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Post-Traumatic Stress Disorder (PTSD)

PTSD is the name given to an extended or delayed response to an exceptionally threatening or catastrophic event or situation.  The causing problem will be one that anybody would find stressful; such as physical or sexual violence, either as a victim or a witness; or some natural or man-made disaster like a bombing or a car crash; or a tragedy like unexpectedly losing a close relative.

To be diagnosed as some variant of PTSD, the symptoms would have to have lasted more than a month and to have occurred within six months (usually) of the traumatic event. This will not always be possible where the event is a long term one such as severe neglect in childhood or a soldier’s gradually escalating stress in combat situations.  Anxiety Care has encountered a soldier, diagnosed with PTSD, whose problems began over twenty years after a particularly harrowing and traumatic event in Northern Ireland. In these latter situations, the diagnosing clinician would almost certainly look first for the presence of other disorders such as OCD, GAD and major depression rather than accepting the presence of PTSD. When the problem occurs many years after the causing event, the trauma is a huge one that would have affected anybody, there is no evidence of previous mental problems and there has been a profound personality change, it is likely that the diagnosis here would be something other than PTSD: probably in the range of personality disorder caused by catastrophic events, which is in a different mental health classification area.
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Several types of PTSD?

Some experts in this field believe that there are at least two types of PTSD: one that occurs after a single traumatic event, and another that occurs as a result of a series of events building up to the: ‘final straw that broke the camels back’ situation. There might even be a third, somewhere between those mentioned above, where a similar trauma to one that occurred years earlier and which this person felt he or she had dealt with, but hadn’t, triggers PTSD.  From Anxiety Care’s experience, with reoccurrences of anxiety disorders in service users years later, this is likely to be due to the event having been hidden away, rather than having been dealt with and overcome.

On the subject of hiding rather than overcoming, it has been suggested that children and adolescents, or adults who have trauma going back into early childhood, might use coping techniques like denying, or forcing themselves to ignore, the stress-generating event in PTSD.  This might have been the only technique available to the child at the time, particularly if the parent/carer was abusive or indifferent and so responsible for some, or all, of the trauma.  The problem is, this is not a good way to deal with PTSD, as part of recovery has to be confronting the emotions and fears it generates and dealing with them, as mentioned.  This might be extremely difficult if the adult or adolescent sufferer has learnt these ‘hiding’ techniques very strongly as a child, and allows no possibility of error to enter his or her mind, as is common with young children and as may easily be carried on into adulthood. The result will be similarly negative if the adolescent or adult cannot accept the ‘camels back’: the building of stress over a long period, and seeks only to counter the current trauma without consideration for the depth of the problem that may be making current difficulties worse.

This is not to say that PTSD sufferers should delve for ‘forgotten childhood abuse’ if they cannot accept the legitimacy of their PTSD. This is rarely useful.  What must be confronted is the necessity to accept the problem, even if it is a trauma made worse, or more likely, because this person was in an emotional state where a stressful event hit him or her much harder than it hit others; and/or this situation occurred through the inadequacy of parental support and care: an inadequacy that is painful to face.
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What is ‘normal’?

Traumatic events do not always, or even often, cause PTSD. It is completely natural to suffer anxiety symptoms or emotional upset after a traumatic event, and these usually diminish and disappear on their own.  Often the development of PTSD rather than recovery depends on factors like: the severity of the trauma or the length of time it lasted, the number of times this person has previously suffered trauma, if the trauma was inflicted by another person (such as rape or a bad beating), or the level of danger involved.  For example, in the latter case, somebody who believed they were going to die is more likely to develop PTSD than the person undergoing the same trauma who did not perceive this as a probability.

With any major trauma there will probably be a period of denial early on as this is a protective device used by the body and mind. Young children will tend to spend a longer period in this state of denial than adults. However, if, in response to trauma, acute symptoms beyond whatever is gauged to be ‘normal’ persist (see symptom list below), but for less than a month, this is called ‘Acute Stress Disorder’.  For diagnosis of this disorder, sufferers will have less symptoms in the various physical and emotional categories, and will probably experience more ‘side effects’ as in feeling dazed, ‘not there’ or even having temporary memory loss about the trauma. Research seems to suggest that Acute Stress Disorder, while more responsive to treatment than PTSD, might be a pointer to a potential for PTSD in the future.  Presumably this means that an excessive reaction to stress once, might make PTDS more likely in face of any severe trauma at a later date; or might feed in to the ‘camel’s back’ situation and the likelihood of ‘cumulative PTSD’ at some point. This is by no means certain of course, but it would be worthwhile to bear the suggestion in mind if a personal response, or the response of a family member, to a traumatic event, seems to be excessive. As the old saying goes: ‘an ounce of prevention is worth a pound of cure’.

Beyond Acute Stress Disorder, PTSD enters acute and chronic stages. These are diagnostic criteria and do not necessarily have anything to do with how difficult the problem is to treat.


…the increased prevalence of PTSD can…result from a greater willingness to report symptoms of PTSD.
…PTSD occurs more frequently among persons who have other psychiatric disorders.
‘Open-mind’

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Symptoms

The PTSD sufferer will experience repetitive recollections of the event or re-enactment of it in the mind that is difficult or impossible to put aside.  There might be dreams or nightmares about it; even ‘day-dreams’ that make it feel as if the event is happening all over again. The person with PTSD will experience a numbing of feelings, loss of interest, feel detached from others; will probably avoid situations and conversations that remind him or her of the event; might have difficulty sleeping and concentrating; be irritable or subject to bursts of anger and may startle easily.  Research in this area seems to suggest that, as mentioned above, people with previous neurotic or depressive problems, or a history of parental abuse or neglect, might be more prone to develop PTSD from a causing event than those without such problems, exposed to the same trauma.

Some people with PTSD might suffer panic attacks when entering a situation that reminds them of the traumatising situation.  Symptoms here might be any or all of the following: sweating, trembling, pounding heart, shaking, shortness of breath, choking feelings, chest pains that don’t come from any particular region of the chest, nausea, body chills, feeling ‘unreal’ or ‘not there’, believing that a heart attack or stroke is imminent, or that insanity is just round the corner.  These panic symptoms are common to many anxiety disorders and can occur as a separate disorder. Obviously, on their own, they do not mean that a person has PTSD.

Other affects might be depression, self-blame, suicidal thoughts, a mistrust of people and an inability to take on social or work situations. Sometimes the trauma is so acute that the sufferer may develop strange beliefs that can resemble delusions or hallucinations.  However, research suggests that these are usually temporary and tend to disappear on their own. Some people turn to alcohol to reduce symptoms and to help them function and, although there may be short-term social and work benefits, allowing this person to function almost normally, alcohol is a depressant and invariably, sooner or later, just adds a further problem to the PTSD sufferer’s life.
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Treatment

As with all anxiety disorders, available treatment consists of medication and/or psychotherapy. Anecdotal evidence suggests that the great majority of people with problems in the anxiety disorder range, resist taking medication.  However, if the level of handicap is so great that the person with PTSD does not see any way to counter the problem: basically spending the days defending him- or herself against symptoms and fear, then medication might well be needed.  In Anxiety Care’s experience, when someone is in this state of ‘siege’, practical steps that involve trying to take one’s life back from the disorder, as will be involved in ‘talking treatments’, often seem impossible to the victim and therefore rarely work.

Research suggests that the following situations would indicate a need for medication: severe and/or long-lasting symptoms; other disorders as well, such as depression or another anxiety disorder; a lot of life stress or difficulty in social or work functioning; suicidal thoughts; that psychotherapy, as mentioned above, isn’t working.

Talking treatments might involve all (if the sufferer is lucky) or any of the following: anxiety management (relaxation, breathing training, assertiveness, perhaps techniques to overcome distressing thoughts).

Cognitive therapy: being helped to challenge and change irrational and self-defeating beliefs.

Exposure therapy: this involves facing the situations that are feared in a hierarchy of steps, starting with something that can just about be managed and working up to what the sufferer wants to be able to achieve with as many steps in between as necessary.  This therapy works best if there are actual situations or objects to confront, such as visiting a feared area, travelling in a car etc.  When the fear is mainly mental, with no particular physical situation that brings on fear, exposure work might not be applicable and cognitive therapy of some sort would be required.

There are a great many types of professional ‘talking treatment’ that fall outside those described above but experts in this field tend to rate them of less benefit, at best. Many sufferers will receive support from the GP and may be referred to a professionally run or voluntary sector support group. Here the sufferer will probably be helped to talk about the trauma and to understand normal responses to it, shock reactions and how to challenge their irrational thoughts and beliefs about the event.
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Medication

As mentioned above, when talking help fails, or symptoms are extreme, medication may be the best option.  Currently the antidepressants: serotonin reuptake inhibitors (SRI’s) seem to be the drug of choice.  When rage or extreme irritability is part of the problem ‘antiadrenergic agents’ or ‘mood stabilizers’ have been known to be added to the SRI’s.  Tranquillisers: benzodiazepines, are often used to combat anxiety but there is little evidence that they are of value for PTSD when used alone and there is always the problem of possible dependency with these drugs.  Some doctors have been known to use a major tranquillizer to ease the period (four weeks or more) between prescribing SRI’s and the time they become effective. A charity client has been prescribed one of these drugs to support his antidepressants in the area of mood problems and extreme edginess over a long period, for another anxiety disorder.

Antidepressant medication is not a short term answer and it is likely that the SRI’s and any other drugs that they are combined with will have to be taken for between one and two years depending on the severity of symptoms and handicap.  If relapse occurs after discontinuing, the medication will probably have to be taken again.  And if the medication does not produce a good response, another SRI might be prescribed or some other combination of drugs.  As the SRI’s are also the medication of choice for other anxiety disorders and many forms of depression, if there are other disorders present (research suggests that up to 80% of PTSD sufferers have another anxiety disorder or depression too) these will probably respond to the SRI.
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PTSD and OCD

Anecdotal evidence within the charity seems to suggest that a single trauma that undermines a child’s confidence, or a ‘camels back’ effect in the early years that came to the same thing, might predispose a child towards irrational thoughts and/or rituals used as coping techniques, that might lay the ground for future susceptibility to obsessive/compulsive disorder (OCD).  Several obsessive clients have detailed worries in the very early years involving inconsistent or incompetent parents that encouraged them to fall back on their own, small and under developed, devices for relief from anxiety and fear.  When such inappropriate techniques are integrated into a developing mind it is easy to see how a feeling of over responsibility might occur, or a need to ritualise as a means of the child controlling his or her environment. There is no available research on this subject and the above does not mean that a child suffering from PTSD will automatically, or even often, go on to develop OCD.  There are probably a great many combinations of developmental and neurological reasons why OCD occurs and this is just one possibility.

As such a high proportion of PTSD sufferers have other disorders, it seems evident that the severity of the problem will be closely linked to the anxious or depressive tendencies of the victim.  This would need to be kept in mind by sufferers and families when trying to work out why this person has reacted so destructively to trauma.
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Helping the person with PTSD

In most cases, it is useful for the PTSD sufferer to talk about his or her feelings.  When this person has been suffering badly, probably reliving the trauma to the alarm of family and friends, it is understandable that they should press for it to be forgotten or ‘toned down’.  If they have a smattering of knowledge, they may go the other way and try to help the sufferer relive the episode to ‘get it out of their system’. Either of these extremes is likely to be counter-productive at best.  Being a sympathetic and supportive listener is probably the best way forward; helping this person to work through painful feelings, confusion and irrational guilt.  It is never useful to tell them that their feelings are silly or nonsensical.  The listener has to accept the PTSD sufferer’s reality, however painful it seems and simply assist them to work towards a better understanding.

Naturally, if the sufferer has parents who have already demonstrated their inability to support this person, the helpers are likely to be friends or other relatives. In this situation, such helpers would have to be ready to support the sufferer as he or she works through the negative or indifferent responses of these parents, which adds another dimension to the problem.


No matter how long you have been suffering from PTSD, something can be done to help you get over it and dramatically improve your life.  It is important to accept that the treatment will also ask something of you – you may need to revisit painful experiences you would rather avoid, and you may need to take medication that might have some side effects. But if you commit yourself to the treatment and stick with it, there is a good chance that you will soon begin to feel better and regain your quality of life.
E.B. Foa PhD, et al

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Source material

American Family Physician, ‘Primary Care Treatment of Posttraumatic Stress Disorder’; http://www.aafp.org/afp/20000901/1035.html

Foa, E.B, PhD et al, ‘Expert Consensus Treatment Guidelines For Posttraumatic Stress Disorder’; A Guide for Patients and Families;  www.psychguides.com

Mentalhealth, Posttraumatic Stress Disorder, European Description’ (F43.1)
http://www.mentalhealth.com/icd/p22-an06.html

Open-mind, ‘Posttraumatic Stress Disorder in Childhood & Adolescence’,
http://open-mind.org/SP/Articles/4g.htm
http://open-mind.org/SP/Articles/4g1.htm

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