work or school – If you feel able, it can help to return to work, school or university. This can give you a sense of routine. However, you should try to avoid being in situations where you might be exposed to further trauma or intense stress. Generally, working in a supportive, lower stress environment is best until you have treatment.
• Eat and exercise regularly – Try to eat when you usually would, even if you don’t feel hungry. If you feel able, try to take regular exercise. This can also help you to feel more tired when it’s time for you to sleep.
• Spend time with others – Taking time to be with the people you care about can give you a sense of support.
• Expect to get better – Focusing on the idea that you will eventually get better will be good for your recovery. Remember not to put pressure on yourself to get better quickly.
• Go back to where the traumatic event happened – Only when you feel able to do this, you might want to go back to where the traumatic event happened. Talk to your therapist or doctor if you are planning to do this, so they can support you with this step.
  

There are also some things you might want to be careful about doing or conscious of while you are recovering. However, doing the ‘right thing’ can be really challenging and you shouldn’t feel guilty if you find yourself doing any of these things:

• Self-criticism - PTSD symptoms are not a sign of weakness. They are a normal reaction to terrifying experiences.
• Keeping your feelings to yourself – If you have PTSD, don’t feel guilty about sharing your thoughts and feelings with others. Talking about how you are feeling can support your recovery.
• Expecting things to go back to normal straight away – Treatment for PTSD can take time. Try not to expect too much of yourself too quickly.
• Staying away from other people – Spending lots of time on your own can increase feelings of isolation and make you feel worse.
• Drinking and smoking – While alcohol can help you relax, over time it might make you feel worse. Coffee and nicotine can act as stimulants which might make you feel worse if you are experiencing symptoms associated with PTSD.
• Getting overtired – PTSD can make sleeping difficult, but try as much as possible to stick to your usual sleeping routine and avoid staying up late, as this can make you feel worse. You can find out more in our resource on sleeping well.

Finally, you might also want to be careful when driving and if you feel unsafe to drive you should let the DVLA know. People can be more prone to accidents after something traumatic has happened.

Some people develop complex post-traumatic stress disorder (complex PTSD). This is caused by experiencing an event or series of events that are extremely threatening or horrifying. These events can happen during childhood or as an adult.

Quite often these events will have been difficult or impossible to easily escape from or avoid. For example:

• torture
• slavery
• genocide campaigns
• living in a war zone
• prolonged domestic violence
• repeated childhood sexual or physical abuse. 

As well as the symptoms of PTSD, people with complex PTSD might also:

• have extremely negative beliefs about themselves as ‘diminished, defeated or worthless’
• have great difficulty in regulating their emotions and emotional responses
• find it extremely difficult to keep relationships and feel close to other people

Lack of trust in other people and the world in general is common in people with complex PTSD. Treatment is often longer to allow them to develop a secure relationship with a therapist. The work someone with complex PTSD does with a therapist will often happen in three stages:

Stabilisation

In the stabilisation stage you will learn to trust your therapist, and understand and control your feelings of distress and detachment.

As part of stabilisation, you might learn 'grounding' techniques. These can help you to concentrate on ordinary physical feelings, and remind you that you are living in the present and not the past.

Stabilisation can help you to 'disconnect' your feelings of fear and anxiety from the memories and emotions that produce them. This can help to make these memories less frightening.

The aim of stabilisation is that you will eventually be able to live your life without experiencing anxiety or flashbacks.

Sometimes stabilisation may be the only help that is needed.

Trauma-focused therapies

Therapy that focuses on trauma, including EMDR or TF-CBT, can help you to process your traumatic experiences. 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 or reconnection

Reintegration, into a routine way of life, can help you to get used to the real world now that you are no longer in the dangerous situation you were in before. It can help you to begin to see yourself as a person with rights and choices.

Reintegration will help you to:

• relate compassionately to yourself and others
• re-establish trust in yourself and others
• reengage in friendships, intimate relationships and activities that promote your health and wellbeing

Medication

As with PTSD, antidepressants or other medication can be used as well as psychotherapy. Medication can also be used if psychotherapy is not working or is not possible for you. It may help to have a mental health specialist review your medication as well.

Self help

If you have complex PTSD, it can be helpful to try and do normal things that have nothing to do with your past experiences of trauma. This could include:

• making friends
• getting a job
• doing regular exercise
• learning relaxation techniques
• developing a hobby
• having pets.

These things can help you to slowly trust the world around you. However, this can take time and there is no shame in finding these things hard or being unable to do them straight away.

If you know someone who has just experienced a traumatic event, there are some things you might want to look out for. These things could be signs that they are struggling to cope:

• Changes in behaviour – Poor performance at work, lateness, taking sick leave, minor accidents
• Changes in emotion – Anger, irritability, depression, a lack of interest and a lack of concentration
• Changes in thoughts – Dwelling on threats or fears, negative views of the future
• Unexpected physical symptoms – such as breathlessness, jumpiness or stomach aches

If you think someone might be showing signs of PTSD, you could encourage them to speak to their GP. If you don’t feel close enough to them to do this, you might want to speak to someone they are close to, who could do this instead.

It may also help for them to look at information about PTSD such as this resource, to help them identify the difficulties they are having.

The following things can help to support someone who has been through something traumatic:

• Talk – Take time to allow them to talk with you about their experiences.
• Listen – Let them talk, and try not to interrupt the flow or share your own experiences.
• Ask general questions – If you do ask questions, try to make them general and non-judgemental. For example, you might want to ask ‘have you spoken to anyone else about this?’ or ‘can I help you to find some extra support?’

You should try to avoid:

• Telling them you know how they feel – Even if you have experienced something similar, people experience situations very differently. It can be unhelpful to make comparisons.
• Telling them they are lucky to be alive – People who have experienced traumatic events often won’t feel lucky. Often, they can feel guilty for being alive if others have died.
• Minimising their experience – Avoid suggesting it could have been worse, even if you are trying to make them feel better. This can make people feel as though their feelings aren’t justified.
• Making unhelpful suggestions – Avoid making suggestions, even if you have found that these have worked for you in the past. People are very different and often they may have already tried what you are suggesting.

Information on PTSD

UK Psychological Trauma Society – here you can find a selection of materials which helpful information for the general public and for health professionals about Post Traumatic Stress Reactions.

Overview of PTSD, NHS – this information from the NHS covers PTSD

Overview of complex PTSD, NHS – this information from the NHS covers complex PTSD

PTSD, Mind – the charity Mind has information on PTSD and complex PTSD

How can friends and family help? Mind – This information offers ideas for how you can help someone you know who has PTSD

Useful contacts, Mind – This page has links to other charities and organisations that offer support to people with PTSD

Charities supporting people with PTSD

Here are some charities that offer support to people who experience PTSD or traumatic events:

PTSD UK – A UK charity dedicated to raising awareness of PTSD

Combat Stress – the UK charity for veterans’ mental health.

Cruse Bereavement Care – a charity offering support for bereaved people in England, Wales and Northern Ireland

Cruse Bereavement Care Scotland – a charity promoting the well-being of bereaved people in Scotland

Rape Crisis – there are three rape crisis charities that offer support to people across the UK:

• Rape Crisis - England and Wales
• Rape Crisis - Scotland
• Rape Crisis - Northern Ireland

Victim Support – there are three victim support charities that offer support to people across the UK who have been victims of crime and traumatic incidents:

• Victim Support - England and Wales
• Victim Support - Scotland
• Victim Support - Northern Ireland

This information was produced by the Royal College of Psychiatrists’ Public Engagement Editorial Board (PEEB). It reflects the best available evidence at the time of writing. 

Special thanks to PTSD UK, who kindly offered their feedback on this resource.

Expert editor: Professor Neil Greenberg 

Full references for this resource are available on request.