ADAVIC Information Sheets
WHAT IS POST TRAUMATIC STRESS DISORDER?
By Shawn Goldberg
Ben was walking home from the station after work as he did every night. But on this particular night two strangers attacked him. He suffered bruising, broken limbs and was hospitalised as a result of the assault. Although his body fully recovered from the attack, three months on, Ben was unable to get that night out of his mind. He found it difficult to sleep, as he was constantly woken by sounds outside the house, and he had ongoing regular nightmares replaying the attack. He had lost weight, was edgy and jumped at most loud sounds. He became irritable, depressed, hardly left the house, and cut off from friends and family. If not busy with some tasks around home, he would have continuous thoughts about what had happened to him. The image of it was constantly on his mind. Ben took to drinking to give himself a break from the ongoing thoughts and images of the attack; he was becoming dependent on alcohol to get through the day. When Ben did manage to leave the house, his heart raced, he often felt disorientated, and confused. Sometime he was so fixated on what happened to him, he would do strange things, like forget to rinse off the soap and shampoo before leaving the shower, or he would drive from one place to another without remembering how he got there. Ben’s life had dramatically changed, and three months on there was no sign of improvement.
Trauma is unfortunately an all too common experience. Living in society wrought with violence, war and natural disasters, it is almost inevitable that we will experience at least one significant traumatic event. However, only a minority of people will experience a lasting psychological affect that is known as Post Traumatic Stress Disorder or PTSD. Ben’s case is a typical example of someone who has experienced a violent attack and developed PTSD. Random attacks like that which happened to Ben are not the only form of trauma.
TRAUMATIC EVENTS
What are traumatic events? It is when there is a perception that your life is in danger or you could be seriously injured. This could involve actual or threatened death or serious injury and cause a reaction of intense fear or helplessness. But it is also traumatising to hear of a loved one being threatened or injured, or to witness a traumatic event.
Traumatic events can be natural disasters (e.g. Hurricane Katrina, the recent tsunami); technological disasters (e.g. plane crashes, chemical spills); criminal violence (e.g. intimate partner abuse, rape, homicide); war/political violence; and human rights abuse (e.g. kidnapping, torture). In general, prolonged stressors deliberately inflicted by people are far harder to bear than accidents or natural disasters. If the abuse is done deliberately in the context of an ongoing relationship, the affects are increased, and more so if the victim is dependent on the perpetrator, as with childhood abuse.
SYMPTOMS
To be diagnosed with PTSD there are a number of symptoms that need to match the Diagnostic Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV, American Psychiatry Press, 1994). This is an internationally recognised manual to help categorise mental health and assist with treatment, understandings and research. PTSD falls under anxiety disorders and is based on experiencing a traumatic event. It usually appears within three months of the trauma, but sometimes the disorder appears later. Symptoms for PTSD fall into three categories:
- Intrusion
- Avoidance
- Hyperarousal
To be diagnosed with PTSD all criteria need to be met, and viewed as a whole.
Intrusion
The most prominent feature of PTSD that differentiates it from other anxiety and affective disorders is the persistent re-experiencing of the trauma or intrusion of reminders of the trauma. Memories reoccur unexpectedly and without control. It can come as disturbing thoughts, or in the form of images, nightmares or flashbacks. A flashback involves sudden, highly disturbing vivid memories, accompanied by painful emotions. The sensations experienced through a flashback are so intense that it feels like the traumatic experience is actually happening. In Ben’s case, he experienced constant nightmares, and daily thoughts of the attack.
Avoidance
Ben made every attempt to avoid the thoughts, feelings and conversations associated with the trauma. In fact he saw less of his family and friends as a result, and became quite isolated. He experienced feelings of detachment, numbness and took up drinking to try and drown out the constant images and nightmares. Ben also avoided going outside, as that was a reminder of the attack.
In general, a person suffering from PTSD often avoids close emotional ties with family, colleagues, and friends. At first, the person may feel numb, have diminished emotions like being unable to have loving feelings, and may only complete routine, mechanical activities. Later, when re-living the traumatic event, the individual may alternate between a flood of emotions caused by the flashback and an inability to feel or express emotions at all.
The inability of a person with PTSD to work out grief, anger or fear from the traumatic event means the trauma can continue to affect the person’s behavior without them being aware of it. Depression, substance abuse, and other anxiety disorders such as agoraphobia, or social phobia are common products of this inability to resolve painful feelings. Trauma-related guilt, anger, and sadness are also a very common among survivors.
Hyperarousal
Ben felt constantly threatened and “on guard” after the attack. He was sensitive to all noises, especially at night, and was suddenly irritable and explosive, even when unprovoked. He had trouble concentrating, and because of the terrifying nightmares he developed sleeping problems. All of these reactions can cause emotional exhaustion, and in turn be expressed through symptoms of depression.
DSM-IV Criteria for Posttraumatic Stress Disorder
A. The person has been exposed to a traumatic event in which both of the following have been present:
(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.
(2) the person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behaviour.
B. THE TRAUMATIC EVENT IS PERSISTENTLY RE-EXPERIENCED IN ONE (OR MORE) OF THE FOLLOWING WAYS:
(1) Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.
(2) Recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.
(3) Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur upon awakening or when intoxicated). Note: In young children, trauma-specific re-enactment may occur.
(4) Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
(5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
C . PERSISTENT AVOIDANCE OF STIMULI ASSOCIATED WITH THE TRAUMA AND NUMBING OF GENERAL RESPONSIVENESS (NOT PRESENT BEFORE THE TRAUMA), AS INDICATED BY THREE (OR MORE) OF THE FOLLOWING:
(1) Efforts to avoid thoughts, feelings, or conversations associated with the trauma
(2) Efforts to avoid activities, places, or people that arouse recollections of the trauma
(3) Inability to recall an important aspect of the trauma
(4) Markedly diminished interest or participation in significant activities
(5) Feeling of detachment or estrangement from others
(6) Restricted range of affect (e.g., unable to have loving feelings)
(7) Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)
D. PERSISTENT SYMPTOMS OF INCREASED AROUSAL (NOT PRESENT BEFORE THE TRAUMA), AS INDICATED BY TWO (OR MORE) OF THE FOLLOWING:
Difficulty falling or staying asleep
Irritability or outbursts of anger
Difficulty concentrating
Hypervigilance
Exaggerated startle response
E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than one month.
F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specify if :
Acute: if duration of symptoms is less than 3 months.
Chronic: if duration of symptoms is 3 months or more.
Specify if :
With Delayed Onset: if onset of symptoms is at least 6 months after the stressor.
RISK FACTORS
Why can an event cause an emotionally traumatic response in one person and not another? There is no clear answer to this question. Factors that may trigger symptoms of PTSD include the type and magnitude of the stressor, and previous history other forms of social marginalisation or previous trauma. However, it is important to note that PTSD can develop in individuals without such predisposing factors and in the presence of solid social support, especially where the traumatic event is severe.
TREATMENT
Many people treated for PTSD can make a full recovery. Treatment can assist people exposed to a traumatic event, their family members, and friends.
Common Components of PTSD Treatment
Ben accessed counselling three months after the attack for assistance as he felt no sign of improvement. There are many treatments available to deal with PTSD. Ben and his counsellor would have accessed some of the following:
- Psycho-education to help him understand what is psychological trauma, how PTSD develops, physiological reactions to trauma, and that PTSD can occur in normal individuals. This information would be provided for reassurance and so that Ben could gain a greater understanding of what is actually happening to him.
- Arousal reduction to teach Ben to manage the distress associated with post-trauma memories, reminders, reactions, and feelings without becoming overwhelmed or emotionally numb. These strategies may include relaxation techniques, and controlled breathing.
- Exposure/ Desensitisation to the memories to enable Ben to confront what has happened. Exposure therapy involves overcoming anxieties of the feared memory by facing them in a controlled and safe environment. To relieve fears, Ben would recall the trauma all at once (flooding) or step-by-step (desensitization) in order to overcome it. Finally, the goal would be for Ben to be capable of remembering what happened without being overwhelmed by distress. This form of treatment would not have been appropriate for Ben if he was diagnosed with a serious mental illness or was self-harming or suicidal.
- Coping skills would be developed so that Ben could find relief from his stress through daily activities he used to do, such as exercise, chores, and outings. This could provide him with a sense of control and distraction. He may also need assistance coping with strong feelings such as anger, shame, or guilt, which are common among survivors of trauma.
- Drug treatment is another option that Ben may take. There are a several medications that have the potential to alleviate symptoms of PTSD, and help manage the chemical imbalance experienced. It is important that medication be taken in conjunction with ongoing counselling.
Ben’s traumatic experience and reactions are not uncommon. Evidence shows us that 8% of those who have gone through traumatic event will end up with PTSD. However, disturbing memories, physiological reactions and avoidance behaviours don’t need to be a life sentence. With therapy, it is possible to remember what happened without being overwhelmed or distressed, as was the case with Ben.
Shawn Goldberg (BAppSci Psych; PGDip Psychology), is an Addiction & Trauma Counsellor /Consultant at Langham Mews Psychological Services, Prahran (www.LanghamMews.com.au). He has worked extensively in community health and private practice across Melbourne for 6 years, specialising in addictions and trauma. He provides counselling, group therapy, education and community awareness for clients, families, and professionals. Contact number: 0413 189 079.
