Posttraumatic Stress Disorder (PTSD) is a mental illness within the anxiety category in the DSM IV. It has been said to sit on an intersection between anxiety and dissociation because both these issues feature strongly in the symptoms. PTSD is only ever diagnosed following a traumatic event of some kind. It is a trauma origin mental illness, that is, a mental illness that occurs following some kind of trauma.
What exactly is a trauma? There’s a lot of different opinions about this. For awhile, a traumatic event was defined as one that you wouldn’t ordinarily expect to encounter in your life. Some people have tried to write definitive lists of things that count as trauma. Other people have made the idea of trauma so broad that every person on the planet would count as being chronically traumatized! Trauma isn’t all that easy to pin down as an idea.
Here’s how I see it – we all have stories, and we all have pain. We’ve all got losses, regrets, challenges. Trauma is different from these things and affects us differently. Traumatic events evoke intense feelings such as terror, helplessness and horror. They can profoundly alter our perspective of the world in a few moments. Traumatic events may involve things happening to us – such as being in a terrible car accident, or things being threatened to be done to us, such as being robbed at gun point. Traumatic events may also involve situations where things happened or harm was threatened to other people, such as seeing someone die.
There’s a common misconception that if something wasn’t done directly to you, or if something was only threatened, then it doesn’t do as much harm. If the situation was one where intense feelings were created and the person knew they were trapped and couldn’t escape, then the effect and the distress sadly is much the same, often with the additional shame for reacting so strongly when “nothing really happened to me”. This issue touches on an important concern when talking about trauma. Humans like to categorize and rank things, and trauma is not easy to do this with. People do react differently to similar circumstances. There’s also a risk of misinterpreting symptoms as being proof of emotional pain. Someone does not have to develop a mental illness in the wake of a traumatic event to ‘prove’ that it was terribly and deeply affected them! Mental illness is not shorthand for describing an experience as appalling.
There is a clear link between the severity and the duration of the trauma and the kind of harm people are left with. For example, soldiers who experience combat with more intense fighting and for longer periods of time are more likely to develop issues such as PTSD than soldiers who experience less duration and intensity of fighting. This is called a ‘dose response’ curve – the greater the ‘dose’ of trauma, the higher the ‘response’- developing PTSD.
More is at play in the development of PTSD than the trauma however. Most people who experience a trauma do not develop PTSD. There are a number of other risk factors that make people more vulnerable to developing PTSD. These are the kinds of things that damage our ability to be emotionally resilient, such as poverty, having few friends or social supports, already struggling with other mental illnesses, being young, and already having come through other traumas. PTSD may also involve certain genetic vulnerabilities that make it difficult to keep fear reactions appropriate. So, a number of different things collide to form PTSD. While we all have our breaking point, some of us have fewer supports and are more vulnerable than others.
For a diagnosis of PTSD to be made, a trauma must be identified, severe symptoms must be present, and they must persist for longer than 1 month. In the immediate aftermath of a trauma, deeply disturbed or distressed people may be diagnosed with an Acute Stress Reaction instead. PTSD does not always start immediately following the trauma, it may be a delayed reaction that starts months or years later, sometimes (but not always) in response to a trigger of some kind that brings back feelings of the initial trauma. The symptoms of PTSD fall into three categories, called hyperarousal, intrustion, and constriction. (they are listed in a slightly different order in the DSM but I find this way of grouping them easier to understand – taken from Judith Herman’s Trauma and Recovery)
These are symptoms that stem from a person being on ‘high alert’ all the time. It’s as if they are always scanning their environment for danger, it’s suddenly impossible to settle and relax. This hyperarousal may present as trouble sleeping, because to sleep is to turn off and relax, and trust that nothing terrible will happen if you do. So many people with PTSD have trouble falling or staying asleep, and may sleep very lightly, easily waking because of normal night sounds. Another common symptom of hyperarousal is called hypervigilence, where people see danger everywhere and are suddenly alert to things like needing to be near exits, or not being comfortable around people who appear bigger or stronger than they are. An exaggerated startle response is also common, this means reacting very strongly to anything unexpected. Someone may scream if a door slams unexpectedly for example. Most of us will have heard of Vietnam Vets falling to the floor in response to a car backfiring. This can also make it difficult to tune out ordinary things in our environment such as the sound of a tap dripping. When someone is experiencing hyperarousal their brain is like a stressed out cat, leaping into the air every time anything happens, even when the person knows nothing dangerous is happening. They can become very sensitive and easily upset. Being on the alert all the time like this is very exhausting, and people often become irritable and have a short fuse.
This refers to different ways people relive aspects of the trauma. People experiencing intrusion can’t ‘move on’ because memories and feelings keep interrupting their lives with such intensity it’s as if the trauma is happening again. Emotions are involved with how we remember things. Strong emotions create different kinds of memories to the every day. That’s why we can clearly remember our best friend’s wedding day ten years ago but not be sure what we had for dinner two nights ago. In the case of trauma, the intense emotions burn those memories into us, while at the same time often triggering massive dissociation as we try to protect ourselves from the overwhelming feelings. So the intrusion of the trauma can take different forms and is often fragmented and broken up. People may have flashbacks when they encounter something that reminds them of the trauma, a smell, a sound, a location. These flashbacks may be like reliving the whole experience, or more commonly, may be very fragmented, perhaps sudden intense fear, or flashes of visual images of the trauma, or sudden body memories.
Another common way intrusion affects people with PTSD is through nightmares. These can be chronic, intensely distressing, and repetitive. They can involve exact memories so the person feels like they are back in the trauma. They can seem like a broken record, bringing up the most distressing memories over and over as if the mind is stuck on them. They can also be less linked to the specific trauma but play out deep fears by ‘imagining’ other terrible things that could happen that invoke the same feelings of being helpless and trapped. Another way that the trauma intrudes is through behaviour, by involuntarily reliving the trauma. Traumatized children may re-enact events in their games or art or writing. People may also inadvertently create the same circumstances in their lives, which seems to be driven by both a desire to prove the trauma didn’t harm them, and a need to make it somehow turn out better this time around. Like many symptoms of PTSD, this can be baffling to other people!
These symptoms don’t get as much press as the first two, because they are less dramatic in nature than nightmares or hypervigilence. Issues with constriction may also persist longer, and go unnoticed because they are subtle. However, they can be very destructive to quality of life. Many of these symptoms are dissociative, such as traumatic amnesia, where people can’t remember hours or even months around the traumatic event, despite also reliving fragments of it. Another is emotional numbing. Many people with PTSD alternate intense negative feelings with feeling flat, numb, and cut off from their feelings. They may go for long periods of time without being able to feel certain emotions at all. It can be difficult to understand that intense distress and numbness can happen at the same time. One way I describe my own experience is that it’s like someone’s screaming in another room. The terror and horror are still happening, but I can’t feel them any more, I’m just distantly aware of them. People with PTSD may feel disconnected from their relationships and may seem distant, irritable and distracted.
Avoidance is another symptom of constriction, where people try to manage their chronic fear by avoiding everything that triggers it. They may avoid speaking about the trauma, or doing anything that may trigger fear or memories. Sometimes people are aware of their avoidance, but it can also operate on a subconscious level. In my life I’ve often found that I’ve inadvertently made choices that lead to terrible isolation without being aware I was doing this. When I’m stressed, I become nocturnal, which is a very effective way of distancing me from life. Constriction also limits the way people think about the future. It can be difficult to imagine having a future, and people with PTSD may show a lack of motivation and ability to plan.
PTSD is also commonly associated with psychosomatic symptoms and chronic suicidal thoughts or feelings. It’s common for people who have PTSD to also have other related issues such as drug or alcohol problems, other anxiety or mood disorders, or other dissociative conditions. This is partly just the way our medical model categories this kind of intense distress. It’s so common for people with DID to also have PTSD that it’s been suggested that DID may actually be PTSD in a more severe form. People who have PTSD can seem to be stuck and often struggle with symptoms that frustrate the people around them. It’s important to realise they are deeply frustrating for the person experiencing them too! I will post another time about some suggestions of how to best respond to someone after a trauma.
There is currently debate about creating a new diagnosis related to PTSD, possibly to be called complex-PTSD. This is because the type and severity of symptoms experienced by people who’ve endured chronic ongoing trauma is a little different to PTSD, often including the kinds of symptoms that people with Borderline Personality Disorder experience. For example, people who were prisoners of war for many years, or people who were repeatedly sexual abused throughout childhood often struggle with severe dissociative symptoms, distortions of personality, chronic shame and self harm issues, and significant psychosomatic problems.
If you are looking for more in depth information about PTSD and recovering from it, I highly recommend the book Trauma and Recovery by Judith Herman. I was diagnosed with PTSD when I was fifteen, and at the time I had no idea what was happening to me. I wasn’t offered any information or treatment, and when I came across this book a few years later, so much made sense and I finally had hope that things could get better for me. It’s unfortunately been a long road, but knowing what was happening and what I needed to heal has made a lot of difference for me.