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PTSD

PTSD

Post Traumatic Stress Disorder (PTSD) and Complex Post Traumatic Stress Disorder (C-PTSD)

What is PTSD?

PTSD has existed at all times and it has been recognised as a psychiatric diagnosis for hundreds of years, but rather confusingly under many different names. Previous terms for what we now call PTSD have included, “irritable heart” during the American Civil War, “traumatic neurosis” in the early 1900s, “shell shock” during WWI, “combat neurosis” during WWII; and “combat stress reaction” during the Vietnam War. It was in the 1980s that the term Post Traumatic Stress Disorder (PTSD) was introduced – the term we most commonly use today.

PTSD is essentially a memory filing error caused by a traumatic event.

It’s worth pointing out that the majority of people exposed to traumatic events experience some short-term distress which resolves without the need for professional intervention; although, unfortunately the small proportion who do develop the disorder are unlikely to seek help. Instead, most battle on despite their symptoms and their quality of life is likely to be substantially reduced; evidence suggests that around 70% of people who suffer with PTSD in the UK do not receive any professional help at all. The disorder also impacts upon their families and other loved ones, work colleagues and the wider community.

The defining characteristic of a traumatic event is its capacity to provoke fear, helplessness, or horror, in response to the threat of injury or death. Examples of traumatic events that can lead to PTSD include:

  • serious accidents
  • being told you have a life-threatening illness
  • being admitted to intensive care
  • exposure to traumatic events at work, including remote exposure
  • bereavement
  • violent personal assault, such as a physical attack, sexual assault, burglary, robbery, or mugging
  • military combat
  • other experiences of war and conflict
  • miscarriage 
  • house fires
  • natural or man-made disasters
  • terrorist attack
  • torture
  • traumatic childbirth
  • prolonged bullying
  • childhood neglect

Your exposure to traumatic event can happen in one or more of these ways:

  • You experienced the traumatic event
  • You witnessed, in person, the traumatic event
  • You learned someone close to you experienced or was threatened by the traumatic event
  • You are repeatedly exposed to graphic details of traumatic events (for example, if you are a first responder to the scene of traumatic events)
      

At the time someone is being exposed to this intensely fearful situation, their mind ‘suspends’ normal operations and it copes as well as it can in order to survive. This might involve reactions such as ‘freezing to the spot’ or instead the opposite ‘flight away’ from the danger.

Until the danger passes the mind does not produce a memory for this traumatic event in the normal way. Unfortunately, when the mind presents the memory for filing and retention, it can be very distressing. The memories such as the facts of what happened, the emotions associated with the trauma, and the sensations touch, taste, sound, vision, movement, and smell can be presented by the mind in the form of nightmares, flashbacks and intrusive unwanted memories.

These re-experiences and flashbacks are a result of the mind trying to file away the distressing memory, but understandably can be very unpleasant and frightening because they repeatedly expose the sufferer to the original trauma.

As the mind continues to try to process the memory, the individual also finds that his or her levels of awareness change. People can find it difficult to control their emotions and suffer intense symptoms of anxiety. This anxiety can present itself as both physical (shortness of breath, tight muscles, profuse sweating and a racing heart) as well as emotional, e.g. feeling on edge (hyper-arousal), or hypervigilance (looking out for signs of danger all the time or feeling panicky).

Hyperarousal can increase emotional response, but many PTSD sufferers also feel emotionally numb and have trouble communicating with others about the way they feel – this may make them more anxious and irritable. Quite often, the feelings and symptoms of PTSD become so unmanageable and Uncomfortable, that the sufferer starts to avoid anything linked to the original trauma which, as you can imagine, can affect day to day life.

The brain is programmed to process memories, and so the more the individual avoids things like thinking about the trauma, the less likely is that any memory processing will occur, and the more likely it is that further attempts at filing a memory will occur automatically. This ultimately leads to further nightmares, flashbacks and intrusive memories which lead on to further hyper-arousal and emotional numbing, and this in turn leads on to more avoidance and so on. This is how the symptoms perpetuate themselves in a vicious cycle which can go on for years – and why some PTSD sufferers ‘manage’ for such a long time without help, but eventually  the symptoms become unmanageable.

Following a trauma, in the majority of people, the immediate psychological reactions settle down after a while. In some people (thought to be 20-30% of those who suffer a trauma) these reactions can ‘stick’ and become chronic. If this is the case, PTSD may be said to be present.

Research shows that PTSD isn’t just a psychological problem with a start, middle, and end, like many kinds of depression. Depression usually lasts around eight months, although it can relapse. But PTSD symptoms often worsen over time and are associated with adverse changes in the structure and function of the brain.

What is Complex-PTSD (C-PTSD)?

C-PTSD is a relatively new diagnosis, although 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. For example, you may find some doctors or therapists use one of the following terms:

  • Difficulty controlling emotions. It’s common for someone suffering from C-PTSD to lose control over their emotions, which can manifest as explosive anger, persistent sadness, depression, and suicidal thoughts, or emotional lability with frequent changes in mood, which can be described as an “emotional rollercoaster”
  • Negative self-view. C-PTSD can cause a person to view themselves in a negative light. They may feel helpless, guilty, or ashamed. They often have a sense of being completely different from other people.
  • Difficulty with relationships. Relationships may suffer due to difficulties trusting others and a negative self-view. A person with C-PTSD may avoid relationships or develop unhealthy relationships because that is what they knew in the past.
  • Detachment from the trauma. A person may feel disconnected from themselves (depersonalization) and/or the world around them (derealisation). Some people might even forget aspects of their traumas (dissociative amnesia).
  • Loss of a system of meanings. This can include losing one’s core beliefs, values, religious faith, or hope in the world and other people.
  • Distorted perception of abuser: this includes becoming preoccupied with the relationship between you and your abuser. It can also include preoccupation with revenge or giving your abuser complete power over your life.

All of these symptoms can be life-altering and cause significant impairment in personal, family, social, educational, occupational, or other important areas of life. It is important to note that symptoms of both PTSD and C-PTSD can vary widely between people, and even within one person over time. For example, you might find yourself avoiding social situations for a period of time, only to start seeking potentially dangerous situations months or years later. If you’re close to someone with C-PTSD, it is also important to remember that their thoughts and beliefs might not always match up with their emotions. They might know that, logically, they should avoid their abuser. However, they might also hold onto a sense of affection toward them.

What risks are associated with PTSD?

Alcohol and drug use: You might use drugs or alcohol to help you to manage your symptoms. Drugs or alcohol can make you more unwell and more likely to try and harm yourself or take your own life.

Other Mental health conditions: Most people with PTSD will have at least 1 one other mental health condition. The most common disorders are: depressive disorders, substance use disorders and anxiety disorders. Other mental health conditions have some of the same symptoms of PTSD. This may be why PTSD is hard to diagnose

Suicidal thoughts and behaviours

Physical health issues: PTSD has been linked with physical symptoms, such as dizziness, tinnitus and blurry vision, diarrhoea or constipation; it has also been linked with physical illnesses such as heart disease, high blood pressure, obesity, Crohn’s and other bowel diseases, and allergies

How is PTSD and C-PTSD diagnosed?

PTSD and C-PTSD can be difficult to diagnose because of the subjective nature of most of the diagnostic criteria (although this is true for many mental disorders), symptom overlap with other mental disorders, and the potential for abuse of alcohol and drugs, which can produce some of the symptoms. Also, there is a potential for over-reporting of symptoms, especially when PTSD could be a mitigating factor at criminal sentencing, or under-reporting due to the fear of stigma, and fear that a diagnosis may preclude employment opportunities.

If you believe you may be suffering of PTSD or C-PTSD, you should ask your GP to refer you to a specialist psychiatrist, either in the NHS or the private sector. Your GP may complete a physical examination and send you for blood tests to determine if your symptoms can be caused by a physical disorder, rather than mental. Many symptoms related to anxiety can be caused by physical disorders. A psychiatrist will complete a psychiatric evaluation and will determine if your symptoms meet sufficient number of diagnostic criteria to be diagnosed. He may then refer you for a psychological evaluation to a psychologist, or other therapist.

How do you treat PTSD?

For treatment to be successful, information processing must be completed. This is why some psychological therapies, such as Trauma focused Cognitive Behavioural Therapy (TF-CBT) or Eye Movement Desensitisation and Reprocessing (EMDR) aimed at helping the individual to process and work through the traumatic material are extremely beneficial; however, there are several types of treatment which can help those with PTSD.

The main treatments for post-traumatic stress disorder (PTSD) are psychological therapies 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 or events occurred, which means it’s never too late to seek help. if you have mild symptoms of PTSD, or you have had symptoms for less than 4 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 get better within a few weeks without treatment. If watchful waiting is recommended, you should have a follow-up appointment within 1 month.

PTSD Therapy has three main goals: a) improve your symptoms b) teach you skills to deal with it c) restore your self-esteem. Most well researched PTSD therapies fall under the umbrella of Trauma focused Cognitive Behaviour Therapy (TF-CBT). The idea is to change the thought patterns that are disturbing your life. This might happen through talking about the trauma or concentrating on where your fears come from. Depending on your situation, group or family therapy might be a good choice for you instead of individual sessions. The following models of therapy are the most commonly used today:

Cognitive Processing Therapy (CPT):  CPT is a 12-week course of treatment, with weekly sessions of 60-90 minutes. At first, you’ll talk about the traumatic event with your therapist and how your thoughts related to it have affected your life. Then you’ll write in detail about what happened. This process helps you examine how you think about your trauma and figure out new ways to live with it. For example, maybe you’ve been blaming yourself for something. Your therapist will help you take into account all the things that were beyond your control, so you can move forward, understanding and accepting that, deep down, it wasn’t your fault, despite things you did or didn’t do

Prolonged Exposure Therapy (PET): If you’ve been avoiding things that remind you of the traumatic event, PET will help you confront them. It involves eight to 15 sessions, usually 90 minutes each. Early on in treatment, your therapist will teach you breathing techniques to ease your anxiety when you think about what happened. Later, you’ll make a list of the things you’ve been avoiding and learn how to face them, one by one. In another session, you’ll recount the traumatic experience to your therapist, then go home and listen to a recording of yourself. Doing this as “homework” over time may help ease your symptoms.

Eye Movement Desensitization and Reprocessing (EMDR): With EMDR, you concentrate on salient aspects of your traumatic memory while you watch or listen to something the therapist is doing — maybe moving a hand, in front of your eyes, or flashing a light, or making a sound alternating from one ear to the other, or tapping your thigh alternating from right to left. It is assumed that the eye movements or the other bilateral stimulations, help the brain to process the memory by triggering or enhancing the natural trauma healing process that the brain, and especially the memory centres have. The goal is to be able to think about something positive while you remember your trauma. It takes about 3 months of weekly sessions. EMDR was first developed in the late 80’s and has been used since, very successfully, in treating PTSD,  but also other conditions such as phobias.

Stress Inoculation Training (SIT): SIT is a type of CBT. You can do it by yourself or in a group. You won’t have to go into detail about what happened. The focus is more on changing how you deal with the stress from the event. You might learn massage and breathing techniques and other ways to stop negative thoughts by relaxing your mind and body. After about 3 months, you should have the skills to release the added stress from your life.

Stress Inoculation Training (SIT): SIT is a type of CBT. You can do it by yourself or in a group. You won’t have to go into detail about what happened. The focus is more on changing how you deal with the stress from the event. You might learn massage and breathing techniques and other ways to stop negative thoughts by relaxing your mind and body. After about 3 months, you should have the skills to release the added stress from your life.

Other drugs used are other antidepressants, like Mirtazapine or Amitryptiline or Phenelzine, Prazosin for nightmares and sleep disturbance, Antipsychotics or second-generation antipsychotics, like Quetiapine or Olanzapine, beta-blockers, and Benzodiazepines or other anti-anxiety drugs like Pregabalin. Second-generation antipsychotics are most likely to be prescribed by specialist Psychiatrists, rather than in Primary care, and although they are not licensed for treatment of PTSD, can have an advantage, for some patients, in helping with some of the symptoms, such as chronic anxiety and hypervigilance, and sleep problems. Their effect is also usually quicker than the effect of conventional antidepressant drugs.

Which one or combination of meds is likely to work best for you depends in part on the kinds of symptoms you have, what the side effects are like, and if you can tolerate them, and whether you also have anxiety, depression, bipolar disorder, or substance abuse problems.

Complementary (or Alternative) Therapies: although these therapies are not recommended by NICE or other guidelines, for some of them there is significant evidence that can complement more conventional therapies, and can assist individuals who cannot tolerate more psychologically demanding therapies, like TF-CBT or EMDR.

  • Moderate exercise, sport and physical activity is a way to distract from disturbing emotions, build self-esteem and increase feelings of being in control again
  • Play therapy for children: it is commonly used, but there have not been enough studies to support it
  • Animal assisted and equine therapies: bonding with an animal can renew capacity to develop healthier relationships, and to give and receive non-sexual caring through physical contact
  • Bodywork, massage, and somatic therapies: some bodywork therapies emphasize deep relaxation, while others incorporate guided imagery and psychological therapy techniques during massage or body awareness exercises
  • Acupuncture: traditional Chinese, electro-acupuncture, and auricular acupuncture are widely used; the 5-element acupuncture, incorporates a spiritual and emotional approach, with Japanese style acupuncture that uses very light needle insertion. It is ideal for young children, the elderly and needle sensitive individuals
  • Breathing and Yoga: good to incorporate daily yoga practice in an on-going self-care program; there is research that yoga breathing leads to reduction of symptoms, and breathing exercises are a well-established part of TF-CBT and other therapies

How do you treat C-PTSD?

C-PTSD is a new diagnosis, and for this reason there aren’t any NICE or other guidelines on best practice; the research evidence base is still under development, and there are no specific treatments. If you have complex PTSD, you may be offered therapies used to treat PTSD, such as trauma-focused cognitive behavioural therapy or eye movement desensitisation and reprocessing (EMDR). Sometimes you may be offered other treatments, like Mindfulness based CBT, or treatments used to treat BPD, like Dialectical Behaviour Therapy (DBT); or you may be offered a combination of treatments. People with complex PTSD often find it difficult to trust other people. You may be offered more therapy sessions than usual so you have time to build a trusting relationship with your therapist. You’ll also be offered treatment for other problems you may have, such as depression or alcohol addiction, and you may be offered medication. You should be offered ongoing support after your treatment ends.

What can I do to help myself?

First, to seek help from your GP or a specialist. You can get help from the NHS, Adult Social services, certain charities, or the Private Sector. You can speak to your GP about your concerns. They will be able to talk to you about treatment options and coping strategies, or prescribe medications, arrange physical health assessment, or refer you to a Consultant Psychiatrist, or psychological services, such as the IAPT services (in North Staffordshire Healthy Minds or Wellbeing service).

In some areas, charities will support people who have PTSD. This may be through support groups where you can talk to other people who have PTSD and other mental health conditions. Group support can help you find ways to manage your symptoms and understand your condition. There may be also other services available, such as employment or isolation support. Some of the main national mental health charities are: Assist, Combat Stress, Rape crisis, MIND, and Richmond Fellowship. You can look for availability in your area in the Rethink website www.rethink.org  by clicking on the “Help in your area” at the top of the webpage. However, there are thigs that you can do to help manage your mental health and wellbeing (self-care). When it comes to what helps people, everyone is different, you may need to make different lifestyle changes until you find what works for you. Such as the following:

  • Learn ways to relax, such as listening to meditation CDs or relaxing music. You can find free meditation videos on YouTube
  • Practice mindfulness and meditation. You can find out more on mindful.org/meditation/mindfulness-getting-started
  • Eat healthy foods and have a balanced diet. You can find nutritional advise on nhs.uk/live-well/eat-well/
  • Keep physically active. Exercise can help reduce stress and anxiety. It can increase the levels of serotonin and endorphins which are your body’s natural “happy” chemicals
  • Have a daily routine. Keeping a routine can help you to keep your mind occupied and focused in healthy thoughts and activities
  • Have healthy relationships. You can find out more tips on how to maintain healthy relationships on mentalhealth.org.uk/sites/default/files/guide-investing-relationships-may-2016.pdf
  • Get enough sleep. You can find out more about improving your sleep by clicking rethink.org/advise-and-information/living-with-mental-illness/wellbeing-physical-health/sleep
  • Be aware of your alcohol or drug intake. Self-medicating with alcohol or drugs is common in PTSD. You may need professional help to do this, which can be offered by your GP or local Addiction services, usually operated by different charities
  • Keep a mood diary.This can help you to be more aware of your symptoms and what makes you better and worse. You can simply use a notebook for this. Or you may want to try online resources or smartphone apps like: MoodPanda: moodpanda.com/ or Daylio: www.daylio.webflow.io/ or Evernote: www.evernote.com/

There is also Self-help online: there are websites which give information about how to manage your mental health. There are also websites which explain how you can use cognitive behavioural therapy (CBT) techniques to improve and manage your mental health. Some people find these useful.

There are also books that can help you to understand better how PTSD and C-PTSD develop, and what can you do about them in terms of self-help. Examples are:

Complex PTSD: From Surviving to Thriving: A Guide Map for Recovering from Childhood Trauma by Peter Walker. Written by a therapist who has recovered from Complex PTSD, this  is a user-friendly self-help guide to recovering from the effects of childhood trauma. It contains practical tools and techniques for recovery, and many examples of his own and others’ journeys of recovering. It deeply explores the causes of CPTSD, which range from severe neglect to systematic and extreme abuse.

Healing Trauma, by Peter Levine. Peter A. Levine found that all animals, including humans, are born with a natural ability to rebound from distressing situations. Levine developed Somatic Experiencing to learn how to address trauma and related symptoms at their source – your body. The book includes: How to develop body awareness to “re-negotiate” and heal traumas rather than relive them, emergency measures for emotional distress and a 60-minute audio CD of guided Somatic Experiencing techniques.

The PTSD workbook: simple effective techniques for overcoming traumatic stress symptoms by Mary Beth Williams and Soili Poijula. This book outlines techniques and interventions used by PTSD experts to offer trauma survivors the most effective tools available to conquer their most distressing symptoms, whether they are a veteran, a rape survivor, or a crime victim. Based on Cognitive Behavioural Therapy, the book is accessible and easy-to-use. The second edition features chapters focusing on veterans with PTSD, the link between cortisol and adrenaline and its role in PTSD and overall mental health, and the mind-body component of PTSD. Includes a very good section on Complex PTSD.

Redeployed: How Combat Veterans Can Fight The Battle Within and Win the War At Home, by Brian Fleming and Chab Robichaux. A bestseller written for combat veterans by actual combat veterans. A Combat-Infantry Sergeant and a Special Operations Force Recon Marine have joined forces to equip and educate other returning combat-veterans and their families on how to “fight” and “win” the most common battles they face after returning home from war (PTSD, TBI, Depression, Anxiety, Isolation, Suicide, Divorce, etc).

*Consultant Psychiatrist, Devon Partnership Trust, Exeter, England

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