In recent years, mental health professionals have adopted the term post-traumatic stress disorder (PTSD) to describe a range of psychological symptoms people may experience following a traumatic event, which is outside the normal human experience. The World Health Organisation has defined it as: ‘A delayed or protracted response to a stressful event or situation (either short or long-lasting) of an exceptionally threatening or long-lasting nature, which is likely to cause pervasive distress in almost anyone.’
‘The depth of my sorrow was no surprise to me, but I was totally unprepared for the other reactions – the shakes, nightmares, panic attacks, memory and concentration problems, and the unrelenting exhaustion.’Bomb attack survivor
Just hearing news of shattering events, such as the September 11 destruction of New York’s World Trade Centre, incidents during the Gulf Wars, the Potter’s Bar train crash and the Hillsborough football stadium disaster, can have a lasting impact on individuals. Anybody actually present during a disaster of this nature is likely to become extremely distressed. Every day, people are involved in, or witness, events such as road accidents, muggings, and sexual or physical assaults that cause them deep emotional injury. There is no doubt that the reactions that may follow can seriously hamper and
interfere with their lives.
Some survivors have objected to the use of the term disorder, because they see such reactions as an entirely normal and understandable response to abnormal events. But the label recognises that events and social conditions that are beyond our control, and which may fill us with fear or horror, can cause extremely disturbing psychological symptoms.
What are the symptoms?
‘Tom had almost denied what happened, didn’t want to talk about it, didn’t want to read any of the articles. Then, one day, a friend mentioned to him that she was worried about her cat, because she had left it that morning trapped up a tree, and it was as though that pushed a button. He broke down and shed lots of tears.’
One of my problems resulted from experiencing upsetting flashbacks: people badly injured; the shocked faces of fellow passengers and staff at the hospital; my husband and brother-in-law splattered with blood and mud. They came to me when I was at my most vulnerable. I don’t think they will ever go completely, but they are fading and are easier to cope with.Train crash survivor
If you have faced a traumatic experience, you may simply feel emotionally numb to begin with, and feelings of distress may not emerge straight away. But sooner or later, you are likely to develop emotional and physical reactions, and changes in behaviour, which may include some of the following:
Reliving aspects of the trauma
vivid flashbacks (feeling as if the trauma is happening all over again)
intrusive thoughts and images
nightmares
intense distress at real or symbolic reminders of the trauma.
Avoiding memories
keeping busy
avoiding situations that remind you of the trauma
repressing memories (being unable to remember aspects of the event)
feeling detached, cut off and emotionally numb
being unable to express affection
feeling there’s no point in planning for the future.
Being easily aroused
disturbed sleep
irritability and aggressive behaviour
lack of concentration
extreme alertness
panic response to anything to do with the trauma
being easily startled.
These responses are all quite normal. Many people find the symptoms will disappear in due course. It’s when they last for longer than a month, or when they are very extreme, that PTSD may be diagnosed. Sufferers may also have other symptoms, such as severe anxiety, a phobia or depression. They may develop a dissociative disorder (see Understanding dissociative disorders) and suicidal feelings. There’s no time limit on distress, and some survivors may not develop post-traumatic symptoms until many years after the event.
What causes PTSD?
PTSD was first described in relation to the veterans of the Vietnam War in the USA, but the problem has been around for a lot longer under various different names. During the First World War, large numbers of soldiers were said to be suffering from 'shell shock', 'soldier’s heart' or 'battle fatigue'. Rather than admit to the horror of war, and in order to explain the large numbers of men involved, the official line was that these were symptoms of an illness.
‘I still have nightmares. They can be triggered by something on television, or the smallest of things, like having the duvet caught round my face. The number of times is lessening, but when they do come I’m learning how to cope. I put the light on, I open the window and say “Yep, look, that was a dream”.’Train crash survivor
Since that time there have been a number of reports made on the effects of war, recording between 6 and 30 per cent of veterans suffering from PTSD.
There are important similarities between the psychological stresses associated with war and those that occur in response to major disasters or to personal trauma. Following the sinking of the Herald of Free Enterprise ferry at Zeebrugge, 90 per cent of the passengers and their relatives who were seen for psychological assessment were found to be suffering from PTSD, either alone or in combination with other problems, such as alcohol misuse.
This highlights the fact that people who have not been directly involved in a trauma of this kind may still experience levels of distress as high as those who were. Civilian survivors of war and refugees also develop PTSD, for example. So do people who have lost relatives and friends as a result of some disaster, as well as rescue workers who tried to save them. After the King’s Cross underground station fire in 1987, mental health professionals drew up a list of 670 people who were potentially at risk from the psychological effects of the experience. Of that number, only 100 had been involved directly; the others came from the emergency services, railway officials and the families of victims and survivors.
Two years after the Lockerbie air disaster, police, firemen and ambulance workers were still traumatised by what they had witnessed.
Personal trauma, violent crime, sexual or physical assault, road traffic accidents or difficulties during childbirth can all produce PTSD. Adult survivors of childhood sexual abuse may be affected. Children who have themselves been abused, or who have witnessed something terrible, such as a murder, are also prone to the disorder.
Why do some people develop PTSD?
‘Every time I hear of any disaster, whether here or abroad, it brings back my own memories, and I can imagine how the families and victims are feeling. My own experience has taught me that you can’t change what happened, but that time does make it easier to cope. The memories don’t go, but they do fade.’
It’s reckoned that about 1.5–3.5 per cent of the general population is likely to be affected by PTSD at some point. Anyone can develop PTSD following experiences such as those mentioned above, but not everyone does so. Nor does everyone develop it to the same degree. There are a number of possible explanations for this.
Fearing for your life
E
vents involving loss of life, or where people have been faced by the prospect of dying, may lead to more long-lasting stress responses. A study of Falklands War veterans found that exposure to combat was the most significant factor in predicting who would develop PTSD.
Harmful intentions
Man-made disasters, particularly those involving deliberate acts of violence or terrorism, seem to cause longer-lasting and more painful emotional consequences than natural disasters. The crucial factor may be that it destroys people’s trust in others, particularly when it involves someone they depended on.
Conscious memories
People who remain conscious through the experience may be more vulnerable to PTSD because of the horrific memories etched on the mind.
Personal circumstances
Your personal history can make you more prone to PTSD. If a traumatic event triggers memories of an earlier distressing experience, the impact is effectively doubled in intensity. Similarly, if you are already going through emotional problems, you are also much more vulnerable. Your temperament may also have a lot to do with it.
Guilt feelings
Survivors often feel extremely guilty, as though they were responsible for the event, or could have done more to save themselves or others. One study showed that those who blamed themselves in some way for the outcome of the disaster were more at risk of severe and long-term distress.
What’s the best way to deal with a traumatic event?
In the aftermath, people often feel numb, dazed and disorientated. Talking about what has happened to them may well be the last thing they want to do. Many survivors have said that what they found most useful, to begin with, was practical advice, information and support with day-to-day tasks.
Expressing your feelings, by talking, may be the best way of coming to terms with the experience. But there are differing views about whether, or not, counselling or some form of psychological de-briefing immediately after the event can prevent serious problems developing later (see NICE recommendations below). Everyone will have their own unique responses, and will need to proceed at their own pace. Survivors may turn to friends, relatives and colleagues when they decide they do want to talk about what they’ve been through. What’s important is that there should be an opportunity to talk to someone about their distress, when they’re ready to do so. Many of those who do develop PTSD are able to come to terms with the traumatic experience, in this way, within a matter of months.
Stress responses that are bottled up over months or years become deeply ingrained and may cause serious problems. Sometimes, people turn to alcohol or drugs in an attempt to blot out painful feelings and memories. Individuals may remain in a state of extreme tension long after the trauma has passed. They may find themselves avoiding situations, in case they remind them of their trauma, so that life becomes increasingly restricted. In trying to avoid the problem, they are also, in effect, avoiding getting appropriate help. There are various organisations that can provide information about counsellors experienced in treating PTSD. (For more information, see Useful organisations.)
It can be very helpful for people to share their experiences with others who have been through something similar. This can be an extremely important step in moving away from isolation, from the role of victim and passive recipient of professional help, towards regaining control of their lives. There are organisations and helplines that specialise in particular groups of people, for example, soldiers who have seen combat, victims of violent crime or sexual assault, and people who have been tortured or who are refugees. You may find it especially useful to contact an organisation geared to your particular experience (see Useful organisations).
What sort of help is available for PTSD?
If you have been suffering from distressing symptoms for months after a traumatic event, you should see your GP, who can refer you for specialist help. There are clinics that focus on PTSD and there are national referral centres. Your GP may also be able to refer you to a local practitioner (a psychologist, psychotherapist or psychiatrist) who has been trained in treating PTSD.
Treatments for PTSD are still being evaluated, but experts agree that for anyone who is still suffering months after the event, an effective approach may be a series of lengthy sessions with a psychologist or other therapist. (See the NICE guidelines below)
Different types of trauma have different types of impact. Survivors of long-term child abuse or prolonged torture may have similar symptoms to people who have survived a traumatic event (single incident trauma), but they may need much more long-term, intensive help and are often diagnosed with ‘complex PTSD’. Specialist programmes have been set up to provide the appropriate therapy for people who were abused as children, victims of political violence, witnesses of murder or those involved in life-threatening situations (see Useful organisations). They may provide very structured treatment plans to clients using a combination of therapies.
At the time of printing, there has only been evidence that EMDR (see below), some forms of cognitive behavioural therapy and antidepressants are effective as treatments. Their impact and usefulness will be different for each person. At the moment, no other forms of psychotherapy or counselling have been proved to be helpful in treating PTSD.
Cognitive behavioural therapy
CBT is based on changing the way we view things: trying to adapt negative ways of thinking into more positive ones. If someone has been through a traumatic experience, they may expect the negative feelings that this evokes to continue, or certain triggers in life may be bringing up old unwanted feelings. CBT helps people to recognise these expectations, and the often automatic negative thought patterns associated with them, and to try and find a more useful way of reacting and behaving.
Trauma-focused CBT has been specially developed to help people with trauma, and includes help to overcome avoidance behaviours and the symptoms of fl ashbacks, for example. Therapists delivering this treatment will need to have special training to practise.
Behavioural therapy
This involves going though the trauma, repeatedly, with a psychologist or therapist, so that people re-experience the emotions they felt at the time. It’s important to go through the details of the trauma many times until they’ve dealt with the feelings and feel comfortable and no longer anxious. Some people may not be able to remember the details of the trauma because they were unconscious, or because they have repressed aspects of the experience. They will be encouraged to focus on their fears about the event and any aspects they do remember. Sometimes sessions are recorded on tape, to be listened to later at home. Research suggests that this kind of self-directed remembering can lead to a significant reduction in symptoms.
Behavioural therapy can also help with the problem of avoidance by encouraging people to confront their fears. For example, if you have been avoiding driving since a car crash, the therapist would help you to overcome this, through a step-by-step programme.
Cognitive therapy
Many survivors develop irrational feelings and beliefs as a result of their trauma. Someone who has been raped may start to believe that all men are rapists, for example, or may feel extremely guilty and blame herself. Cognitive therapy involves challenging self-damaging thoughts and beliefs about the event and encourages everyone to replace destructive ideas with a more realistic outlook.
Eye movement desensitisation and reprocessing (EMDR)
This treatment has been around for about 10 years, and is based on behavioural techniques, in which the patient makes rhythmic eye movements while imagining the traumatic event. The eye movements are designed to stimulate the information-processing system in the brain, and the aim of the treatment is to help along the processing of the traumatic events, and speed up readjustment and recovery.
Medication
Many people with PTSD are also extremely depressed. Taking antidepressants may help relieve some of the symptoms and help people to get the best from the psychological treatments. Since antidepressants can be addictive, they should be used with caution and with full knowledge of the possible side effects they may create (see Mind’s booklet Making sense of antidepressants).
NICE recommendations
The National Institute for Health and Clinical Excellence (NICE) recommends that psychological treatment for PTSD should not start until four weeks after the trauma; however, support and information can be made available earlier than this, together with ‘watchful waiting’ to monitor any ‘natural’ recovery. Once PTSD is diagnosed, only psychological treatments that are designed for PTSD (EMDR and CBT are recommended) should be used and should be offered on a regular and continuous basis for 8-12 weeks by the same therapist. More sessions may be needed in certain circumstances (see the NICE website for more details). The person with PTSD should be given all the information about the treatments available to make an informed decision. Medication should not be offered as routine first-line treatment for adults with PTSD, but may be suitable if the person also has depression. For children and young people with PTSD, families should be involved with their treatment. The impact of the traumatic event on all family members should be assessed and appropriate support provided.
What should friends or relatives do?
‘
As the shock wore off, I felt under more and more pressure to get on with my life and to behave as though nothing had happened. As a consequence, I became less and less able to do this... It was a great strain trying to balance the need to talk about what had happened, and the consequences, and giving others as little excuse as possible to come out with phrases such as, “Life goes on” and,
“You’ve got to pull yourself together”.’
Survivors may need to be given permission to express their feelings about what they’ve been through. Relatives and friends can help by:
encouraging them to talk about it allowing them to be upset (without necessarily trying to console them), getting them to talk to other survivors, helping them to contact organisations that offer specialist support not letting them get into a pattern of avoiding situations that remind them of the trauma.
