This information is for anyone who has been through a harrowing experience, who has been abused or tortured, or who knows someone who this has happened to.
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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 short.
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 in more detail below.
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 be:
- 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 PTSD.
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.
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.
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.
- muscle aches and pains
- irregular heartbeats
- feelings of panic and fear
- drinking too much alcohol
- using drugs (including painkillers).
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 narrowly-avoided death.
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 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.
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.
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
- 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.
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 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.
When you can:
- think about it without becoming distressed
- not feel constantly under threat
- not think about it at inappropriate times.
- 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.
Have you 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 than 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.
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.
- 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
- 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 more
- get overtired
- miss meals
- take holidays on your own.
What can interfere with getting better?
You may find that other people may:
- 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 such things.
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 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 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 blue.
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 minutes.
Cognitive Behavioural 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 & Reprocessing)
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 to work.
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.
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 stress.
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-focused psychological therapies (CBT or EMDR) should be offered before medication, wherever possible.
- 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.
- tell a survivor you know how they feel – you don’t
- 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 themselves together".
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 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'.
It is worse if:
- it happens at an early age – 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.
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 – 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 properly.
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.
UK 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.
PTSD – non-military links.
- Post-traumatic Stress Disorder – The Invisible Injury ( 2002). David Kinchin. Successunlimited.
- Effective Treatments for PTSD: Practice Guidelines from the International Society of Traumatic Stress Studies (2nd edition) (2010). Eds. Foa E, Keane T, Friedman M & Cohen JA.
- 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 2007) 13:358-368.
- Bisson JI, Pharmacological treatment of post-traumatic stress disorder. Advances in Psychiatric Treatment (March 2007) 13:119-126.
- 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 information was produced by the Royal College of Psychiatrists Public Education Committee Editorial Sub-Committee. It reflects the best available evidence at the time of writing.
- Series Editor: Dr Philip Timms
- Expert : Dr Gordon Turnbull