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Post Traumatic Stress Disorder (PTSD)
Most people experience stressful events, but when the event is exceptionally stressful it may be called trauma or a traumatic experience. Certain events— such as a home lost in a fire or even a community in the midst of a flood, a terrible injury in a car wreck, or the loss of family members in a plane crash—are traumatic for most people. The threat of serious injury to yourself or loved ones can also be traumatic. What usually makes an experience traumatic is a sense of horror, utter helplessness, serious injury, or the threat of physical injury or death. In some instances, the survivor of trauma may witness a horrifying event rather than being directly injured or threatened with injury. The following experiences are commonly recognized by mental health professionals as traumatic:
- rape or sexual assault
- spouse abuse
- crime victimization, including mugging, assault, robbery, shooting
- children victimized by physical, sexual, or verbal abuse
- natural disasters, such as fires, floods, hurricanes, and earthquakes
- war-related experiences, especially combat
- serious injury situations, such as airplane or automobile crashes
Research has shown that the best predictor of whether a person will suffer problems after the trauma is how severe the incident was—that is, how horrifying or threatening it was. No one is immune from developing emotional or psychological problems after a trauma. Whether or not a person begins to have problems after a trauma partly depends upon the individual’s psychological health prior to the event, other stressors in the survivor’s life, the age of the survivor (the young and the elderly may be more at risk), and the support the individual has from friends, loved ones, and the community.
What Problems Can Arise After a Trauma?
Two types of problems can result from the experience of being traumatized. They mainly differ in the length of time before the survivor experiences problems after the trauma. The first, called acute stress disorder, or ASD, typically occurs in the first month following a catastrophic stressor. Fifty percent to 75% of the population may experience symptoms of ASD after a severe community trauma, such as a hurricane. Most people will recover from these symptoms on their own, but the majority of people will benefit from the help of family, friends, emergency services, or psychologists. Some of those suffering from ASD will go on to develop the second problem cluster: posttraumatic stress disorder or PTSD.
PTSD is virtually identical to ASD in the kinds of problems experienced by the survivor, except that the problems persist beyond 3 months (acute phase), for many months, or, in some people, even years. Some survivors do not show symptoms immediately; PTSD symptoms that appear some time after the trauma are called delayed-onset symptoms. All of the difficulties associated with ASD or PTSD, described at greater length below, are categorized into three main clusters: reexperiencing, avoidance, and hyperarousal.
Reexperiencing: “I Can’t Shake the Memory”
Many times the trauma is so unusual or horrible that a person cannot let go of the memory. Even worse, vivid images, sounds, or other sensations reminiscent of the trauma can interrupt or dominate thoughts. At times, an individual can actually feel as if the event were happening again. These experiences are referred to as flashbacks. Other times, the survivor cannot shake the memories, which are intrusive but less serious and incapacitating than flashbacks. Although these intrusions happen while one is awake, trauma-related nightmares are also common. These experiences are often accompanied by fear, tension, or anxiety in the form of heart palpitations (heart racing), rapid breathing, and excessive sweating.
Avoidance: “I Can’t Be Around Anything That Reminds Me of What Happened” or “I Feel Numb”
If someone was sexually assaulted in a parking garage, they may feel frightened when approaching their garage—or any garage. The person may feel unable to drive. Sometimes the fear related to trauma leaves people housebound. Moreover, while many people try to avoid situations that remind them of the trauma, some will also try to avoid thoughts and feelings about the trauma as well as the physical reminders. Combat veterans may feel unable to watch any news for fear of being reminded of the horrors of wartime experiences. When a person encounters a reminder of the trauma, she may feel extremely tense or anxious. Some people will paradoxically find themselves in situations that are like the original trauma or actually seek out reminders in their environment. This type of behavior does not typically make the person feel better; often these experiences will increase the fear, sadness, isolation, or anger.
Trauma involves loss. This may be limited to material loss (e.g., a home), or it may mean the loss of life: a husband, wife, child, coworker, or friend. Grief and sadness after traumatic loss can be so overwhelming and difficult to talk about that a person can only report feeling numb. This response is not unusual. One way of adapting to horrible events is to “shut down,” protect oneself emotionally for a time, and seemingly have no feelings. Trauma survivors often feel guilt for not feeling the way they believe they should or not feeling sadness or compassion for other survivors or those who died in the same traumatic event they escaped. For some, the feeling of numbness causes isolation or withdrawal from social contact.
Another way that people avoid the anxiety is called “dissociation,” where people disengage from their surroundings. It is literally feeling as if not being present. Occasionally, this is a feeling of being cut off from surroundings, including people. It can also be similar to “zoning out,” where someone loses thoughts or stops listening to another. In effect, the survivor’s body is present, but the mind has gone elsewhere.
Hyperarousal: “I Can’t Calm Down”
People who have been traumatized are usually quite anxious. Although it may not be obvious, trauma survivors’ bodies may be working overtime. Their heart rate, blood pressure, and sweat response may be higher. They often have an exaggerated startle response; a sharp noise may cause them to jump, or a horn may result in a pounding heart or an involuntary “safety response,” such as ducking down or scrunching the head between the shoulders. Such people may become irritable or have a quick temper. Anger outbursts may lead to other problems, such as violence and child abuse. Some people resort to drugs or alcohol to manage the anxiety.
Any one of the above problems in isolation may not necessarily mean ASD or PTSD. But, if a number of problems are there, a mental health professional may be able to diagnose its presence and, more importantly, provide help in relieving symptoms.
Can Psychotherapy Help?
Psychotherapy for survivors of trauma with ASD or PTSD can help a person gain relief from many of the symptoms mentioned above. Most therapists agree that telling one’s story is central to feeling more in control. In addition, the earlier the survivor obtains help, the more likely serious problems can be averted or prevented. Cognitive behavior therapists have a practical focus with two fundamental goals: to decrease the anxiety or hyperarousal and to increase the connection the survivor has with family, friends, or the job setting (i.e., decrease avoidance). This is usually done in a gradual fashion.
Survivors are caught in a vicious cycle in which the memories and thoughts surrounding the traumatic event keep returning. Because the survivor reacts to these with anxiety and, sometimes, horror, he or she pulls away from the thoughts and memories, thereby reinforcing the anxiety and pain by immediately removing the thoughts and memories. The survivor never comes to understand or process the memory, because it is always cut off before the person can make sense of it. In cognitive behavior therapy, the individual is assisted in processing the memory in ways that make it tolerable. The memory will never be a happy one, but it will no longer cause intense physiological distress.
Cognitive behavior therapists try to make the symptoms understandable to the survivor. In the context of a caring and trusted relationship with the survivor, the therapist helps the survivor reduce the symptoms by using techniques like relaxation. Therapists also try to take away the power of the memories or flashbacks by having the survivor relive and reexperience them. Sometimes the therapist will explore the survivor’s thoughts about the traumatic incident and, where appropriate, help the survivor understand when his or her beliefs about the incident are contrary to reality. Cognitive behavior therapists often teach additional skills, such as how to grieve, how to manage anger and rage, and how to socialize again, depending upon client needs. The ultimate goal is to reintegrate the survivor into his or her social structure.
Cognitive behavior therapists sometimes use techniques such as deep relaxation or hypnosis to help clients manage the fear and anxiety. Medication can be an appropriate adjunct to therapy for survivors of trauma, especially those for whom depression or anxiety is severe. Although most therapy is conducted on a weekly basis over the course of months on an outpatient basis, some people with more severe problems may choose to see a therapist more frequently or may benefit from a brief hospital stay to help them stabilize.
Survivors of trauma need not suffer in isolation. Professional therapy, cognitive behavior therapy in particular, can provide hope and practical ways of enjoying life again after the horror of a traumatic event. For more specific information, please refer to the following Fact Sheets in the Survivors of Trauma series: Combat-Related PTSD, PTSD and Crime Victims, and Natural Disasters. These are all available from ABCT or from your therapist.