Post-Traumatic Stress Disorder
Bernadette Connolly BSc (Hons) OstMed. 27th July 2017. Wordpress. Epsom, United Kingdom
When we hear the word "trauma" we often think of a being hurt or involved in an accident, yet this word covers a broader spectrum of events which can be physical, psychological or both. Traumatic experiences can cause long term complications with anxiety, isolation, depression and in some cases suicidal thoughts. Complications such as these, following a traumatic event are often referred to as post traumatic stress disorder (PTSD).
PTSD is often associated with war veterans, military personnel and first responders of emergency services. Sadly this condition is not limited to work related experiences and affects people throughout the UK for various reasons.
Definitions of PTSD.
According to the National Health Service (NHS) website PTSD is an anxiety disorder caused by very stressful, frightening or distressing events. This suggests that the cause of the disorder is primarily an external factor which causes an internal stress reaction.
According to mental health charity Mind:
"Post-traumatic stress disorder (PTSD) is a type of anxiety disorder which you may develop after being involved in, or witnessing, traumatic events. The condition was first recognised in war veterans and has been known by a variety of names, such as 'shell shock'. But it's not only diagnosed in soldiers – a wide range of traumatic experiences can cause PTSD."
Again this definition seems to suggest PTSD developing after an external event.
Causes of PTSD.
The NHS website lists a number of potential causes of PTSD:
- 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
- a diagnosis of a life-threatening condition
- an unexpected severe injury or death of a close family member or friend.
The Mayo clinic website includes PTSD causes:
- Inherited mental health risks, such as a family history of anxiety and depression.
- Inherited features of your personality — often called your temperament.
- The way your brain regulates the chemicals and hormones your body releases in response to stress.
The NHS website also details theories on PTSD development being:
- A survival mechanism to help cope should a similar event happen.
- Due to abnormal stress hormone levels.
- Due to smaller or malfunctioning hippocampus of the brain.
Risk factors of PTSD.
People of any age can develop PTSD. However, there are certain risk factors which can increase the chance of PTSD after a traumatic event, such as:
- Intense or long-lasting trauma
- Trauma earlier in life, such as childhood abuse
- A job that increases your risk of being exposed to traumatic events, such as military personnel and first responders
- Other mental health problems, such as anxiety or depression
- Substance misuse, such as excess drinking or drug use
- Lacking a good support system of family and friends
- Having blood relatives with mental health problems, including anxiety or depression.
A lot of sites also state that being female is a risk factor for PTSD as the symtpoms of PTSD are more commonly seen in females and trauma is often experienced by females through domestic abuse (physical and psychological), sexual assault or childbirth
According to Harker et al (2013) 1 in 5 children have experienced serious physical abuse, sexual abuse or severe physical or emotional neglect during in their lifetime.
Bentley et al (2017) noted that recent years there has been an increase in emotional abuse as a reason for children being on a child protection plan or register in England and Wales. There have also been increases in police-recorded child sexual offences and indecent image offences across the UK and increases in child cruelty and neglect offences in all UK nations except Scotland.
PTSD in children was not a recognised condition until 1980. Approximately 1% of children and adolescents have PTSD and some estimate that up to 50% of young people will go on to develop PTSD following a violent attack, abuse or trauma (Yule et al, 2000).
Refuge states that 1 in 4 women will experience domestic violence within the UK and Wales, on a global scale 1 in 3 women will experience violence from a partner. Men can also experience domestic violence but at a smaller reported percentage than women. This does not mean that it doesn't occur at a similar rate just that it is less reported.
Traumatic childbirth is an often overlooked cause of PTSD. Jennifer Jamison Griebenow (2006) states:
"Too many times women must give birth unsupported, while being poked and prodded in a depersonalizing and sometimes literally violent process."
Women often feel pressured to get the baby out in a limited time. A vacuum extraction (ventouse), forceps delivery, an episiotomy, and cesareans are all commonly used today to ensure the delivery is timely. But what is rarely considered is the effect these interventions have on the mother, forcing her to allow someone else (often a stranger) to deliver her child for her. Further to this the effects resulting from the pain of childbirth both before and during these interventions, the drastic hormone changes and the resulting tears, scars and pains from both the pregnancy and the labour itself.
Postpartum depression (PPD) is the more accepted diagnosis for psychological difficulties faced after childbirth, but as Midwifery Today has noted: less attention is given to the symptoms that seem like PPD yet don't quite fit so could be PTSD yet are often ignored and assumed as the former.
It is also highly probable that partners who witness a traumatic labour are also at risk of developing PTSD. Sadly this is even less acknowledged by health professionals than postpartum PTSD.
Addiction and substance abuse.
Addiction is defined by the American Society of Addiction Medicine (ASAM) as a brain disease brought on by chronic drug use that makes changes to brain circuitry and chemistry, which lead to compulsive drug-using behaviors.
With repeated drug use it becomes harder for the brain to regulate amounts of dopamine, adrenaline, and GABA normally. Drug cravings and uncomfortable withdrawal symptoms include anxiety, depression, insomnia, and irritability. This heightens the risk of PTSD development.
Chronic stress can interfere with a person’s impulse control, learning, and memory functions (Sinha, 2008). Drugs can temporarily increase pleasure, decrease anxiety, and provide a distraction from difficult emotions. As a result drugs can be used as a coping mechanism for the symptoms of chronic stress or PTSD, making it more likely for a person to turn to drugs or alcohol as a means of escape.
Symptoms of PTSD.
There are a vast range of symptoms associated with PTSD. These are grouped under intrusive memories, avoidance, negative mental adaptations, changes in physical or emotional reactions.
Intrusive memory symptoms.
- Recurring distressing memories of the traumatic event
- Reliving the traumatic event as if it were happening again (flashbacks)
- Nightmares either about the event or similar.
- Distress at real or symbolic reminders of the trauma
Negative psychological symptoms.
- Negative thoughts about yourself, other people or the world.
- Feeling unsafe.
- Finding it hard to trust others.
- Blaming yourself for the event.
- Hopelessness about the future.
- Difficulty maintaining close relationships
- Feeling isolated from family and friends.
- Loss of interest in activities you once enjoyed.
- Difficulty experiencing positive emotions.
- Being easily overwhelmed with negative emotions of guilt, shame, anger or sadness.
- Keeping busy and feeling you have to.
- Avoiding reminders of the trauma.
- Memory loss of the traumatic event.
- Emotional numbness or feeling cut off from your emotions.
- Physical numbness or detachment from your body.
- Being unable to express affection.
- Alcohol or drug use to escape memories or emotions.
Changes in physical and emotional reactions.
- Being easily startled or frightened.
- Being overly alert, also sometimes called 'hypervigilance'.
- Difficulty concentrating, even on simple or everyday tasks.
- Panicking when reminded of the trauma. Increased anxiety attacks.
- Self-destructive behavior, such as drinking too much or driving too fast.
- Disturbed sleep or a lack of sleep.
- Irritability, angry outbursts or aggressive behaviour.
PTSD symptoms can start within one month of a traumatic event, but in a lot of cases symptoms may not appear until years later. People suffering with PTSD will display a variety of some of these symptoms, though not all. PTSD symptoms can vary in intensity over time. You may have more PTSD symptoms when you're stressed in general, or when reminded of the trauma.
Complex PTSD is a fairly new term. Professionals have recognised for a while that some types of trauma can have additional effects to PTSD, but have disagreed about whether this is a form of PTSD or an entirely separate condition, and what it should be called (Crabtree, A., 2017).
Complex PTSD (sometimes abbreviated to C-PTSD or CPTSD), is a condition where you experience some symptoms of PTSD along with additional symptoms, such as:
- Difficulty controlling your emotions.
- Feeling very hostile or distrustful towards the world.
- Constant feelings of emptiness or hopelessness.
- Feeling as if you are permanently damaged or worthless.
- Feeling as if you are completely different to other people.
- Feeling like nobody can understand what happened to you.
- Avoiding friendships and relationships, or finding them very difficult.
- Often experiencing dissociative symptoms such as depersonalisation or derealisation.
- Regular suicidal feelings.
(Crabtree, A., 2017).
Self care for PTSD.
If you have disturbing thoughts and feelings about a traumatic event for more than a month or if you feel you're having trouble getting your life back under control, talk to your doctor or a mental health professional. Getting treatment as soon as possible can help prevent PTSD symptoms from getting worse.
If you or someone you know has suicidal thoughts, get help right away through one or more of these resources:
- Reach out to a close friend or loved one.
- Make an appointment with your doctor or a mental health professional.
- Contact a suicide hotline. UK charity Samaritans can be contacted for free on 116 123 (UK) or 116 123 (ROI).
- If you're worried about being overheard on the phone, you can email Samaritans at email@example.com.
- Free online counselling is available via Turn2me.
- PAPYRUS is a voluntary organisation supporting teenagers and young adults who are feeling suicidal, call for free on 0800 068 41 41.
- Depression Alliance is a charity for people with depression. It doesn't have a helpline, but offers a wide range of useful resources and links to other relevant information.
- Students Against Depression is a website for students who are depressed, have a low mood or are having suicidal thoughts.
You are not alone, no matter how painful things may seem. Please talk to someone if you feel there is no way out, there always is, it just takes time and support. Please know that you are loved and there is help available.
Other practical methods of self help include:
- Learn your triggers. What causes your emotional outbursts or anxiety attacks?
- Confide in someone. This may be a friend or a health professional, but learning to discuss your feelings can help even if you are unable to talk about the event itself.
- Allow yourself time. Be patient with yourself and understand everyone copes with things in their own way.
- Look after your physical health. By monitoring your diet and activity level you can make a difference to your physical health which can have a positive effect on your mental health.
Flashbacks can be very distressing, but there are things you can do that might help.
- Focus on your breathing. When you are frightened, you might stop breathing normally. This increases feelings of fear and panic, so it can help to concentrate on breathing slowly in and out while counting to five.
- Carry an object that reminds you of the present. Some people find it helpful to touch or look at a particular object during a flashback. This might be something you decide to carry in your pocket or bag, or something that you have with you anyway, such as a keyring or a piece of jewellery.
- Tell yourself that you are safe. It may help to tell yourself that the trauma is over and you are safe now. It can be hard to think in this way during a flashback, so it could help to write down or record some useful phrases at a time when you're feeling better.
- Comfort yourself. For example, you could curl up in a blanket, cuddle a pet, listen to soothing music or watch a favourite film.
- Keep a diary. Making a note of what happens when you have a flashback could help you spot patterns in what triggers these experiences for you. You might also learn to notice early signs that they are beginning to happen.
- Try grounding techniques. Grounding techniques can keep you connected to the present and help you cope with flashbacks or intrusive thoughts. For example, you could describe your surroundings out loud or count objects of a particular type or colour.
Treatments for PTSD.
There are a number of psychological therapies available to assist with PTSD.
Cognitive Behavioural therapy (CBT) is a talking therapy that focuses on how your thoughts, beliefs and attitudes affect your feelings and behaviour, and teaches you coping skills for dealing with different problems by adopting methods to alter your thought patterns.
Trauma-focused cognitive behavioural therapy (TF-CBT) is a form of cognitive behavioural therapy (CBT) specifically adapted for PTSD.
Eye movement desensitisation and reprocessing (EMDR) is a fairly new treatment that can reduce PTSD symptoms. It involves making rhythmic eye movements while recalling the traumatic event. The eye movements are intended to create a similar effect to the way your brain processes memories and experiences while you’re sleeping.
Exposure therapy helps you safely face both situations and memories that you find frightening so that you can learn to cope with them effectively.
Group therapy can be used to teach you ways to manage your symptoms and help you understand the condition.
Medications are often prescribed to help with PTSD symptoms.
There are a large number of tablets which can help with sleep difficulties and insomnia, rather than buying over the counter tablets please consult your GP for advice, especially as some drugs may affect alertness while working or driving.
Antidepressants such as paroxetine, sertraline, mirtazapine, amitriptyline or phenelzine are sometimes used to treat PTSD in adults. Paroxetine and sertraline are the only medications licensed specifically for the treatment of PTSD. However, mirtazapine, amitriptyline and phenelzine have also been found to be effective and may be recommended.
It is advised that you speak to your GP about your more severe symptoms to get the most suitable medication. Anxiety is often the worst symptom of PTSD. Tranquilisers such as diazepam or lorazepam can be prescribed to help with this.
Complications of long term PTSD.
Other than the previously mentioned substance abuses and mental health complications PTSD is associated with many chronic conditions and diseases. These include:
- Heart disease.
- Liver disease.
- Autoimmune disease.
- Interstitial cystitis.
- Irritable bowel syndrome (IBS).
- Fibromyalgia (FM).
- Chronic fatigue syndrome (CFS).
- Other chronic pain conditions.
According to Elements Behavioral Health (2017):
"Higher risk for diseases might be attributed to the presence of secondary health risk factors such as smoking or obesity. However, studies have begun to link some conditions to trauma in the absence of other risk factors. For example, heart disease is more prevalent in survivors of childhood trauma despite controlling for other health risks."
As these conditions are becoming more prevalent in the UK I will be looking at the physiology of each and the link to chronic stress and PTSD in future posts.
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- Crabtree, A. (2017). Understanding Post-Traumatic Stress Disorder. [online] Mind.org.uk. Available at: https://www.mind.org.uk/media/6167912/post-traumatic-stress-disorder-2017.pdf [Accessed 18 Jan. 2018].
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Harker, L., Jütte, S., Murphy, T., Bentley, H., Miller, P. and Fitch, K. (2018). How safe are our children? 2013. [online] NSPCC. Available at: https://www.nspcc.org.uk/services-and-resources/research-and-resources/2013/how-safe-are-our-children-2013/ [Accessed 18 Jan. 2018].
Sinha, R. (2008). Chronic Stress, Drug Use, and Vulnerability to Addiction. Annals of the New York Academy of Sciences, 1141(1), pp.105-130.
Yule, W., Bolton, D., Udwin, O., Boyle, S., O'Ryan, D. and Nurrish, J. (2000). The Long-term Psychological Effects of a Disaster Experienced in Adolescence: I: The Incidence and Course of PTSD. Journal of Child Psychology and Psychiatry, 41(4), pp.503-511.[online] Midwifery Today. Available at: https://midwiferytoday.com/mt-articles/healing-the-trauma/ [Accessed 18 Jan. 2018].