Understanding post-traumatic stress disorder

The Mind
by Jane Gorman
‘The depth of my sorrow was no surprise to me, but I was totally unprepared for the other reactions – the shakes, nightmares, panic attacks, memory and concentration problems, and the unrelenting exhaustion.’
Bomb attack survivor

‘I still have nightmares. They can be triggered by something on television, or the smallest of things, like having the duvet caught round my face. The number of times is lessening, but when they do come I’m learning how to cope. I put the light on, I open the window and say “Yep, look, that was a dream”.’
Train crash survivor

‘One of my problems resulted from experiencing upsetting flashbacks: people badly injured; the shocked faces of fellow passengers and staff at the hospital; my husband and brother-in-law splattered with blood and mud. They came to me when I was at my most vulnerable. I don’t think they will ever go completely, but they are fading and are easier to cope with.’
Train crash survivor

Post-traumatic stress disorder may emerge months or sometimes years after a traumatic experience, affecting people’s ability to lead their lives. This booklet describes the causes and the symptoms, and tells you what help is available and how to get it.

What is post-traumatic stress disorder?
In recent years, mental health professionals have adopted the term post-traumatic stress disorder (PTSD) to describe a range of psychological symptoms people may experience following a traumatic event, which is outside the normal human experience. The World Health Organisation has defined it as: ‘A delayed or protracted response to a stressful event or situation (either short or long-lasting) of an exceptionally threatening or long-lasting nature, which is likely to cause pervasive distress in almost anyone.’

Just hearing news of shattering events, such as the September 11th destruction of New York’s World Trade Centre, incidents during the Gulf Wars, the Potter’s Bar train crash and the Hillsborough football stadium disaster, can have a lasting impact on individuals. Anybody actually present during a disaster of this nature is likely to become extremely distressed. Every day, people are involved in, or witness, events such as road accidents, muggings, and sexual or physical assaults that cause them deep emotional injury. There is no doubt that the reactions that may follow can seriously hamper and interfere with their lives.

Some survivors have objected to the use of the term disorder, because they see such reactions as an entirely normal and understandable response to abnormal events. But the label recognises that events and social conditions that are beyond our control, and which may fill us with fear or horror, can cause extremely disturbing psychological symptoms.

What are the symptoms?
‘He’d almost denied what happened, didn’t want to talk about it, didn’t want to read any of the articles. Then, one day, a friend mentioned to him that she was worried about her cat, because she had left it that morning trapped up a tree, and it was as though that pushed a button. Dick broke down and shed lots of tears.’

If you have faced a traumatic experience, you may simply feel emotionally numb to begin with, and feelings of distress may not emerge straight away. But sooner or later, you are likely to develop emotional and physical reactions, and changes in behaviour, which may include some of the following:

Reliving aspects of the trauma
vivid flashbacks (feeling as if the trauma is happening all over again)
intrusive thoughts and images
nightmares
intense distress at real or symbolic reminders of the trauma.
Avoiding memories
keeping busy
avoiding situations that remind you of the trauma
repressing memories (being unable to remember aspects of the event)
feeling detached, cut off and emotionally numb
being unable to express affection
feeling there’s no point in planning for the future.
Being easily aroused
disturbed sleep
irritability and aggressive behaviour
lack of concentration
extreme alertness
panic response to anything to do with the trauma
being easily startled.

These responses are all quite normal. Many people find the symptoms will disappear in due course. It’s when they last for longer than a month, or when they are very extreme, that PTSD may be diagnosed. Sufferers may also have other symptoms, such as severe anxiety, a phobia or depression. They may develop a dissociative disorder (see Understanding dissociative disorders, under Further reading) and suicidal feelings. There’s no time limit on distress, and some survivors may not develop post-traumatic symptoms until many years after the event.

What causes PTSD?PTSD was first described in relation to the veterans of the Vietnam War in the USA, but the problem has been around for a lot longer under various different names. During the First World War, large numbers of soldiers were said to be suffering from shell shock, soldier’s heart or battle fatigue. Rather than admit to the horror of war, and in order to explain the large numbers of men involved, the official line was that these were symptoms of an illness. It has since been estimated that 31 per cent of war veterans suffer from PTSD.

There are important similarities between the psychological stresses associated with war and those that occur in response to major disasters or to personal trauma. Following the sinking of the Herald of Free Enterprise ferry at Zeebrugge, 90 per cent of the passengers and their relatives who were seen for psychological assessment were found to be suffering from PTSD, either alone or in combination with other problems, such as alcohol misuse.

This highlights the fact that people who have not been directly involved in a trauma of this kind may still experience levels of distress as high as those who were. Civilian survivors of war and refugees also develop PTSD, for example. So do people who have lost relatives and friends as a result of some disaster, as well as rescue workers who tried to save them. After the King’s Cross underground station fire in 1987, mental health professionals drew up a list of 670 people who were potentially at risk from the psychological effects of the experience. Of that number, only one hundred had been involved directly; the others came from the emergency services, railway officials and the families of victims and survivors. Two years after the Lockerbie air disaster, police, firemen and ambulance workers were still traumatised by what they had witnessed.

Personal trauma, violent crime, sexual or physical assault, road traffic accidents or difficulties during childbirth can all produce PTSD. Adult survivors of childhood sexual abuse may be affected. Children who have themselves been abused, or who have witnessed something terrible, such as a murder, are also prone to the disorder.

Why do some people develop PTSD?
‘Every time I hear of any disaster, whether here or abroad, it brings back my own memories, and I can imagine how the families and victims are feeling. My own experience has taught me that you can’t change what happened, but that time does make it easier to cope. The memories don’t go, but they do fade.’

It’s reckoned that about one per cent of the general population is likely to be affected by PTSD at some point. Anyone can develop PTSD following experiences such as those mentioned above, but not everyone does so. Nor does everyone develop it to the same degree. There are a number of possible explanations for this.

Fearing for your life
Events involving loss of life, or where people have been faced by the prospect of dying, may lead to more long-lasting stress responses. A study of Falklands War veterans found that exposure to combat was the most significant factor in predicting who would develop PTSD.

Harmful intentions
Man-made disasters, particularly those involving deliberate acts of violence or terrorism, seem to cause longer-lasting and more painful emotional consequences than natural disasters. The crucial factor may be that it destroys people’s trust in others, particularly when it involves someone they depended on.

Conscious memoriesPeople who remain conscious through the experience may be more vulnerable to PTSD because of the horrific memories etched on the mind.

Personal circumstances
Your personal history can make you more prone to PTSD. If a traumatic event triggers memories of an earlier distressing experience, the impact is effectively doubled in intensity. Similarly, if you are already going through emotional problems, you are also much more vulnerable. Your temperament may also have a lot to do with it.

Guilt feelings
Survivors often feel extremely guilty, as though they were responsible for the event, or could have done more to save themselves or others. One study showed that those who blamed themselves in some way for the outcome of the disaster were more at risk of severe and long-term distress.

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