Understanding PTSD: The Basics
-Master Sergeant, C. Stillwell, USA, Retired
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Introduction
Post-Traumatic Stress Disorder (PTSD) is a debilitating mental disorder that affects roughly 7-8% of the population, according to the U.S. Department of Veteran Affairs. PTSD is a trauma or stressor-related disorder. People suffering from PTSD experience a certain set of symptoms brought on by a traumatic event or series of traumatic events. Though PTSD is most commonly associated with people who have served in the military, anyone who goes through a traumatic experience is at risk for developing it. The American Psychiatric Association defines PTSD this way:
Post-traumatic stress disorder (PTSD) is a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event such as a natural disaster, a serious accident, a terrorist act, war/combat, rape, or who have been threatened with death, sexual violence or serious injury.
Populations commonly exposed to traumatic events have a higher average of PTSD than the average citizen. For instance, those who served in Operation Iraqi Freedom (OIF) and Enduring Freedom (OEF) returned with a 10-20% rate of PTSD. Of those who served in the Vietnam War, around 15% were diagnosed with PTSD. In this Blog post we will expand on this topic, taking a closer look at the history of PTSD, main causes and symptoms of PTSD, and the treatments available for those suffering from PTSD.
The History of PTSD
Although PTSD has been around since the beginning of humanity, it wasn’t added to the Diagnostic and Statistical Manual of Mental Disorders until 1980. The term PTSD became much more familiar to the common American after the Vietnam War, and continued to become more common after recent conflicts. In other times in American history, PTSD was referred to as other things. Physicians noted changes in people, usually soldiers, that couldn’t be wholly explained by wounds or injuries.
Here are the names used to describe PTSD before 1980:
Nostalgia was coined by Swiss physician Dr. Johannes Hofer in the late 1600s to describe soldiers experiencing deep despair and homesickness. He noted other common PTSD symptoms like sleeplessness and anxiety.
Soldier's heart or irritable heart was a term used by Dr. Jacob Mendez Da Costa to describe physical issues soldiers in the Civil War experienced that were not related to combat wounds. These issues included constricted breathing, heart palpitations, and other heart issues.
Railway spine or railway brain were PTSD terms that weren’t related to soldiers. During the 1800s railroad travel became very common. It also saw a stark rise in railroad related accidents. People who survived these accidents sometimes suffered from anxiety and sleeplessness that they referred to as railway brain.
Shell shock was a term used after World War I. World War I was a particularly brutal war, with many soldiers coming home experiencing things like anxiety, nightmares, impaired sight and vision, tremors, and fatigue. Many of the soldiers who came home with these symptoms were directly exposed to exploding shells on the battle field, giving the name “shell shock” it’s origin.
Battle fatigue, combat fatigue, and combat stress reaction were the terms used to describe PTSD symptoms in relation to World War II. It was believed that the symptoms exhibited were due to long deployments.
Gross stress reaction was the term used in the DSM-I in 1952 to diagnose psychological issues connected to traumatic events. At this time, it was believed that symptoms would only last a short period of time. If symptoms persisted longer than 6 months, it was no longer thought to be related to a speci traumatic event.
Adjustment reaction to adult life. In 1968, PTSD-related terms were removed and replaced with the words “adjustment reaction to adult life.” Many experts believe this change failed to truly encompass the disorder and related complications and was a step in the wrong direction.
Post-traumatic stress disorder was officially added to the DSM-III in 1980. Writers of the DSM-III used symptoms from people who had survived traumatic events such as war veterans, Holocaust survivors, and sexual victims to help develop the diagnosis description.
PTSD Defined in the 1980s
The 1980s term PTSD was a major shift in the way that people began looking at the reaction to trauma. During World War I, many perceived soldiers with PTSD symptoms as being weak or feeble. It was thought that the things they were feeling were due to a poor constitution. The change during the 1980s put PTSD in an entirely new light. According to the U.S. Department of Veterans Affairs:
From an historical perspective, the significant change ushered in by the PTSD concept was the stipulation that the etiological agent was outside the individual (i.e., a traumatic event) rather than an inherent individual weakness (i.e., a traumatic neurosis). The key to understanding the scientific basis and clinical expression of PTSD is the concept of "trauma." In other words, anyone can be susceptible to a physical and mental reaction to a highly traumatic life event. An outside factor like war or sexual abuse can have a serious effect on a person.
PTSD in the DSM-5 (in 2013)
In 2013, the Diagnostic and Statistical Manual was updated. At this time, PTSD was changed from being categorized as an anxiety disorder to being classified as a “trauma or stressor-related disorder.” One of the reasons for this change is that PTSD is not only exhibited as anxiety. Psychiatrist Dr. Tracey Marks explains:
With the Diagnostic and statistical manual that came out in 2013, it was moved to the category of trauma and stress-related disorders. The significance of this is that PTSD is more than anxiety. People have very complex emotions afterward that include guilt, shame, and anger and those are just examples...but lots of things more than just anxiety.
What Causes PTSD?
PTSD is not limited to one demographic or a single type of trauma. It’s not limited to an age group, gender, or socioeconomic background. While PTSD is most often associated with veterans, it is also common with:
💥Accidents such as a car crash
💥Violent attacks
💥Sexual assault or threatened sexual abuse
💥 Being bullied or harassed
💥 Kidnapping
💥 Witnessing someone else being harmed or killed
💥 Traumatic birth (either from the mother or the partner witnessing a traumatic birth)
💥 Terrorist attack
💥 Natural disaster
💥 Living in a war zone
💥 A history of trauma or abuse
While other people may develop mental disorders from trauma in their life, PTSD is reserved for a distinct type of trauma. For example, people who are going through a difficult life experience such as sickness, divorce, or loss of a job may experience anxiety, depression, or other mental health issues. However, PTSD is defined for a certain group of people experiencing a specific set of symptoms. The type of trauma used to diagnose PTSD as defined by the DSM-5 is:
A person exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as follows: Directly experiencing the traumatic event Witnessing a traumatic event in person. Indirect exposure to a traumatic event such as an event that happened to a close friend or loved one. The event must be violent in nature.
Experiencing repeated or indirect exposure to aversive details of a traumatic event. This usually happens in the course of normal job duty, such as a police officer repeatedly working on child abuse cases, or first responders cleaning up the aftermath of a car crash.
Note: This does not include non- professional exposure such as people watching the news or watching movies depicting traumatic events). Some people may feel invalidated when they do not receive a PTSD diagnosis, thinking that they’re being told that their trauma isn’t serious enough to warrant the diagnosis. While these feelings are understandable, it doesn’t mean that they are not feeling or experiencing symptoms brought on by mental health issues or by trauma. People with anxiety often have heart palpitations and avoidance is a common symptom of depression. The difference between PTSD and other trauma-based or mental health diagnoses is not meant to downplay or delegitimize their experience, but rather to illuminate a specific mental health disorder with a very specific set of symptoms.
Risk Factors for PTSD
While PTSD can be experienced by any demographic, there are some factors that do increase the probability of it developing. These risk factors include:
💥 History of anxiety or depression Lack of support
💥 Early childhood trauma
💥 History of abuse
💥 History of drug or alcohol abuse
💥 Women are more likely to suffer from PTSD than men
💥 Family history of mental illness
💥 Past traumatic experiences
💥 Poor coping skills
💥 Ongoing stress
💥 Working in jobs that include potentially traumatic events such as first responders, hospital workers, or those who are in the military
Symptoms of PTSD
As mentioned, PTSD has a fairly clear set of symptoms that make it unique from other mental disorders. PTSD may not look the same in every person, and not all people will experience the same severity of symptoms. However, all people with PTSD will exhibit four main symptoms. The main symptoms are:
👉Re-Experiencing, or Intrusion Avoidance
👉 Hyperarousal or “on edge” or Hypervigilance
👉 Negative Cognitions
👉 Mood Symptoms (Feeling worse about yourself or the world)
Most people will experience one or two of these symptoms as a result of a traumatic event, but people with PTSD will suffer from all of them to some degree. Symptoms usually appear within 6 months of the trauma, though at times they might begin manifesting at a later time. According to the DSM-5, in order to be diagnosed with PTSD, symptoms must last longer than 1 month. Symptoms must be severe enough that they interfere with daily life, and they must not be related to other factors such as medication, substance abuse, or illness. That isn’t to say that people experiencing PTSD may not also struggle with things like substance abuse, but that it isn’t the initial source of it.
Re-Experiencing, or Intrusion
Re-experiencing, or intrusion, is one of the tale-tell signs of PTSD. When a person re-experiences something, means they’re involuntarily reliving the traumatic event that triggered their PTSD. This intrusion of thought may manifest in a variety of ways including:
💣Nightmares
💣 Flashbacks
💣 Recurring memories
💣 Distressing thoughts
💣 Becoming stressed in physical ways like sweating or heart palpitations
Re-experiencing can be triggered by anything that reminds someone of the event such as words, locations, objects, people, smells, or similar situations.
What are Flashbacks?
Of the intrusion symptoms, flashbacks are often the most troubling. A person who has a flashback feels like they’re actually re-experiencing the traumatic event in real time. Dr. Matthew Tull, a professor of psychology writes:
Researchers have found that most often, a flashback centers on the “Warning! Watch out!” moment when, at the time the trauma occurred, the person first felt the threat of danger. This helps to explain why people having flashbacks may take sudden and strong defensive actions, sometimes causing harm to themselves or others—they’re feeling seriously threatened right now.
Avoidance
A person who experiences a traumatic event may find themselves wanting to avoid things that remind them of the event. They may also become afraid of doing something or going somewhere similar to the original traumatic event. For instance, someone who has been in a serious car accident may want to avoid driving or may be afraid to drive in certain circumstances such as heavy traffic or snowy roads. Someone who has been sexually abused may want to avoid intimacy in the future.
Other symptoms of avoidance include:
💣 Avoidance of talking about or having conversations that remind a person of the traumatic event
💣 Attempt to avoid close relationships with people that may lead to detachment or estrangement
💣 Lack of interest in social events or activities
💣 Self-medicating with drugs, alcohol, or risky behavior
Hyperarousal
Hyperarousal is a symptom that makes someone with PTSD overreact to their outside stimulus. The body goes into high alert thinking about a traumatic event and may make the person feel like they are currently in danger. This feeling can result in a myriad of responses that are confusing to friends and loved ones. Because loved ones aren’t sharing the same feelings of danger, it can be scary or even frustrating to be with someone responding to unseen trauma. Some of the symptoms of hyperarousal are:
💣 Trouble sleeping
💣 Outbursts of anger
💣 Irritability or ongoing anger
💣 Panic
💣 Easily startled
💣 Difficulty concentrating
💣 Always being on guard from threats (hypervigilance)
💣 Chronic anxiety
💣 Inability to tolerate loud noises (hyperacusis)
💣 Panic attacks
💣 Risky destructive behavior
💣 Negative Alterations to Cognitions and Mood
Another key symptom of PTSD is a negative outlook on self and the world around. These feelings are newly formed after the traumatic event and are not typical for the person experiencing PTSD. These negative feelings may appear like this:
😟Intense feelings of guilt
😟 Distorted sense of blame related to the trauma
😟 Ongoing negative feelings such as guilt, shame, anger, or sadness
😟 Hopelessness
😟 Lowered interest in activities one used to enjoy
😟 Detached or estranged from loved ones
😟 Inability to experience joy or happiness
People suffering from PTSD may have feelings of worthlessness or may feel deep shame for things they have done or witnessed. These feelings may interfere with forming or maintaining relationships with friends and family. It could also diminish their ability to pursue gainful employment or advance their career. According to Dr. Matthew Tull:
...Maladaptive thoughts, errors in thinking or irrational thoughts, cognitive distortions refer to unpleasant thoughts that are extreme, exaggerated or not consistent with what is actually going on in the real world. As a result, cognitive distortions can have a negative influence on our mood and eventually lead to unhealthy behaviors. The connection between thoughts and actions is part of the reason cognitive distortions are considered a central part of cognitive-behavioral therapy.
Different Types of PTSD
Although major symptoms are similar across the board, there are different types of PTSD. Depending on what type of PTSD someone has, their symptoms may be more severe or long-lasting or they may require different types of therapeutic treatments.
Complex PTSD: PTSD may have become more familiar to the common person, but there is a lesser-known variation of PTSD called complex PTSD (c- PTSD).
The traditional form of PTSD may emerge after a single traumatic event. An example may be a life-threatening car crash. A person who lived through a car crash may find themselves afraid of driving, may avoid getting in the car or driving in traffic, and may have other symptoms associated with PTSD. C-PTSD, on the other hand, is the result of repeated or ongoing traumatic events. Those who develop C-PTSD may have suffered ongoing childhood abuse, neglect, or repeatedly witnessed violence acted out on someone else. C-PTSD is more often associated with people who experience trauma in their childhood. It affects the way that a person develops, since they’re exposed to trauma during a highly developmental time in their life. This term is not in the DSM-5, but it is a term that mental health workers use to help describe the difference between someone who has experienced a single traumatic event, and one that has experienced chronic trauma, especially in childhood.
Symptoms of C-PTSD are similar to PTSD, but they also include additional behavioral differences. Dr. Tracey Marks explains c-PTSD in this way:
...the [early childhood] trauma shapes your development and your personality. It's like you have a fractured self and people suffering from this can spend years trying to mend a fracture. So unlike a person with PTSD who may be checking locks, and having flashbacks, and refusing to drive or jumping every time I hear a loud noise, [those] with c-PTSD [have] more behavioral things like relationship dif ficulties, poor self-esteem, anger problems, [and] mood instability.
She went on to say:
The person with c-PTSD can develop depression or anxiety secondary to these problems but at the core is the issue of this fractured self that came from a serious emotional disruption during the formative years.
Additional symptoms associated with c- PTSD are: Negative self-view. Those with c-PTSD may think very poorly of themselves or may carry ongoing feelings of guilt, shame, and helplessness. Trouble controlling or regulating emotions. They may have what’s considered an explosive temper, given easily to sadness, or even have feelings of depression or suicidal thoughts. Difficulty developing or maintaining relationships. Those with complex PTSD often have trouble trusting others and will avoid starting relationships with others. Feelings of distrust. In general, people with c-PTSD may have significant trust issues towards the world and other people. Dissociative symptoms are disconnected thoughts, memories, actions, and identity. It’s a brain’s defense mechanism that tries to escape reality. Some people with dissociative disorders develop alternative identities, but they may also suffer from amnesia. People with dissociative symptoms may struggle with concentration or may disconnect from the world around them. Therapy can help people diagnosed with c- PTSD, but it’s usually a longer process and takes more effort from a therapist and patient to undo the damage done in childhood.
Post-Traumatic Stress
PTS or Post Traumatic Stress is actually not a type of PTSD, but it could be a precursor for it. When people experience a traumatic event, it’s normal to be affected by it. Those with PTS experience many of the same symptoms as PTSD such as avoidance or nightmares. The difference is that those who suffer from PTS experience those symptoms with less severity and for a shorter period of time. People with PTSD will continue showing those symptoms for longer periods of time and with greater intensity. According to Dr. James Bender of the Deployment Health Clinical Center:
PTS is a common, normal, and often adaptive response to experiencing a traumatic or stressful event. Common occurrences, like car accidents, can trigger PTS as well as more unusual events like military combat or kidnapping. Almost everyone who experiences a scary situation will show at least a few signs of post-traumatic stress. Dr. Bender went on to say that the symptoms from PTS will subside after a few days and they won’t interfere with a person’s life in any meaningful way. The traumatic event may make them more careful in the future, but it won’t stop them from living their life normally.
Comorbid PTSD
Those with comorbid PTSD are people who have both PTSD and another mental disorder. In this case, someone may have PTSD and depression, or PTSD and generalized anxiety disorder. Anxiety, depression, and substance abuse are the most common types of comorbidity with PTSD. It’s estimated that as much as 80% of people with PTSD have another co-occurring psychiatric disability.
PTSD And Risky Behavior
People with PTSD are more likely to engage in risky or destructive behavior. If PTSD is triggered by trauma, doing something that might lead to additional trauma is difficult to understand. It’s a common belief that people with PTSD turn to these behaviors as a way to escape the symptoms of PTSD, especially intrusion. Those who use drugs or alcohol may be using them as a coping mechanism to help them avoid thinking about their original trauma. It may also be a way to assuage guilt or shame associated with the trauma.
Types of risky behavior may include:
😟 Gambling
😟 Drinking
😟 Drunk driving
😟 Aggression
😟 Drugs
😟 Unsafe sex with strangers
😟 Extreme sports without regard for self- protection
This self-destructive behavior may diminish symptoms of PTSD momentarily, but ultimately the stress of these choices prolongs PTSD symptoms and make the disorder worse. Dr. Naomi Sadeh, an Assistant Professor the National Center Boston VA/Boston University, is quoted saying:
For individuals with PTSD, exposure to new stressful events will often prolong their symptoms and can even make them worse. So these findings suggest that treatment providers should ask trauma-exposed veterans about reckless behavior to make sure they are not engaging in harmful behaviors that could make their PTSD symptoms worse.
When it comes to treating PTSD, a therapist will try to address any risky behaviors the patient may be engaging in to help reduce the risk of continued trauma.
PTSD and Relationships
It’s no secret that PTSD can strain relationships, particularly with a spouse or partner. There have been many cases of strong marriages unable to withstand the effects of severe PTSD. Though both members may want to maintain the relationship, there are times when people are unable to resolve the inherent issues with PTSD. In 2019, Meagan Drillinger wrote a piece for Healthline called “6 Things I Learned From Dating Someone With PTSD.” In the article she explained, “For three years, I was in a relationship with a man who experienced PTSD symptoms daily. My ex, D., was a decorated combat veteran who served in Afghanistan three times. The toll it took on his soul was heartbreaking.”
She went on to say:
Being the partner of someone who has PTSD can be challenging — and frustrating — for many reasons. You want to take away their pain, but you’re also dealing with your own guilt at needing to care for yourself, too. You want to have all the answers, but you often have to come to grips with the reality that this is a condition that can’t be loved out of someone.
In this section, we will look at some of the things you can do to support loved ones with PTSD. That being said, it’s extremely important to know that supporting someone with PTSD does not mean you’re responsible for making them better . If you have a relationship with someone who has PTSD, you can’t heal them with support. You can make their road easier, but your loved one should seek professional help to give them the tools needed to help with their disorder.
With that said, there are some things that you can do that might help ease their burden and lessen the strain in your relationship:
1. Understand that PTSD is real. Perhaps one of the first steps in helping someone with PTSD is acknowledging that it’s a real disorder that produces real symptoms. Though mental disorders are difficult to understand or relate to for those who are not experiencing them, to people with the disorder, it is very real and very debilitating.
2. Give them room not to talk. Talking about a traumatic event might help someone who has PTSD, but that doesn’t mean they’re always willing or able to discuss the details of their trauma. Their resistance to talking about the traumatic event is not a sign of being unloving or untrusting, it’s more likely because they want to avoid thinking about the event. Bringing it up often is more likely to cause them to pull away and become uncommunicative. Gently encourage them to talk about it when it seems appropriate but allow them to be the one to discuss it when they’re ready.
3. Work with a routine. A routine is a good way to help establish order in your home for a person suffering from PTSD. Doing this can give a person with PTSD a sense of security and stability and provide comfort in a world that feels chaotic and out of control. The schedule you use will be different than someone else’s, but it may include exercise, meditation or prayer, planned mealtimes, and daily chores.
4. Learn more about PTSD. Educating yourself on PTSD will be one of your biggest strengths for helping a loved one and yourself cope with the reality. You can do this by reading, watching videos, talking with other people who have PTSD, or discussing it with a therapist.
5. Understand that caregiver burden is real. People taking care of someone struggling mentally or physically can be extremely stressful and draining.
In a study published in part by the National Institute of Health, the authors explain,
Unlike professional caregivers such as physicians and nurses, informal caregivers, typically family members or friends, provide care to individuals with a variety of conditions including advanced age, dementia, and cancer. This experience is commonly perceived as a chronic stressor, and caregivers often experience negative psychological, behavioral, and physiological effects on their daily lives and health.
Though the study was specifically talking about people taking care of loved ones with cancer or advanced age, the sentiment is the same for general, non-professional caregivers. Long-term care of a person can lead to secondary issues and can be a burden for them as well. To help lighten this load, if you’re a caregiver, it’s a good idea to take time for yourself. Every moment of every day can’t be consumed with PTSD. Take time to do things that you love and enjoy. Another good solution is to find a support group for those who are also caring for loved ones with PTSD. Finding a community of people dealing with the same thing can help you manage your own feelings and concern. In addition, seek loved ones in your life and allow them to be part of your greater support network.
Seek Professional Treatment
Seeking outside help is essential for helping you and your loved one cope with PTSD. Although some may feel there’s a stigma with working with professional help, this viewpoint is becoming less common as people open up about mental health issues across the board. There is no shame in seeking professional help. If you’re living with or helping care for someone with PTSD, it is often beneficial to seek therapy as well.
Treatment for PTSD
There isn’t a one-size- fits-all solution to PTSD, and it isn’t something that will be resolved in a short amount of time. Not only that, but if there are comorbidities involved, it will take longer for the therapist to determine what diagnosis and treatment are appropriate.
Note: If substance abuse is present, look for a therapist trained to help with both PTSD and substance abuse.
What type of treatment you or your loved one will get is up to your therapist, but below are some common forms of treatment for people with PTSD.
Cognitive Processing Therapy
Cognitive Processing Therapy (CPT) is a speci fic type of therapy used to help people change the way they view trauma. It has been effective in helping reduce symptoms of PTSD, and many mental health specialists recommend this course of action for people diagnosed with the disorder. It’s thought to be one of the most effective treatments available. CPT is usually performed over 12 sessions (often 12 weeks) in 60-90-minute sessions. Sessions can be either individual or in a group setting. Trauma changes the way a person feels about themselves and the world, often causing them to develop an overly negative and hopeless view of things. This type of therapy can help them begin to reprocess the way they think about things.
Prolonged Exposure Therapy
Since avoidance is a symptom of PTSD, therapists will sometimes use a treatment called Prolonged Exposure therapy (PE). This treatment helps people confront the things they’re avoiding in increments. PE is usually broken down into 15 individual sessions lasting around 60-120 minutes. Sessions usually begin with the therapist asking questions about the original trauma to help develop an understanding of the issue. This type of therapy will induce more anxiety and stress than CPT typically does, so therapists will try to equip their patients with anxiety-reducing coping skills. For example, a patient might be taught breathing exercises to help manage the stress. There are several ways that therapists expose a patient with the thing they’re avoiding. These techniques are:
Imaginal exposure: In this type of exposure, the patient describes the traumatic event in present tense.
In vivo exposure: This type of exposure is performed outside of the therapy session. The therapist and patient work together to come up with a list of things the patient has been avoiding. Then they agree on which ones to confront between therapy sessions in a gradual fashion.
Eye Movement Desensitization and Reprocessing: EDMR is a different kind of treatment than talking through traumatic events. Instead, the patient is asked to think about the traumatic event while the therapist directs their eye movement. It’s thought that the eye movement while remembering a traumatic event can help drain the emotion and negative feelings attached to it. This type of therapy is still relatively new and is considered a non-traditional form of therapy. Though non-traditional, It is still considered to be an effective form of therapy.
Medication For PTSD
For some, medication may be helpful in addition to therapy. According to the National Center for PTSD, antidepressants are sometimes effective for treating symptoms of PTSD. These types of medications include SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin-norepinephrine reuptake inhibitors). Your doctor or therapist can help you determine if medication might be right for you.
PTSD and the Road to Healing
Treatment for PTSD may not be a cure, as with most mental health disorders total recovery can be difficult or unobtainable. However, many people who receive therapy see a significant and life changing improvement of symptoms. For some, therapy may even lead to a near absolution of symptoms. If you’re suffering from PTSD or you know someone who is, know that there are people who can help:
The Substance Abuse and Mental Health Services Administration is available 24/7 by calling 1-800-662-HELP (4357).
For veterans, the National Center for PTSD is also available by calling 1-800-273-8255 or you can reach online here: https://www.veteranscrisisline.net
Hotlines are a good short-term solution that should be followed up with therapy work from a trained professional. Build up a support network of people ready and willing to help when symptoms of PTSD become overwhelming. Be patient with yourself (or your loved one) because PTSD is a real disorder that requires time and care to improve. Remember that setbacks don’t erase all progress. For best results, learn all you can about PTSD, seek professional help, and keep your focus on healing.
Good Luck and God Bless You
