Post Traumatic Stress Disorder

Post-traumatic stress disorder (PTSD) is an anxiety disorder caused by very stressful, frightening or distressing events.

The types of events that can cause PTSD include:

  • Serious road accidents
  • Violent personal assaults, such as sexual assault, mugging or robbery
  • Prolonged sexual abuse, violence or severe neglect
  • Witnessing violent deaths
  • Military combat
  • Being held hostage
  • Terrorist attacks
  • Natural disasters, such as severe floods, earthquakes or tsunamis

PTSD can develop immediately after someone experiences a disturbing event or it can occur weeks, months or even years later.

PTSD is estimated to affect about 1 in every 3 people who have a traumatic experience, but it’s not clear exactly why some people develop the condition and others don’t.

Signs and symptoms
Someone with PTSD will often relive the traumatic event through nightmares and flashbacks, and may experience feelings of isolation, irritability and guilt.

They may also have problems sleeping, such as insomnia, and find concentrating difficult.

These symptoms are often severe and persistent enough to have a significant impact on the person’s day-to-day life.

When to seek medical advice
It is normal to experience upsetting and confusing thoughts after a traumatic event, but in most people these will improve naturally over a few weeks.

You should visit your GP if you or your child is still having problems about four weeks after the traumatic experience, or if the symptoms are particularly troublesome.

If necessary, your GP can refer you to mental health specialists for further assessment and treatment.

How PTSD is treated

PTSD can be successfully treated, even when it develops many years after a traumatic event.

Any treatment depends on the severity of symptoms and how soon they occur after the traumatic event. Any of the following treatment options may be recommended:

  • Watchful waiting – waiting to see whether the symptoms improve without treatment
  • Psychological treatment – such as trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR)

Causes of post-traumatic stress disorder (PTSD)

Post-traumatic stress disorder (PTSD) can develop after a very stressful, frightening or distressing event, or after a prolonged traumatic experience.

Types of events that can lead to PTSD include:

  • Serious road accidents
  • Violent personal assaults, such as sexual assault, mugging or robbery
  • Prolonged sexual abuse, violence or severe neglect
  • Witnessing violent deaths
  • Military combat
  • Being held hostage
  • Terrorist attacks
  • Natural disasters, such as severe floods, earthquakes or tsunamis

PTSD is not usually related to situations that are simply upsetting, such as divorce, job loss or failing exams.

PTSD develops in about 1 in 3 people who experience severe trauma. It is not fully understood why some people develop the condition while others don’t, but there are factors that appear to make certain people more likely to develop PTSD.

If you’ve had depression or anxiety in the past, or you don’t receive much support from family or friends, you are more susceptible to developing PTSD after a traumatic event.

There may also be a genetic factor involved in PTSD. For example, having a parent with a mental health problem is thought to increase your chances of developing the condition.

Possible causes
Although it is not clear exactly why people develop PTSD, a number of possible reasons have been suggested. These are described below.

Survival mechanism
One suggestion is that the symptoms of PTSD are the result of an instinctive mechanism intended to help you survive further traumatic experiences.

For example, the flashbacks many people with PTSD experience may occur to force you to think about the event in detail so you are better prepared if it happens again, and the feeling of being “on edge” (hyperarousal) may develop to help you react quickly in another crisis.

However, while these responses may be intended to help you survive, they are actually very unhelpful in reality because they mean you can’t process and move on from the traumatic experience.

Adrenaline levels
Studies have shown that people with PTSD have abnormal levels of stress hormones.

When in danger, the body produces these hormones, such as adrenalin, to trigger a reaction in the body. This reaction, often known as the “fight or flight” reaction, helps to deaden the senses and dull pain.

However, people with PTSD have been found to continue to produce high amounts of fight or flight hormones even when there is no danger. It is thought this may be responsible for the numbed emotions and hyperarousal experienced by some people with PTSD.

Changes in the brain
In people with PTSD, parts of the brain involved in emotional processing appear different in brain scans.

One part of the brain responsible for memory and emotions is known as the hippocampus. In people with PTSD, the hippocampus appears smaller in size. It is thought that changes in this part of the brain may be related to fear and anxiety, memory problems and flashbacks.

The malfunctioning hippocampus may prevent flashbacks and nightmares from being properly processed, so the anxiety they generate does not reduce over time.

Treatment of PTSD results in proper processing of the memories so, over time, the flashbacks and nightmares will gradually disappear.

Symptoms of post-traumatic stress disorder (PTSD)

The symptoms of post-traumatic stress disorder (PTSD) can have a significant impact on your day-to-day life.

In most cases, the symptoms develop during the first month after a traumatic event. However, in a minority of cases, there may be a delay of months or even years before symptoms start to appear.

Some people with PTSD experience long periods when their symptoms are less noticeable, followed by periods where they worsen. Other people have severe symptoms that are constant.

The specific symptoms of PTSD can vary widely between individuals, but they generally fall into the categories described below.

Re-experiencing
Re-experiencing is the most typical symptom of PTSD. This is when a person involuntarily and vividly re-lives the traumatic event in the form of flashbacks, nightmares or repetitive and distressing images or sensations. This can even include physical sensations such as pain, sweating and trembling.

Some people will have constant negative thoughts about their experience, repeatedly asking themselves questions that prevent them from coming to terms with the event. For example, they may wonder why the event happened to them and if they could have done anything to stop it, which can lead to feelings of guilt or shame.

Avoidance and emotional numbing

Trying to avoid being reminded of the traumatic event is another key symptom of PTSD. This usually means avoiding certain people or places that remind you of the trauma, or avoiding talking to anyone about your experience.

Many people with PTSD will try to push memories of the event out of their mind, often distracting themselves with work or hobbies.

Some people attempt to deal with their feelings by trying not to feel anything at all. This is known as emotional numbing. This can lead to the person becoming isolated and withdrawn, and they may also give up pursuing the activities that they used to enjoy.

Hyperarousal (feeling ‘on edge’)
Someone with PTSD may be very anxious and find it difficult to relax. They may be constantly aware of threats and easily startled. This state of mind is known as hyperarousal.

Hyperarousal often leads to irritability, angry outbursts, sleeping problems (insomnia) and difficulty concentrating.

Other problems
Many people with PTSD also have a number of other problems, including:

  • Depression, anxiety and phobias
  • Drug misuse or alcohol misuse
  • Headaches, dizziness, chest pains and stomach aches

PTSD sometimes leads to work-related problems and the breakdown of relationships.

PTSD in children
PTSD can affect children as well as adults. Children with the condition can have similar symptoms to adults, such as having trouble sleeping and upsetting nightmares.

Like adults, children with PTSD may also lose interest in activities that they used to enjoy and they may have physical symptoms such as headaches and stomach aches.

However, there are some symptoms that are more specific to children with PTSD, such as:

  • Bedwetting
  • Being unusually anxious about being separated from a parent or other adult
  • Re-enacting the traumatic event(s) through their play

When to seek medical advice
It is normal to experience upsetting and confusing thoughts after a traumatic event, but in most people these will improve naturally over a few weeks.

You should visit your GP if you or your child is still having problems about four weeks after the traumatic experience, or if the symptoms are particularly troublesome.

Your GP will want to discuss your symptoms with you in as much detail as possible. They will ask whether you have experienced a traumatic event, either in the recent or distant past, and whether you have re-experienced the event through flashbacks or nightmares.

Your GP can refer you to mental health specialists if they feel you would benefit from treatment. See treating PTSD for more information

Treating post-traumatic stress disorder (PTSD)

The main treatments for post-traumatic stress disorder (PTSD) are psychotherapy and medication.

Traumatic events can be very difficult to come to terms with, but confronting your feelings and seeking professional help is often the only way of effectively treating PTSD.

It is possible for PTSD to be successfully treated many years after the traumatic event occurred, which means it is never too late to seek help.

Assessment
Before having treatment for PTSD, a detailed assessment of your symptoms will be carried out to ensure treatment is tailored to your individual needs.

Your GP will often carry out an initial assessment, but you will be referred to a mental health specialist for further assessment and treatment if you have had symptoms of PTSD for more than four weeks or your symptoms are severe.

There are a number of mental health specialists you may see if you have PTSD, such as:

  • A psychologist – an expert in how the mind works
  • A community psychiatric nurse – a nurse who specialises in mental healthcare
  • A psychiatrist – a mental health specialist who diagnoses and treats mental health conditions

Watchful waiting
If you have mild symptoms of PTSD, or you have had symptoms for less than four weeks, an approach called watchful waiting may be recommended.

Watchful waiting involves carefully monitoring your symptoms to see whether they improve or get worse. It is sometimes recommended because 2 in every 3 people who develop problems after a traumatic experience will get better without treatment within a few weeks.

If watchful waiting is recommended, you should have a follow-up appointment within one month.

Psychotherapy
If you have PTSD that requires treatment, psychotherapy is usually recommended first. A combination of psychotherapy and medication may be recommended If you have severe or persistent PTSD.

Psychotherapy is a type of therapy often used to treat emotional problems and mental health conditions such as PTSD, depression, anxiety and obsessive compulsive disorder.

The treatment is carried out by trained mental health professionals who will listen to you and help you come up with effective strategies to resolve your problems.

The two main types of psychotherapy used to treat people with PTSD are described below.

Cognitive behavioural therapy (CBT)
Cognitive behavioural therapy (CBT) is a type of therapy that aims to help you manage your problems by changing how you think and act.

Trauma-focused CBT uses a range of psychological treatment techniques to help you come to terms with the traumatic event.

For example, your therapist may ask you to confront your traumatic memories by thinking about your experience in detail. During this process your therapist will help you cope with any distress you feel, while identifying any unhelpful thoughts or misrepresentations you have about the experience.

By doing this, your therapist can help you gain control of your fear and distress by changing the negative way you think about your experience, such as feeling that you are to blame for what happened or fear that it may happen again.

You may also be encouraged to gradually restart any activities you have avoided since your experience, such as driving a car if you had an accident.

You will usually have 8-12 weekly sessions of trauma-focused CBT, although fewer may be needed if the treatment starts within one month of the traumatic event. Sessions where the trauma is discussed will last for around 90 minutes.

Eye movement desensitisation and reprocessing (EMDR)

Eye movement desensitisation and reprocessing (EMDR) is a relatively new treatment that has been found to reduce the symptoms of PTSD.

EMDR involves making side-to-side eye movements, usually by following the movement of your therapist’s finger, while recalling the traumatic incident.

It is not clear exactly how EMDR works, but it may help the malfunctioning part of the brain (the hippocampus) to process distressing memories and flashbacks so that their influence over your mind is reduced.