Posttraumatic Stress Disorder (PTSD)
Posttraumatic Stress Disorder
(PTSD)
I’m going to refer to the work of the World Health Organisation when discussing the diagnosis and not to the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM5). The wording of the WHO is simpler and the DSM5 does not give separate criteria for complex PTSD (CPTSD).
What causes PTSD?
PTSD may develop following exposure to an extremely threatening or horrific event or series of events.
What does PTSD feel like?
People may re-experience the traumatic event or events in the present. These can be intrusive memories, flashbacks or nightmares. The phrase “in the present” is important.
Re-experiencing
One feature of PTSD is that events do not feel as if they have become history like other events. It feels as though they are still part of our present. Most memories fade over time and become less important. In PTSD they intrude into our lives, even after the events have passed.
Flashbacks refer to events which are relived as though they are currently happening. With intrusive memories, we know it is a memory, even though it still feels different to other memories. With a flashback, it is a complete reliving. The present has receded and we are re-experiencing the traumatic event as though it is currently happening.
I’m going to refer to the work of the World Health Organisation when discussing the diagnosis and not to the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM5). The wording of the WHO is simpler and the DSM5 does not give separate criteria for CPTSD.
What causes PTSD?
PTSD may develop following exposure to an extremely threatening or horrific event or series of events.
What does PTSD feel like?
People may re-experience the traumatic event or events in the present. These can be intrusive memories, flashbacks or nightmares. The phrase “in the present” is important.
Re-experiencing
One feature of PTSD is that events do not feel as if they have become history like other events. It feels as though they are still part of our present. Most memories fade over time and become less important. In PTSD they intrude into our lives, even after the events have passed.
Flashbacks refer to events which are relived as though they are currently happening. With intrusive memories, we know it is a memory, even though it still feels different to other memories. With a flashback, it is a complete reliving. The present has receded and we are re-experiencing the traumatic event as though it is currently happening.
Avoidance
In order to try to cope, people avoid thoughts and memories of the event(s), or activities, situations, or people reminiscent of the event(s). We do this because reminders of the event bring up the event and all the emotions associated with it. Although this may work short term, it doesn’t work long term. As we avoid situations, memories, thoughts, activities and people we feel better as we do not relive the events.
This rewards avoidance and it becomes more likely that we will avoid the same triggers in the future. This confirms to us that whatever has happened is so terrible that we can never cope with it.
Our avoidance can also begin to generalise. We may have started by avoiding a particular mall where there was an armed robbery, but we then realise it could happen at any mall. We start to avoid more malls. We then realise it could happen wherever there are many people, so we avoid our child’s school, or the church we usually attend and so on.
Constant ongoing threat
The third cluster of symptoms refers to a persistent perception of heightened current threat. Again, the threat has not passed; it is ongoing. I am constantly in danger. This makes me jumpy. I startle at loud or sudden noises. I struggle to fall or stay asleep, can have outbursts of anger and so on. In all these examples, it is clear I am living as though the trauma is still happening.
Duration of symptoms
These symptoms persist for at least several weeks and cause significant impairment in functioning (WHO, 08 June 2022).
They shut the road through the woods
Seventy years ago.
Weather and rain have undone it again,
And now you would never know
There was once a road through the woods
Before they planted the trees.
It is underneath the coppice and heath,
And the thin anemones.
Only the keeper sees
That, where the ring-dove broods,
And the badgers roll at ease,
There was once a road through the woods.
They shut the road through the woods
Seventy years ago.
Weather and rain have undone it again,
And now you would never know
There was once a road through the woods
Before they planted the trees.
It is underneath the coppice and heath,
And the thin anemones.
Only the keeper sees
That, where the ring-dove broods,
And the badgers roll at ease,
There was once a road through the woods.
Yet, if you enter the woods
Of a summer evening late,
When the night-air cools on the trout-ringed pools
Where the otter whistles his mate,
(They fear not men in the woods,
Because they see so few.)
You will hear the beat of a horse’s feet,
And the swish of a skirt in the dew,
Steadily cantering through
The misty solitudes,
As though they perfectly knew
The old lost road through the woods.
But there is no road through the woods.
Rudyard Kipling (1865-1936)
Yet, if you enter the woods
Of a summer evening late,
When the night-air cools on the trout-ringed pools
Where the otter whistles his mate,
(They fear not men in the woods,
Because they see so few.)
You will hear the beat of a horse’s feet,
And the swish of a skirt in the dew,
Steadily cantering through
The misty solitudes,
As though they perfectly knew
The old lost road through the woods.
But there is no road through the woods.
Rudyard Kipling (1865-1936)
Complex Posttraumatic Stress Disorder (CPTSD)
What is complex PTSD, sometimes abbreviated to CPTSD? It has a very long history and the World Health Organisation (WHO) made it available as a diagnosis in 2018.
When do we diagnose CPTSD?
The diagnosis of Complex PTSD was developed to cover situations where we are exposed to long-lasting trauma or to multiple events. The symptoms we see in someone who has been exposed to things like domestic violence and childhood abuse or what we see in first responders or in people who work in the police is very different to people who have been exposed to a single event.
What does CPTSD look like?
In CPTSD we have the usual symptoms of PTSD which I described earlier. But because of the long-term exposure we have other symptoms developing. Three additional clusters of symptoms namely emotional dysregulation, negative self-cognitions and interpersonal hardship, (Giourou, Skokou, Andrew, Alexopoulou, Gourzis & Jelastopulu, 2018) are commonly seen in CPTSD.
Treating CPTSD
To recover from CPTSD we have to address both areas: memory and the long-term impact of trauma. It is insufficient to only address the memories of the event as we have traditionally done with PTSD. CPTSD has far wider implications and affects far more of someone’s life.
Complex Posttraumatic Stress Disorder (CPTSD)
What is complex PTSD, sometimes abbreviated to CPTSD? It has a very long history and the World Health Organisation (WHO) made it available as a diagnosis in 2018.
When do we diagnose CPTSD?
The diagnosis of Complex PTSD was developed to cover situations where we are exposed to long-lasting trauma or to multiple events. The symptoms we see in someone who has been exposed to things like domestic violence and childhood abuse or what we see in first responders or in people who work in the police is very different to people who have been exposed to a single event.
What does CPTSD look like?
In CPTSD we have the usual symptoms of PTSD which I described earlier. But because of the long-term exposure we have other symptoms developing. Three additional clusters of symptoms namely emotional dysregulation, negative self-cognitions and interpersonal hardship, (Giourou, Skokou, Andrew, Alexopoulou, Gourzis & Jelastopulu, 2018) are commonly seen in CPTSD.
Treating CPTSD
To recover from CPTSD we have to address both areas: memory and the long-term impact of trauma. It is insufficient to only address the memories of the event as we have traditionally done with PTSD. CPTSD has far wider implications and affects far more of someone’s life.
Since we agreed to let the road between us
Fall to disuse,
And bricked our gates up, planted trees to screen us,
And turned all time's eroding agents loose,
Silence, and space, and strangers - our neglect
Has not had much effect.
Since we agreed to let the road between us
Fall to disuse,
And bricked our gates up, planted trees to screen us,
And turned all time's eroding agents loose,
Silence, and space, and strangers - our neglect
Has not had much effect.
Leaves drift unswept, perhaps; grass creeps unmown;
No other change.
So clear it stands, so little overgrown,
Walking that way tonight would not seem strange,
And still would be allowed. A little longer,
And time would be the stronger,
Leaves drift unswept, perhaps; grass creeps unmown;
No other change.
So clear it stands, so little overgrown,
Walking that way tonight would not seem strange,
And still would be allowed. A little longer,
And time would be the stronger,
Drafting a world where no such road will run
From you to me;
To watch that world come up like a cold sun,
Rewarding others, is my liberty.
Not to prevent it is my will's fulfillment.
Willing it, my ailment.
Philip Larkin (1922-1985)
Drafting a world where no such road will run
From you to me;
To watch that world come up like a cold sun,
Rewarding others, is my liberty.
Not to prevent it is my will's fulfillment.
Willing it, my ailment.
Philip Larkin (1922-1985)
What do we have to do after a traumatic event
What can we expect after exposure to something potentially very traumatising? And what are the immediate steps we should take?
What is trauma?
Let me first explain what I mean by potentially traumatising. I’m not talking about something that is upsetting. Many things happen in life that are upsetting. My partner leaves me. I lose my job. A friend backstabs me. All these are common, upsetting events. In everyday speech people may say they were traumatised when one of these things happened. They actually mean these events upset them. An appropriate response to these sorts of events is to be upset.
When we talk about traumatic events, most of the time we are talking about events that are potentially life-threatening or have attacked our physical integrity. Physical integrity means our right to decide what happens to our bodies. Something like a rape, may not necessarily be life-threatening, but it certainly affects our physical integrity. Someone holding a gun to your head is potentially traumatising.
How common is PTSD?
I say potentially, because although it is certainly possible that you may develop symptoms following such an event, it is not necessarily the case. Many (actually most) people don’t.
What is normal following a traumatic event?
When exposed to something potentially traumatising, we can respond in various ways. All sorts of things affect our reaction. Apart from reactions where we may want to hurt ourselves or someone else, all the rest is acceptable. Some people talk, others don’t. Some people immediately resume their lives, others can’t. People may have difficulties with sleep, struggle with emotions, and so on. A lot depends on what skills we have developed through the years, our personality and the culture we come from. A response style is less important than whether or not it helps us to cope with what has happened.
Following a traumatic event, people need safety and the care and comfort of friends and family. We know that telling everyone to talk about it and to express emotions can worsen coping and even increase the risk of posttraumatic stress disorder.
When to get help?
If someone struggles to recover from what has happened they may need assistance. If somene is continuously distressed without finding periods of calm after the first few weeks, it is possibly a sign that they are struggling to come to terms with what has happened. Severe dissociation (feeling separate from myself) or memories that don’t stop, even though we are safe, can be signs we are struggling. Sleep that does not return to normal after a few days and persistent nightmares can show difficulties with coping. If flashbacks continue they may also need help. During a flashback, we relive the experience. It is as if it is happening again and it is not just a memory of the event. It is a reliving of the event. If we are extremely anxious and avoid all reminders of the event, like emotions, activities and sensations, it is also concerning.
If these severe responses continue, we need to deal with what has happened. This means we don’t talk around it, but confront the event directly. I’ll pick up on this in the section on Treatment of PTSD.
Treating traumatic incidents
In this piece I will refer to treating single incident trauma. Treatment of trauma depends on a few factors. One of them is whether it is a single incident (for example, a home invasion) or whether numerous incidents are involved (as for example with first responders).
First appointment
As with all psychotherapy you will initially be asked for a history. This involves questions around your background. I’m looking for information on how you approach life, what support you have, how you have responded to possible previous trauma and so on.
What works in treating trauma
The methods for treating trauma that work are all based on exposure. There is research on non-exposure models, but for the moment all the approaches that have sufficient research to recommend using them are based on exposure.
If you struggle to manage emotions, I will help you develop skills to learn to manage what you are feeling. Most of the time these skills need to be practiced to be able to use them effectively.
What works in dealing with memories of the tauma
We have effective methods for treating PTSD. These have developed over years and we have lots and lots of research proving how effective they are. The approaches are prolonged exposure, cognitive behavioural therapy with a trauma focus, cognitive processing therapy, narrative exposure therapy and eye movement desensitisation and reprocessing (EMDR).
Eye Movement Desensitisation and Reprogramming
I usually use eye movement desensitisation and reprogramming (EMDR). In my experience, EMDR gives quicker results than the other methods. EMDR has a lot of research behind it which indicates it works. You can read up on it at www.emdr.com. Nothing works for everyone and if you do not respond well to EMDR we can try one of the other evidence-based approaches.
During EMDR we use eye movements (or tapping or tones) while you keep images, thoughts, emotions, or body sensations in mind. I explain each step as we go, and the process is not difficult or complicated.
People experience EMDR in different ways and it is not possible to predict. We do communicate the entire time and if you are too uncomfortable or want to stop you can indicate it at any time. A useful way of approaching it is with curiosity.
Most people experience a lot of relief following EMDR.
Working through memories
What does working through memories entail and why would we do it? Let’s start with the why. Sometimes people have active memories. When memories are active, they keep coming into awareness and disturbing the present. For example, if you were raped a few years ago, the memory may continue to affect your ability to form a romantic relationship. You question your partner’s motives; you find you cannot trust him or her when trying to engage sexually. Until the interfering memories are dealt with, it is not possible to change how you are interacting.
How do we do it?
Single memories
When we are dealing with a single memory, it is relatively easy. I will still check that there are not other events in your past that can give problems, and which we have to consider, but apart from that, we just start working on the memory. Irrespective of the technique we are using, we will go through the memory repeatedly, often checking on how much it is currently upsetting you.
Multiple memories
When we work on multiple memories, such as we have in CPTSD, I like to group them as far as possible. Memories with a similar theme are often linked together. I then prefer to work either with the earliest memory or with the most upsetting. The reason for the first is that sometimes, at that point, you have made a decision. A decision which is now affecting your ability to live your life the way you want to. Working with the most upsetting memory is useful. It may sound cruel to begin with the most upsetting, but it can work extremely well. Very often, if we work through the most upsetting memory, all similarly themed memories are better.
Two roads diverged in a yellow wood,
And sorry I could not travel both
And be one traveler, long I stood
And looked down one as far as I could
To where it bent in the undergrowth;
Then took the other, as just as fair,
And having perhaps the better claim,
Because it was grassy and wanted wear;
Though as for that the passing there
Had worn them really about the same,
And both that morning equally lay
In leaves no step had trodden black.
Oh, I kept the first for another day!
Yet knowing how way leads on to way,
I doubted if I should ever come back.
I shall be telling this with a sigh
Somewhere ages and ages hence:
Two roads diverged in a wood, and I—
I took the one less traveled by,
And that has made all the difference.
Robert Frost 1874-1963
Two roads diverged in a yellow wood,
And sorry I could not travel both
And be one traveler, long I stood
And looked down one as far as I could
To where it bent in the undergrowth;
Then took the other, as just as fair,
And having perhaps the better claim,
Because it was grassy and wanted wear;
Though as for that the passing there
Had worn them really about the same,
And both that morning equally lay
In leaves no step had trodden black.
Oh, I kept the first for another day!
Yet knowing how way leads on to way,
I doubted if I should ever come back.
I shall be telling this with a sigh
Somewhere ages and ages hence:
Two roads diverged in a wood, and I—
I took the one less traveled by,
And that has made all the difference.
Robert Frost 1874-1963
Where we should start
You and I will spend some time discussing the memories you have and where we should start.
People often comment that they only have fragments of memories. That is not usually a problem. If you have some emotional response to a fragment, it is enough to recall the trauma and work through it.
Long-term memory is not static. Many people see it as a video recording, but it is very different.
I have added a video (https://www.youtube.com/watch?v=PB2OegI6wvI) to this page which gives a good idea of how long-term memory works.
Dealing with memories
I start with noting the images, sounds, smells, thoughts, sensations you have when you think of the memory.
In most ways of dealing with trauma we use a SUD (subjective unit of distress) score. This is simply how upsetting the memory is on a 0 to 10 point scale when you think of it. If is common to start with an 8, 9, 10 SUD score. We want it to drop to
We then start to access the memory, combining the memory with eye movements, or tapping, if we are doing EMDR. Other approached follow a similar pattern of access, with some variations. All current trauma treatments use exposure to the trauma memories.
What do people experience?
You may experience various images. The images may change. Emotions are common while accessing the memory. Thoughts may arise and may change. You may become aware of all the sensory experiences (e.g. smell). They may all change or become less intense while we are accessing the memory. We will continue to access the memories until they have far less impact when you think of them. It is common for people to say that the traumatic memory feel like a normal memory when we finish. Or to say it has little impact on them when they think of it. It is almost always different from when we started.
This works for dealing with the images that we encounter when someone has PTSD. Once the images are less upsetting, it is easier to think about what has happened. This has the effect of making it easier to confront the other emotions that are often present in PTSD, such as disappointment, betrayal, grief, anger and sadness. It is necessary to recognise what you feel when dealing with traumatic events in order to cope with what you have experienced.
CPTSD and treating symptoms that are not memories
Because CPTSD is a new diagnosis, we do not have sufficient research to tell us yet what the best options are for the symptoms that are part of CPTSD. The ones I am referring to are: difficulties with emotional regulation, low self-worth and difficulties with relationships.
But, Dialectical Behavioural Therapy (DBT) helps with this problem. DBT has been around since the 1980s and it has a lot of research showing its efficacy in treating the symptoms that are common in borderline personality disorder.
Treating long-standing issues
As I have said, DBT is a good choice for improving the symptoms of difficulties with emotional regulation, low self-worth, and difficulty with relationships. The other approach which is useful is Acceptance and Commitment Therapy or ACT (pronounced as “act”). Both approaches have good research supporting their use.
In the references I have added a booklet “Doing what matters in times of stress”. This is a summary of ACT and well-worth reading. the World Health Organisation distributes it. Research shows that even in very distressed populations (for example, refugees), that implementing the skills it gives, leads to a large drop in symptoms. It seems that it increases psychological flexibility.
Dialectical Behavioural Therapy has four skill areas. There is a protocol for DBT when it is used with borderline personality disorder. For CPTSD we don’t have to do the full protocol, but we can draw from the skills training that has been developed in DBT. The four areas are: mindfulness, distress tolerance, emotional regulation and interpersonal effectiveness.
Mindfulness is being in the present on purpose, while noticing what you are experiencing non-judgementally. In mindfulness, we encourage you to notice what you are experiencing and putting words to it. It is always non-judgemental. We don’t judge the experience, we just notice it.