What is PTSD?
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’, ‘battle fatigue’ and ‘anxiety reaction’. It is not only diagnosed in soldiers – a wide range of traumatic experiences can cause PTSD.
Traumatic experiences can include:
• a natural disaster such as an earthquake or flood
• car or plane crashes and other serious accidents
• neglect and abuse (either physical or sexual) in childhood
• severe physical injury
• rape or sexual assault
• domestic violence
• mugging or robbery
• war or other attack
• witnessing murder or violent death
• a traumatic birth experience
• a life-threatening medical diagnosis
• and other extreme or life-threatening events.
An initial reaction to such an event might be shock and disbelief. Over time this can fade. More troubling thoughts and feelings can emerge. These might include anger, helplessness or fear. It can be difficult to process your memories of the event, or to understand what happened and why. You might re-experience the incident through intrusive flashbacks, nightmares or upsetting thoughts about it. These reminders can trigger intense distress, in the form of panic attacks. Following such an experience, it is also common to have heightened awareness, to feel on edge and to avoid situations and places that remind you of the incident.
Complex PTSD is a more serious reaction to a long-lasting traumatic experience, for example abuse, neglect or frequent violence.
How common is PTSD?
It is difficult to know how common PTSD is, as many people describe it in different ways, and many will never receive a formal diagnosis. However, it is estimated around 4 to 5 percent of the UK population will fit the criteria for a PTSD diagnosis in any week.
War veterans and emergency services workers generally have higher rates of PTSD.
Not everyone who goes through a traumatic event gets PTSD. The chances of developing it and how severe it is vary based on things like personality, history of mental health issues, social support, family history, childhood experiences, current stress levels, and the nature of the traumatic event.
Children and teens who go through the most severe trauma tend to have the highest levels of PTSD symptoms. The more frequent the trauma, the higher the rate of PTSD.
Studies show that people with PTSD often have atypical levels of key hormones involved in the stress response. For instance, research has shown that they have lower-than-normal cortisol levels and higher-than-normal epinephrine and norepinephrine levels — all of which play a big role in the body’s “fight-or-flight” reaction to sudden stress. (It’s known as “fight or flight” because that’s exactly what the body is preparing itself to do — to either fight off the danger or run from it.)
About one or two in every 100 women have post-traumatic stress after giving birth.
Symptoms of PTSD
Causes of PTSD
A wide range of traumatic experiences can cause PTSD.
Traumatic experiences can include:
- a natural disaster such as an earthquake or flood
- car or plane crashes and other serious accidents
- neglect and abuse (either physical or sexual) in childhood
- severe physical injury
- rape or sexual assault
- domestic violence
- mugging or robbery
- war or other attack
- witnessing murder or violent death
- a traumatic birth experience
- a life-threatening medical diagnosis
- and other extreme or life-threatening events.
It is thought that PTSD is caused by the brain laying down memories in the wrong place. During the traumatic event it’s as if the brain gets overwhelmed. The memories get filed in the ‘immediate action’ part of the brain, instead of in ‘storage’, and so mind thinks that something needs to be done to get you out of the traumatic situation and to make you safe, even though the traumatic event may no longer be happening.
Different types of PTSD
If you are given a diagnosis of PTSD, you might be told that you have mild, moderate or severe PTSD. This explains what sort of impact your symptoms are having on you currently – it’s not a description of how frightening or upsetting your experiences might have been.
PTSD may be described differently in some situations:
- Delayed-onset PTSD– if your symptoms emerge more than six months after experiencing trauma, this might be described as ‘delayed PTSD’ or ‘delayed-onset PTSD’. In some people, symptoms may take years to develop. There is no difference in the symptoms of PTSD and delayed-onset PTSD.
- Complex PTSD– if you experienced trauma at an early age or it lasted for a long time, you might be given a diagnosis of ‘complex PTSD’.
- Birth trauma– PTSD that develops after a traumatic experience of childbirth is also known as ‘birth trauma’.
- Secondary trauma – If you experience some PTSD symptoms while supporting someone close to you who’s experienced trauma, this is sometimes known as ‘secondary trauma’.
Diagnosing birth trauma
Research suggests that about 4% of women who give birth go on to develop postnatal PTSD, or birth trauma. That works out at about 30,000 new cases every year in the UK.
An estimated 30% experience some symptoms of PTSD, but not the full-blown condition.
Witnesses to a trauma can also experience PTSD. This means that some partners suffer PTSD after witnessing a traumatic birth. The exact numbers are not known, but they are likely to be smaller. One research study showed that a third of midwives who had experienced traumatic perinatal events have PTSD symptoms.
When a new mother tells her health visitor or GP that she’s been feeling anxious or jumpy or replaying the birth in her head, it’s easy to reach for a diagnosis of postnatal depression (PND). Because many people still aren’t aware of postnatal PTSD, some women will accept the PND diagnosis, even while feeling it’s not quite right. But treatment pathways for depression and PTSD are very different, so it is important to ask about women’s symptoms in detail.
The four symptoms of PTSD are:
- re-experiencing the trauma (e.g. flashbacks and nightmares);
- avoidance (the woman avoids any reminder of the trauma);
- negative cognitions and mood (such as feelings of guilt);
- arousal (such as hypervigilance). In effect, the brain is still in flight-or-fight mode, constantly alert to the threat of danger.
What is the impact of birth trauma?
PTSD is a distressing experience for anyone. For women experiencing the condition after giving birth, there are additional factors that make it particularly difficult:
Women with birth trauma often find it hard to bond with their baby. After a traumatic birth, it’s not unusual for the mother and baby to be separated, either because the mother is ill, or the baby is. Sometimes women give birth by caesarean section under general anaesthetic and are not present for their baby’s birth. Women who have experienced this early separation often mourn the loss of those important early moments with their baby. Sometimes they feel guilty, and that they have let the baby down. Many feel a sense of distance from their baby, and mention that they are “going through the motions” of motherhood without feeling the overwhelming love that most mothers report. Others go to the other extreme and become overly-anxious about their baby, watching over it constantly and refusing to let other people even hold the baby.
Reminders of the birth, such as a visit to the hospital, or even the sight of another woman with a new-born baby, can trigger flashbacks. For this reason, many women with birth trauma avoid contact with the hospital, or with medical professionals, or with new mothers. This is worrying because it means women may miss important medical appointments or stay away from mother-and-baby groups, leading to them becoming isolated.
PTSD can make people extremely anxious and irritable, leading to relationship difficulties. When a woman has birth trauma, it can feel to those around her as if she is a completely different woman. Frequently, partners don’t understand why the woman feels this way and think she should be able to just snap out of it, leading to further deterioration in the relationship. Friends and family also tend to advise women that they should “move on”, or change the subject by making comments such as, “But you have a lovely baby” leading to women feeling even more isolated.
Many women who have had a traumatic birth suffer from painful and distressing physical symptoms, sometimes as a result of tearing or other obstetric damage. This can make an already difficult situation even worse.
A traumatic birth can make women reluctant to try for another baby, so many women with birth trauma stop at one child. A subsequent pregnancy can also reawaken the trauma of the first birth.
Treating birth trauma
It’s not just lay people who find postnatal PTSD hard to understand: some health professionals do too. Women often mention that their health visitor or GP has told them they should be grateful that they have a healthy baby and put the difficult birth behind them.
PTSD doesn’t work like that, however. It doesn’t matter whether PTSD was caused by a violent attack, time spent in a war zone, or by a traumatic birth: PTSD is not something that can be treated by positive thinking. It’s entirely involuntary. Telling women to focus on the positive only makes them feel more isolated.
Fortunately, help is available. Treatments such as Rapid Resolution Therapy, trauma-focused CBT and eye movement desensitisation and reprocessing (EMDR) have very good results with PTSD patients.
Preventing birth trauma
Postnatal PTSD is the result of a traumatic birth. A birth can be traumatic for a number of reasons: perhaps the woman was left in extreme pain for a number of hours; there may have been a sudden emergency, in which the baby’s life was at risk, leading to a caesarean section; there may have been a postpartum haemorrhage, in which the woman lost several litres of blood. But a traumatic birth doesn’t have to lead to PTSD. Some women who have apparently very difficult birth experiences recover mentally without developing PTSD symptoms. Why?
The vast majority of women suffering postnatal PTSD say that the way they were treated in hospital has been a major factor in developing the condition. Often communication was poor, so when they tried to voice a concern, they were ignored. Sometimes, they’ve been kept in the dark as to what is happening, leading to them feeling frightened that they or their baby are about to die. Procedures such as internal examination have been performed on them without their consent. They have been laughed at or told to stop making a fuss.
Many cases of postnatal PTSD could be prevented simply by treating women with courtesy, kindness and respect during labour: by making sure to seek consent, by listening to women’s concerns that something is wrong and to requests for pain relief, by informing women about what is happening and by showing sympathy when they are distressed.
Children and PTSD
How Can I Help My Child?
Above all, your child needs your support and understanding. Sometimes other family members like parents and siblings will need support too. While family and friends can play a key role in helping someone recover, help usually is needed from a trained therapist.
Here are some other things parents can do to support children with PTSD:
Most children will need a period of adjustment after a stressful event. During this time, it’s important for parents to offer support, love, and understanding.
Try to keep children’s schedules and lives as similar as possible to before the event. This means not allowing your child to take off too much time from school or activities, even if it’s hard at the beginning.
Let them talk about the traumatic event when and if they feel ready. Praise them for being strong when they do talk about it, but don’t force the issue if they don’t feel like sharing their thoughts. Some children may prefer to draw or write about their experiences. Either way, encouragement and praise can help them get feelings out.
Reassure them that their feelings are typical and that they’re not “going crazy.” Support and understanding from parents can help with handling difficult feelings.
Some children and teens find it helpful to get involved in a support group for trauma survivors. Look online or check with your paediatrician or the school counsellor to find groups nearby.
Get professional help immediately if you have any concern that a child has thoughts of self-harm. Thoughts of suicide are serious at any age and should be treated right away.
Help build self-confidence by encouraging children to make everyday decisions where appropriate. PTSD can make children feel powerless, so parents can help by showing their children that they have control over some parts of their lives. Depending on a child’s age, parents might consider letting him or her choose a weekend activity or decide things like what’s for dinner or what to wear.
Tell them that the traumatic event is not their fault. Encourage children to talk about any feelings of guilt, but don’t let them blame themselves for what happened.
Stay in touch with caregivers. It’s important to talk to teachers, babysitters, and other people who are involved in your child’s life.
Do not criticize regressive behaviour (returning to a previous level of development). If children want to sleep with the lights on or take a favourite stuffed animal to bed, it might help them get through this difficult time. Speak to your child’s doctor or therapist if you’re not sure about what is helpful for your son or daughter.
How can I help myself?
Living with PTSD can feel overwhelming. This page offers some practical suggestions for looking after yourself.
Get to know your triggers
You might find that certain experiences, situations or people seem to trigger flashbacks or other symptoms. These might include specific reminders of past trauma, such as smells, sounds, words, places or particular types of books or films. Some people find things especially difficult on significant dates, such as the anniversary of a traumatic experience.
Confide in someone
Lots of people who experience PTSD find it hard to open up to others. This may be because you feel unable to talk about what has happened to you. However, you don’t need to be able to describe the trauma to tell someone how you are currently feeling.
It could help to talk to a friend or family member, or a professional such as a GP or a trained listener at a helpline.
Give yourself time
Everyone has their own unique response to trauma and it’s important to take things at your own pace. For example, it may not be helpful to talk about your experiences before you feel ready. Try to be patient with yourself and don’t judge yourself harshly for needing time and support to recover from PTSD.
Try peer support
Peer support brings together people who have had similar experiences, which some people find very helpful.
Find specialist support
You might find it useful to contact an organisation that specialises in advice and support for PTSD. It could also be helpful to find an organisation with expertise in the particular type of trauma you have experienced.
Look after your physical health
Coping with PTSD can be exhausting. You might feel like you can’t find the energy to take care of yourself, but looking after your physical health can make a difference to how you feel emotionally. For example, it can help to:
Think about your diet. Eating regularly and keeping your blood sugar stable can help you cope when things feel difficult.
Try to exercise. Exercise can be really helpful for your mental wellbeing.
Spend time outside. The outside world might feel overwhelming, but spending time in nature can boost your wellbeing.
Avoid drugs and alcohol. While you might want to use drugs or alcohol to cope with difficult feelings, memories or physical pain, they can make you feel worse in the long run. They can also make other problems worse, such as difficulty sleeping.
PTSD and sleep problems
Lots of people who experience PTSD have problems sleeping. You might find it hard to fall or stay asleep, feel unsafe during the night, or feel anxious or afraid of having nightmares.
Learn about your condition and talk to those close to you about your PTSD.
- Keep track of changes in your sleeping and eating patterns.
- Ask for help when you need it – talk to your GP, therapist or call a helpline.
- Join a support group.
How have you been coping so far?
Think about what you’ve done so far to cope, and how effective these strategies have been.
Will it be helpful in the long-term, or is it possible that they might be keeping your difficulties going? For example, asking someone else to go shopping for you instead of driving to the supermarket because you worry that you might have a crash.
Think about how you might have coped well with difficulties in the past.
What is going well currently and what you are doing to achieve that?
What coping strategies and support do you have available to you? Could you be making better use of these?
Challenging unhelpful thoughts
The way that we think about things has an impact on our mood. Many of these thoughts occur outside of our control and can be negative or unhelpful. It is therefore important to remember that they are just thoughts, without any real basis, and are not necessarily facts. Even though we may believe a lot of our unhelpful thoughts when we have experienced a traumatic event, or feel stressed or low, it is good to remember that they should be questioned as they are often based on wrong assumptions.
This simple technique involves focusing on and slowing down our breathing patterns. Many people find this simple exercise very relaxing. It can be particularly helpful for those who feel dizzy or light headed when they feel worried or stressed. This sometimes happens because people’s breathing changes and gets quicker when they feel distressed.
This can be an uncomfortable and unpleasant experience. It can make people even more on edge, and a vicious cycle can occur. Learning controlled breathing exercises can help you to manage these feelings more effectively. It can also help to give your mind and body a chance to calm down.
Remember, you can use this exercise to help you relax at any time. You could even use it to help you get off to sleep. However, it is particularly useful if you ever feel light-headed, dizzy or faint.
People often get into the habit of avoiding situations that cause them difficulty. This coping strategy can unfortunately make the problem worse. This is because the longer we avoid something, the more intimidating it becomes. By avoiding situations, we also stop ourselves from proving that we can cope in them. As a result, our anxiety towards the situation continues and our confidence remains low.
Watchful waiting involves carefully monitoring your symptoms to see whether they improve or get worse. It may be recommended in cases of PTSD where the symptoms are mild or have been present for less than four weeks after the traumatic event.
If watchful waiting is recommended, you should have a follow-up appointment within one month.
- There is no need to feel guilty or embarrassed. These thoughts and feelings are not your fault.
- Accept that recovering takes time – don’t be hard on yourself.
- Accept the help that is offered to you.
- Talk to your partner, family or a friend about what happened and how you are feeling, if you can.
- Keep life as normal as possible, try and resume your previous routine, go back to work
- Take care when driving – as you might experience poor concentration.
- Speak to your GP
- Don’t excessively smoke, drink alcohol or coffee.
- DO NOT be hard on yourself, do not think that PTSD is a sign of weakness; – it is a normal reaction, in a normal person to an incredibly abnormal and terrifying situation
- DO NOT expect memories of the event to go away immediately – accept that these maybe with you for some time
- Allow yourself to make mistakes, not be as efficient as you were previously.
- Expect to get better.
Tips on coping with flashbacks
Flashbacks can be very distressing, but there are things you can do that might help. You could:
- 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.
Treatment of PTSD
What is complex PTSD?
Complex post-traumatic stress disorder (complex PTSD, sometimes abbreviated to c-PTSD or CPTSD) is a condition where you experience some symptoms of PTSD along with some 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.
Other terms for complex PTSD
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.
For example, you may find some doctors or therapists use one of the following terms:
- enduring personality change after catastrophic experience (EPCACE)
- disorders of extreme stress not otherwise specified (DESNOS) – this term is more common in America than the UK.
Complex PTSD and emotional flashbacks
If you have complex PTSD you may be particularly likely to experience what some people call an ’emotional flashback’, in which you have intense feelings that you originally felt during the trauma, such as fear, shame, sadness or despair. You might react to events in the present as if they are causing these feelings, without realising that you are having a flashback.
What causes complex PTSD?
The types of traumatic events that can cause complex PTSD include:
- childhood abuse, neglect or abandonment
- ongoing domestic violence or abuse
- repeatedly witnessing violence or abuse
- being forced to become a sex worker
- torture, kidnapping or slavery
- being a prisoner of war.
You are more likely to develop complex PTSD if:
- you experienced trauma at an early age
- the trauma lasted for a long time
- escape or rescue were unlikely or impossible
- you have experienced multiple traumas
- you were harmed by someone close to you.
Misdiagnosis with BPD
Some of the symptoms of complex PTSD are very similar to those of borderline personality disorder (BPD), and not all professionals are aware of complex PTSD. As a result, some people are given a diagnosis of BPD or another personality disorder when complex PTSD fits their experiences more closely. It’s also possible to experience both complex PTSD and BPD at the same time.
If you’re worried that the diagnosis you’ve been given doesn’t fit the way you feel, it’s important to discuss it with a mental health professional so you can make sure you’re getting the right treatment to help you.
What treatments are there?
You may find standard treatments for PTSD helpful, but many people with complex PTSD need more long-term, intensive support to recover.