What is Post Traumatic Stress Disorder (PTSD) and why does it come about?
1. Diagnosing Post Traumatic Stress Disorder
As the diagnosis suggests, post traumatic stress disorder comes about after the person has experienced some kind of trauma. Formal diagnosis of psychiatric disorders is based on criteria in two reference works:
- the "Diagnostic and Statistical Manual" (DSM) published by the American Psychiatric Association currently in issue five (DSM-V)
- and the "International Classification of Diseases" (ICD) published by the World Health Organization, currently in issue 10 (ICD-10).
Whereas most other psychiatric diagnoses simply need to fulfil criteria based on symptoms, PTSD requires there first to have been a specific incident from which the symptoms evolved.
DSM-V lists various criteria which have to be met to qualify for a diagnosis of post traumatic stress disorder. Importantly the trauma consists of a single specific incident and has to fall into one of the following categories:
"The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence in one of the following ways:
- Direct exposure
- Witnessing the trauma
- Learning that a relative or close friend was exposed to a trauma
- Indirect exposure to aversive details of the trauma, usually in the course of professional duties (e.g. paramedics. etc)"
DSM-V then goes on to list other essential criteria for the diagnosis.
2. What it feels like to have PTSD
I have come across people who claim to have posttraumatic stress disorder simply because they have experienced a degree of phobia or bad dreams following an unfortunate incident of some sort. It is normal for us to have some bad dreams after a negative experience but in most cases these resolve themselves as we come to terms with whatever it was.
True PTSD is devastating. Sufferers' everyday lives are turned upside down. They are unable to concentrate or sleep. If they do sleep they experience terrifying nightmares about what happened. It is also common for them to be unable to make eye contact when they first start therapy and to just sit and shake.
DSM-V lists the presence of various examples of the following symptoms:
- Person constantly re-experiences the trauma by at least one of the following: nightmares, flashbacks, intrusive thoughts, physical or emotional reaction to reminders of the trauma
- Person experiences at least two of the following: general negative feelings, loss of interest in daily activities, inability to feel good about anything, inability to recall details of the incident, exaggerated need to blame self or others for what happened.
- Two of the following also need to be present: aggression or irritability, increased startle responses, hypervigilance and being on the lookout for danger constantly, difficulty concentrating and sleeping.
- In addition the symptoms must have lasted for more than a month for Post Traumatic Stress Disorder to be diagnosed and to not be related to any other cause such as other illness, medication, etc. Prior to that it is classed as "acute stress disorder".
3. Common incident triggers for PTSD
The World Health Organisation studied loss and other traumatic events in 21 countries. The overall finding was that PTSD had affected 3.6% of the world's population.
Of respondents to the survey
21.8% had witnessed violence
18.8% experienced personal violence
17.7% had accidents
16.2% were exposed to war
12.5% were exposed to trauma to a loved one
At present by far the most common cause of PTSD in the UK is being involved in a car accident.
It is important to realise, however, that not everyone who experiences trauma will come to suffer from Post Traumatic Stress Disorder. This is due to a combination of various factors including the person's personality, their inherited arousal system, and the circumstances of the trauma itself.
Many trauma sufferers manage to resolve their anxieties within the first month or so. In effect they manage, albeit usually without realising what they're doing, to convince their survival instinct that the danger has passed, that they now are safe, and it can switch off. Those that don't, and who develop PTSD, continue to feel as if the disaster is still ongoing.
4. How does Post Traumatic Stress Disorder develop?
The answer lies with the symptoms.
People with Post Traumatic Stress Disorder have nightmares and/or flashbacks. During these the traumatic event is replayed like a film in their minds. They re-live it and feel the same emotions that they felt when it happened.
To the survival instinct there is no difference between real danger that's actually happening and your very vivid memory of that danger as you re-live it in your head. This is because the survival instinct bases its response on how you react to the warnings it gives.
If you react to them by being fearful all over again, it will keep giving you reminders because it believes the danger is still present.
Let's look at the example of a car accident.
As a therapist, I have never needed to treat anyone who had been involved in an accident and who also recognised that it was entirely their own fault.It seems that when someone causes an accident due to carelessness or maybe lack of attention, they don't usually also experience Post Traumatic Stress Disorder.
The most logical explanation for this would appear to be that the person who caused the accident is able to tell themselves that if they hadn't done such and such then it wouldn't have happened. This belief enables them to still feel a sense of control over their fate.
It's the sudden realisation that, although they were doing nothing wrong, they could easily have been killed that takes root in the mind of the innocent victim.
The innocent victim was doing nothing wrong yet, as they suddenly realise, they could have been killed. This not only evokes fear, but also causes many sufferers to experience a general loss of confidence. We each tend to feel confident when we feel able to control those things that matter most to us.
Being able to keep ourselves safe is paramount. It will then come as no surprise that people who are suddenly traumatically confronted by the realisation that they do not have such control will become anxious and feel vulnerable and lose confidence in their own abilities. This is explained as a symptom under loss of confidence.
At the time of the trauma, the survival instinct recognises the raised negative arousal (extreme fear) in the person and assumes that what's going on is life threatening. It then tries to record anything which it believes is connected to the trauma so that if/when it comes across it again it can warn them of the danger in advance.
So it might decide that being in a car itself is a danger signal. It may also link over factors that were present at the time such as flashing blue lights and/or sirens, the nature of the weather, the particular place it happens, etc.
Because the survival instinct is a very primitive system it sometimes makes links with aspects which aren't threatening in themselves - maybe someone who came to help at the scene was wearing a safety vest. It could well remember this as a danger signal in days to come simply because it was on the danger scene at the time.
In the days following the trauma, the PTSD sufferer is more anxious than usual simply because what happened was a shock. For this reason they are experiencing higher ongoing arousal than usual. Once the arousal level increases, the survival instinct is more alert and more ready to warn of danger.
It sees reminders of what happened, maybe on TV, in things people say, anywhere. Each time it finds such a reminder it gives the person a startle warning and a reminder. The person then starts recalling what happened all over again, having images of it in their mind and becoming anxious (raised negative arousal). This response to the startle warning just serves to let it know that yes, they are scared and so it was right to warn them. This encourages it to look for even more things to warn them about - and so it goes on.
When the sufferer goes to bed they are often unable to sleep. They tend to have constant raised arousal which their survival instinct interprets as meaning there's danger around. There is no way the survival instinct is going to let the person sleep when it has every reason to believe life is threatened.
If the sufferer does manage to fall asleep, they tend to dream about the trauma. This wakes them and they then go over what they just dreamt in their minds, and feel afraid in response to it. Again this keeps the arousal high and the fear flowing.
It is not therefore surprising that another symptom of ptsd, along with insomnia, nightmares, flashbacks, exaggerated startle responses and constant anxiety, is the inability to concentrate. If your survival instinct is constantly alerting you to possible dangers and locking your awareness onto them, there is no spare awareness to focus on everyday things.
5. Rationale for overcoming Post Traumatic Stress Disorder
To overcome PTSD the sufferer has to be taught to do three things:
1. To retrain the survival instinct to believe that the reminder warnings it keeps giving about what happened are no longer relevant. That the danger has passed.
This is done by learning to recognise the warnings and choosing not to buy into them.
2. To recognise when they are responding to startle warnings with more negative arousal and learn and apply techniques for reducing it instead.
3. Finally the loss of confidence has to be addressed although once a sufferer realises they are making progress with 1 and 2 their confidence receives a boost anyway.
EMDR is an effective treatment for Post Traumatic Stress Disorder although not all sufferers feel able to undergo it. Sometimes those with very severe PTSD benefit just from some simple brief mindfulness exercises or just sleeping with Baroque largo music playing softly in the background in order to begin to feel a little calmer before treatment can proceed.
The approach to overcoming anxiety described on this website as the Feelgood Way contains necessary information and techniques to enable a PTSD sufferer to understand and to begin to overcome their anxieties. Many sufferers will probably need professional help to guide them through treatment and help them feel more confident about it.