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Post-Traumatic Stress Disorder (PTSD)

Sadly, many of us will experience trauma at some point in our lives. During and after a traumatic experience it is common to feel shocked, scared, numb, guilty, ashamed, angry, or vulnerable. With time most people recover from their experiences without needing professional help. However, for a significant proportion of people the effects of trauma last for much longer and they develop a condition called post-traumatic stress disorder (PTSD). People with PTSD experience strong unwanted memories of their trauma, to the point where it can feel as though the trauma is happening again right now in the present. This feels terrifying, and as a result those with PTSD often feel on-edge and on the lookout for danger. It is thought that between 3 and 5 people out of every 100 will experience PTSD every year [1]. There are a range of excellent psychological therapies for PTSD including trauma-focused cognitive behavioral therapy (TF-CBT), eye movement desensitization and reprocessing (EMDR), prolonged exposure (PE), and cognitive processing therapy (CPT).

What is it like to have PTSD?

Sushma’s fear, disgust, and shame

Sushma grew up in a chaotic household. Her father and brothers were violent and in and out of prison. Her mother was a mixture of critical and neglectful. When she was fourteen Sushma was given alcohol by a boy in her local park who then raped her. She remembers feeling terrified during the attack and feeling frozen to the spot. She did not tell her parents what had happened for fear of how they would respond. When she came to therapy Sushma was having daily flashbacks of the attack, and of many of frightening experiences that had happened during her childhood. She would wake at night terrified but with her body unable to move (sleep paralysis) and would sometimes wet the bed which she was terribly ashamed of. When she was asked about her trauma she would sometimes dissociate so strongly that she would seem to ‘forget’ where she was, and would once again feel like a terrified fourteen year old. Sushma was convinced that she was a bad person (“I’m rotten to the core”) and that she had deserved everything that had happened to her. She punished herself by denying herself rest and was extremely self-critical. At the start of therapy she was not very hopeful of recovering, but felt that she should give it a try for the sake of her husband who she described as kind and patient.

Aspects of therapy that Sushma found helpful

Sushma’s therapy proceeded gradually. She was wary of her therapist to begin with but began to trust her as the weeks went by. Sushma found it difficult to talk about her life, but her therapist helped her to get an ‘overview’ of all the significant things that had happened to her – good and bad – and Sushma got glimpses of the enormity of what she had experienced. She and her therapist practiced a range of grounding techniques which helped her to stay ‘present’ whenever then needed to talk about a trauma – Sushma found that standing up and moving around was a helpful way of not dissociating. She and her therapist made a list of her most significant traumas – ones that she felt most strongly about. They did sessions of exposure to the memories which her therapist called ‘memory processing’: in a number of these sessions she asked Sushma to slowly describe the events before, during, and after the day in the park – including all of her mental images, emotions, and body sensations. Sushma found this an incredibly painful thing to do, but when she reflected back at the end of therapy she felt that this had been a turning point. One of the most important outcomes of describing this event in such detail was that Sushma was now able to view her fourteen year old self from the perspective of her adult self – and instead of viewing a “rotten and vile monster” she saw a vulnerable young girl who was easily manipulated by what she had thought was kind attention but which she now knew to be deliberate grooming. Viewing her younger self with compassion changed some important meanings for Sushma – she began to entertain the possibility that she was not such a horrible person. This meaning changed further when her therapist suggested that they conduct an anonymous online survey. Together they wrote a short but fair description of Sushma’s childhood including her trauma and included a series of questions about what people thought of her. Sushma genuinely expected more than half of the people who took the survey to judge her as being at fault and was shocked when all of the respondents blamed her attacker for the attack, and her parents for failing to protect her. Looking back on therapy Sushma described this as an important turning point in how she viewed herself. By the end of therapy Sushma no longer had flashbacks of the attack, and no longer blamed herself: she said that when she remembered it now she felt sad for her younger self, and had resolved to try to treat herself with more kindness in future.

What is trauma?

Many of us will experience trauma at some point in our lives – an experience which is overwhelming, threatening, frightening, or out of our control. Common traumas include:

  • Being in an accident, such as a road traffic accident, or an accident at work.
  • Being the victim of violence, such as being physically or sexually assaulted, imprisoned or tortured.
  • Being in a life-threatening situation, such as a war, a natural disaster, or a health emergency.
  • Witnessing violence towards another person, or witnessing death.

Some traumas are isolated one-off events that are unexpected and happen ‘out of the blue’. Other traumas are frightening in different ways: they are expected, anticipated, and dreaded. Some people’s jobs expose them to trauma: military or emergency service personnel often experience or witness distressing events. Children can experience trauma too – and the effects can be more profound and long-lasting if the people who were supposed to care for them were responsible for perpetrating harm.

What is post-traumatic stress disorder (PTSD)?

It is normal to be affected by traumatic experiences. Victims of trauma might feel shocked, scared, guilty, ashamed, angry, or vulnerable. With time most people recover from their experiences, or find a way to live with them, without needing professional help. However, in a significant proportion of people the effects of trauma last for much longer and may develop into post-traumatic stress disorder (PTSD). Symptoms of PTSD are split into groups [2]:

Re-experiencing symptoms. Re-experiencing memories of the trauma means that memories of the event(s) play over and over in your mind. These memories can come back as ‘flashbacks’ during the day or as nightmares at night. The memories can be re-experienced in any of your five senses – you might see images of what happened, but may also experience sounds, smells, tastes, or body sensations associated with the trauma. Emotions from the trauma can also be re-experienced and it might feel as though the events are happening again. Re-experiencing symptoms include:

  • Upsetting memories of the event intruding into your mind.
  • Having nightmares about the event.
  • Feeling physical reactions in your body when you are reminded of the event.

Arousal symptoms. It is common to be ‘on edge’ or ‘on guard’ following a trauma. You might find it very difficult to relax or find that your sleep is affected. Arousal symptoms include:

  • Always looking out for danger (hypervigilance).
  • Feeling ‘on edge’ or easily startled.
  • Difficulty falling or staying asleep.
  • Problems concentrating.

Avoidance symptoms. A normal human way of dealing with physical or emotional pain is to avoid it, or to distract ourselves. You might try to avoid any people, places, or any other reminders of your trauma. You might try very hard to distract yourself in order to avoid thinking about what happened. Avoidance symptoms include:

  • Avoiding reminders of the trauma.
  • Trying not to talk or think about what happened.
  • Feeling ‘numb’ or like you have no feelings.

Negative thoughts and mood. Trauma has a powerful effect on how we think. You might blame yourself for what happened, even if it was not your fault. Or you might replay parts of the trauma and think “what if …?” or “if only …”. Many people with PTSD also experience depression. Negative thoughts and mood about the trauma might include:

  • Negative thoughts about yourself.
  • A sense of guilt about what happened.
  • Feeling depressed or withdrawn.
  • Feeling that no-one can be trusted.

We can separate the effects of PTSD into thoughts (and images), feelings, and behaviors.

What might go through your mind How you might feel How you might act
  • Intrusive memories (flashbacks) of the trauma
  • Thoughts that the trauma is happening again right now
  • Thoughts that what happened was your fault or that you could have prevented it
  • Thoughts that you are going mad
  • Images in your mind of what has happened, or what might happen
  • Scared
  • Angry
  • Terrified
  • Humiliated
  • Ashamed
  • Disgusted
  • Any emotions that you experienced at the time of the trauma
  • Dissociation (feeling separate or detached from what is happening)
  • Feelings in your body that are the same as those you experienced during the trauma
  • Avoid people or places that remind you of what happened
  • Avoid thinking or talking about what happened
  • Try to push memories away, or try to forget what happened
  • Avoid going to sleep for fear of nightmares
  • Use alcohol or drugs to numb yourself
  • Keep yourself busy

What is complex PTSD (cPTSD)?

Complex PTSD (cPTSD) is a relatively new diagnosis. A little bit of history is useful here. The term post-traumatic stress disorder (PTSD) first began to be used in the 1970s to describe military veterans of the Vietnam war. At that time PTSD was classified as an ‘anxiety disorder’. Research since then has indicated that PTSD can look a bit different depending on:

  • how much trauma person has experienced
  • the type of trauma,
  • and when it happened in their life.

People who have experienced a lot of trauma, have experienced trauma early in their lives, or have experienced trauma perpetrated by caregivers, often present with extra symptoms in addition to PTSD. You can think of it as ‘PTSD+’. When people experience the following symptoms as well as PTSD mental health professionals might label it Complex PTSD [3, 4]:

  • Severe problems in managing your emotions (affect regulation).
  • Strong beliefs about yourself as diminished, defeated, or worthless, accompanied by deep feelings of shame, guilt, or failure related to your traumatic experiences.
  • Difficulties in sustaining relationships and in feeling close to others.

What causes PTSD?

PTSD and cPTSD are unique in that their main cause is exposure to traumatic, life-threatening, or frightening events. One puzzle is that not everybody who experiences a trauma goes on to develop PTSD so there must be factors that make some people more likely to develop PTSD after a traumatic experience. These include:

  • How much social support you have. Psychologists have found that people with higher levels of social support are less likely to develop PTSD following a trauma. If you have people to talk to, with whom you can make sense of an event, it can act as a ‘protective shield’ from the effects of the trauma [7].
  • Genetic and biological factors. There is some evidence that genetic and biological factors can influence who develops PTSD following a trauma. For example, the size of part of the brain called the hippocampus is thought to influence whether memories of your trauma are experienced in problematic ways.
  • The way your brain processes memories of your trauma. Memories in PTSD are different from ‘normal’ memories, they are much more vivid and intense, and have the ability to ‘trick’ you into thinking that the trauma is happening again – even many years after the trauma is over [5]. Scientists think that there are differences in the way that your brain encodes, stores, and retrieves trauma memories which mean that some people develop PTSD [6].

What keeps PTSD going?

Cognitive behavioral therapy (CBT) is always very interested in what keeps a problem going. This is because if we can work out what keeps a problem going we can treat the problem by intervening to interrupt this maintenance cycle. Psychologists Anke Ehlers and David Clark identified three processes which explain why people with PTSD feel a current sense of threat even though the trauma has already happened [8]. These include:

  • Unprocessed memories.
  • Beliefs about trauma and its consequences.
  • Coping strategies including avoidance.

Unprocessed memories

Memories in PTSD have some unique properties. Psychologists think that they are stored differently by the brain [6]. This explains why memories in PTSD are:

  • easily triggered by things around you,
  • are intrusive (pop into your mind unexpectedly),
  • are especially detailed and vivid,
  • and can feel as though the events are happening right now in the present moment.

Until your brain has completed the job of ‘processing’ your trauma memories you might be vulnerable to these re-experiencing symptoms.

Beliefs about your trauma and its consequences

CBT says that the way we think (our beliefs) and the way we act affect the way we feel. Strong (traumatic) events can produce correspondingly strong beliefs, sadly not always helpful ones. Psychologists increasingly believe that one of the most important jobs of therapy is working with the meaning their client has made of their trauma [9]. Some examples are given below of the meanings of their trauma expressed by some real clients at the start and end of their therapy:

At the start of therapy At the end of therapy
“I’m in danger now” “The accident happened in the past. I survived and I am safe”
“What happened was my fault” “The abuse was not my fault. I was only 8 years old”
“People would think I’m a terrible person if they knew” “Nobody would judge me as harshly as I did. The abuse was the fault of the person who hurt me”
“I deserved what happened to me” “Nobody deserves that. My abuser wanted me to believe I deserved it, but that is not the truth”

Coping strategies including avoidance

Avoidance is natural but that doesn’t mean that it is helpful. At the core of PTSD is a feeling of threat. Your ways of coping with the threat might include avoiding perceived dangers, or doing things that help you to cope in the short-term but which may be harmful in the long-term. Unhelpful coping strategies that prevent recovery from PTSD include:

  • Avoiding memories of the trauma (which means the memories stay ‘unprocessed’).
  • Avoiding reminders of the trauma.
  • Using alcohol or other substances to block out memories or feelings.
  • Not talking about what happened.

Understanding these mechanisms tells us what we need to do to treat PTSD. The treatments described in the next section all include ingredients of:

  • Exposure to memories. Trauma therapists sometimes call this ‘trauma memory processing’. Almost all evidence-based treatments for PTSD  include at least some talking about (or facing) what happened to you, although they can differ a bit in terms of how this is done. Psychologists think that exposure may allow “aspects of the trauma to become clearer, new pieces of the puzzle may emerge, and new perspectives may be gained” [10].
  • Work to change meaningsThis means examining how you made sense of what happened to you and seeing whether these perspectives are fair or helpful.
  • Reducing unhelpful coping strategies. Reducing avoidance helps you to challenge unhelpful beliefs and allows you to begin reclaiming your life.

Treatments for PTSD

Psychological treatments for PTSD

Psychological treatments for PTSD which have a good research support include:

  • Cognitive Behavioral Therapy (CBT) / Trauma-focused CBT [11, 12]
  • Eye Movement Desensitization and Reprocessing (EMDR) [11]
  • Cognitive Processing Therapy (CPT) [12]
  • Prolonged Exposure (PE) [12]
  • Narrative Exposure Therapy (NET) [13]

There is emerging evidence that the way these therapies work is by changing the way we think about the trauma and its aftermath. Research into trauma-focused therapies show that if we can change the meaning of the trauma we can change how you feel [14, 15, 16].

Medical treatments for PTSD

The UK National Institute of Health and Care Excellence (NICE) guidelines for post-traumatic stress disorder [11] found that the was evidence that SSRIs and venlafaxine are effective in treating PTSD. However, they state that they are less effective than psychological treatments and should not be offered as a first-line treatment for PTSD. The NICE guideline also found some evidence that antipsychotic medication may be helpful as an adjunct to psychological therapy in some cases.

How can I overcome my PTSD?

Professional treatment for PTSD often (but not always, see [17]) proceeds in stages:

  1. Stabilization. The first stage is about feeling ‘safe enough’ to begin therapy. Tasks may include learning about PTSD and learning grounding techniques to help you to feel more in control. This is something that you can do with a therapist or can begin to do on your own.
  2. Making sense of your trauma. The second stage is about making sense of what happened to you. This can involve talking about what happened and understanding how the events affected you. Tasks at this stage might include exposure to your trauma memories by talking about them, imagining them in your mind, or by writing about them.
  3. Reclaiming. The third stage is about reclaiming your life. PTSD might have made you live a shadow of your former life. Once the major symptoms of PTSD are resolved your task is to claim back the life that you want to lead.

Depending on how severe your trauma was, and how strongly your PTSD affects you, you may want to speak to a therapist. However, there are lots of things that you can do for yourself that will help you to overcome PTSD and cPTSD. These include:

  • Understanding about PTSD, cPTSD, and dissociation
  • Recognizing your triggers
  • Using grounding to manage dissociation and stay in the moment
  • Retraining your brain (discriminating triggers)
  • Memory processing (by doing written exposure therapy)

Understanding about PTSD and cPTSD

An important first step in overcoming PTSD and cPTSD is to understand more about your condition. Many people find it reassuring to know that they are experiencing normal reactions to severe events. Some Psychology Tools information resources to help you understand more about your PTSD include:

Recognizing your triggers and flashbacks

Some people with PTSD feel as though unwanted memories and other symptoms appear ‘out of the blue’. This can make you feel out of control, and can make you afraid to engage with your life. You will find it helpful to learn to recognize your triggers – things in the world that cause you to have strong feelings or unwanted memories. The Psychology Tools Intrusive Memory Record is the right tool for collecting information about your triggers and the content of your intrusive memories.

Grounding exercises to manage flashbacks and dissociation, and to stay in the moment

The intrusive symptoms of PTSD act to take your mind away from the present moment: flashbacks and intrusive memories take you back to the past; worries take you to the future. It is normally the case that neither of these feels particularly safe. Grounding exercises are a great antidote. They are designed to help you to bring your attention back to the present moment, where you are safe. Psychology Tools resources to help you to develop grounding skills include:

Brain retraining (stimulus discrimination)

Your brain is a learning machine and it is always trying to help you to live safely. If you have been hurt by something your brain learns this and tries to warn you if you encounter anything similar in the future. Sometimes brains do this job too well – they set off an alarm even if we encounter something similar but not dangerous. Psychologists think that this happens in PTSD – your brain makes a mistake when it encounters reminders of your trauma, and then sets off your body’s alarm system making you feel panicky. Your alarm system has become oversensitive. The solution is to retrain your alarm system so that your brain can tell the difference between ‘dangerous’ and ‘not dangerous’. This is called ‘stimulus discrimination’ because you are retraining yourself to discriminate between things (stimuli) that are threatening and safe. Psychology Tools has a Stimulus Discrimination worksheet and full instructions are included as part of the Psychology Tools for Overcoming PTSD Audio Collection.

Memory processing (written exposure therapy)

Safe exposure to your trauma memories is a key component of treating your PTSD. One reason why psychological treatments for PTSD often emphasize exposure to trauma memories is because it may allow “aspects of the trauma to become clearer, new pieces of the puzzle may emerge, and new perspectives may be gained” [10]. Approaching trauma memories is something that people with PTSD often choose to do with a therapist during their therapy. In face to face therapy for PTSD exposure to traumatic material is attempted in a variety of ways including : describing the traumatic events slowly and in detail (a process called ‘reliving’), drawing the traumatic events, revisiting locations associated with the trauma in person (called ‘site visits’) or using Google Earth (virtual site visits).

There is emerging evidence to suggest that some people find written exposure therapy helpful as a self-help intervention. However, do be aware that if you are prone to dissociation then doing this too suddenly can trigger dissociative reactions. The Psychology Tools guide to Trauma, Dissociation and Grounding includes detailed instructions about using written exposure therapy as a self-help technique. Good reasons not to try written exposure therapy on your own include: currently feeling suicidal; current dependence on alcohol or drugs, or very severe dissociation. In these cases face-to-face therapy is advised.

References

[1] Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 617-627.

[2] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

[3] Herman, J. L. (1992). Complex PTSD: A syndrome in survivors of prolonged and repeated trauma. Journal of Traumatic Stress, 5(3), 377-391.

[4] Brewin, C. R., Cloitre, M., Hyland, P., Shevlin, M., Maercker, A., Bryant, R. A., … & Somasundaram, D. (2017). A review of current evidence regarding the ICD-11 proposals for diagnosing PTSD and complex PTSD. Clinical Psychology Review, 58, 1-15.

[5] Brewin, C. R., Gregory, J. D., Lipton, M., & Burgess, N. (2010). Intrusive images in psychological disorders: characteristics, neural mechanisms, and treatment implications. Psychological Review, 117(1), 210.

[6] Whalley, M. G., Kroes, M. C., Huntley, Z., Rugg, M. D., Davis, S. W., & Brewin, C. R. (2013). An fMRI investigation of posttraumatic flashbacks. Brain and Cognition, 81(1), 151-159.

[7] Brewin, C. R., Andrews, B., & Valentine, J. D. (2000). Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology, 68(5), 748.

[8] Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38(4), 319-345.

[9] Grey, N., Young, K., & Holmes, E. (2002). Cognitive restructuring within reliving: A treatment for peritraumatic emotional “hotspots” in posttraumatic stress disorder. Behavioural and Cognitive Psychotherapy, 30(1), 37-56.

[10] Grey, Nick (@nickdgrey) (2019, June 10). “And by allowing yourself to sit with the memory aspects of it may become clearer, new pieces of the puzzle may emerge, and new perspectives may be gained – leading to further cognitive and emotional change” [Twitter Post]. Retrieved from https://twitter.com/nickdgrey/status/1137993861647732737

[11] National Institute for Health and Care Excellence (2018). Post-traumatic stress disorder. Retrieved from: https://www.nice.org.uk/guidance/ng116/resources/posttraumatic-stress-disorder-pdf-66141601777861

[12] Watkins, L. E., Sprang, K. R., & Rothbaum, B. (2018). Treating PTSD: a review of evidence-based psychotherapy interventions. Frontiers in Behavioral Neuroscience, 12, 258.

[13] Robjant, K., & Fazel, M. (2010). The emerging evidence for narrative exposure therapy: A review. Clinical Psychology Review, 30(8), 1030-1039.

[14] Zalta, A. K., Gillihan, S. J., Fisher, A. J., Mintz, J., McLean, C. P., Yehuda, R., & Foa, E. B. (2014). Change in negative cognitions associated with PTSD predicts symptom reduction in prolonged exposure. Journal of Consulting and Clinical Psychology, 82(1), 171.

[15] Kleim, B., Grey, N., Wild, J., Nussbeck, F. W., Stott, R., Hackmann, A., … & Ehlers, A. (2013). Cognitive change predicts symptom reduction with cognitive therapy for posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 81(3), 383.

[16] Gallagher, M. W., & Resick, P. A. (2012). Mechanisms of change in cognitive processing therapy and prolonged exposure therapy for PTSD: Preliminary evidence for the differential effects of hopelessness and habituation. Cognitive Therapy and Research, 36(6), 750-755.

[17] De Jongh, A., Resick, P. A., Zoellner, L. A., Van Minnen, A., Lee, C. W., Monson, C. M., … & Rauch, S. A. (2016). Critical analysis of the current treatment guidelines for complex PTSD in adults. Depression and Anxiety, 33(5), 359-369.

About this article

This article was written by Dr Matthew Whalley and Dr Hardeep Kaur, both clinical psychologists. It was reviewed by Dr Hardeep Kaur and Dr Matthew Whalley on 2019-09-19.