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Can PTSD be mild? Do the traumas have to be of a certain kind?

Can PTSD be mild? Do the traumas have to be of a certain kind?


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As far as I know, PTSD was first used as a broader label for symptoms associated with so-called shell-shock, and has been diagnosed for symptoms of a milder nature.

But is there a lower limit to the point at which PTSD can be diagnosed? For example, is it possible to have such a mild form of PTSD that it does not interfere with normal functioning, but exhibits the same features?

The reason I ask, is I live in the UK where the National Health System (NHS) is increasingly struggling with funding. Their website on PTSD seems to only state the most extreme of traumatic events as possible causes. In short, I think it is to get out of giving help to all but the absolute worst cases. Hospitals and many mental health services have large burdens and turn many seeking help away.

If someone where to suggest they have PTSD, I feel that with literature such as the above, it belittles anyone experiencing "mild" events such as domestic abuse, which barely fits into their categories. Not only might they not get treated, but experience or perceive scorn.

If one were to seek help for PTSD and have to justify the help needed, regardless of the cause, how might it be done? Could the symptoms be misdiagnosed as, for example, regular stress, or anxiety, and would treatment for those be different to that required to help with PTSD?


In order for something to be diagnosed as a disorder by a mental health professional, the client typically experiences distress and impairment in activities of daily functioning.

If the time frame is under 3 to 6 months, please consider "Acute Stress Disorder" as a possibility. I agree that the DSM V is going to be a useful resource for diagnostics.

Trauma, in any form, does pose very specific challenges for diagnostics and a treatment plan. For further reading on trauma therapy, I highly suggest "Life After Trauma: A Workbook for Healing" by Rosenbloom and Williams (2010). Treatment will be dependent on the practitioner's training, and the formulated diagnosis. You are welcome to research efficacies of therapeutic interventions.

Therapy is very useful for any and all of the items you have mentioned. If you are attempting to get insurance coverage, usually a diagnosis from a qualified professional will qualify you for therapy (at least here in the United States). A good diagnosis could take a few sessions to formulate. It's sometimes a longer process if someone suspects trauma.


The DSM (Diagnostics and Statistics Manual) is used here in the UK as well as in the US. The 5th edition, which is the current edition, stipulates the criteria required to diagnose PTSD here is an info sheet on it. You could get a copy of DSM-5 in the library or buy it from Amazon.

To answer your specific questions:

Do the traumas have to be of a certain kind?

Yes, the DSM states that triggers for PTSD are "exposure to actual or threatened death, serious injury or sexual violation". But this is not the whole story, further criteria are:

The exposure must result from one or more of the following scenarios, in which the individual:

  • directly experiences the traumatic event;
  • witnesses the traumatic event in person;
  • learns that the traumatic event occurred to a close family member or close friend (with the actual or threatened death being either violent or accidental); or
  • experiences first-hand repeated or extreme exposure to aversive details of the traumatic event (not through media, pictures, television or movies unless work-related).

The disturbance, regardless of its trigger, causes clinically significant distress or impairment in the individual's social interactions, capacity to work or other important areas of functioning. It is not the physiological result of another medical condition, medication, drugs or alcohol.

And to your first question

Can PTSD be mild?… But is there a lower limit to the point at which PTSD can be diagnosed? For example, is it possible to have such a mild form of PTSD that it does not interfere with normal functioning, but exhibits the same features?

I would say, given the criteria above, there is no mild form. If it does not interfere with normal functioning it does not meet the criteria and is therefore not diagnosed as PTSD.


The top 10 questions about trauma, PTSD, and psychotherapy our patients ask: answered honestly

As psychotherapists specializing in treating the impact of traumatic events and chronic adversity, we are often asked a number of questions about trauma, PTSD, and psychotherapy.

Here, we have compiled the most common of these questions in order to help you, the brave reader seeking help for yourself or someone you love, better understand the effects of trauma on us all, the similarities and differences between how we may respond to experiencing/witnessing traumatic events, what it takes to heal from their impact, and what you can expect in therapy.

Have you have ever wondered why, for instance, some people develop Post-Traumatic Stress Disorder after traumatic events and others do not? Do you worry if the panic, pain, shame, or nightmares will go away on their own or how long it would take? If you will ever feel safe again? Have you wondered what psychotherapy for healing from traumatic events looks like? Then read on, we are here to help! (This article is going to be long…we wanted to provide an exhaustive list of questions and answers, feel free to scroll down to the ones you are most interested in)

The Definition of Trauma

According to the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a traumatic event is an event or situation which may involve:

This definition is expanded, however, from past definitions. Nowadays, we know that a traumatic reaction can be experienced after more indirect exposure to traumatic events, such as:

  • witnessing someone go through such event, or
  • learning about a situation in which a loved one experienced violent or accidental death, or
  • chronic exposure to or witnessing of distressing events, like through one’s job as a correspondent in a war-torn country, police officer or firefighter, is also recognized as trauma.

The Experience of Trauma

In previous editions, the DSM had also required that the event cause one significant feelings of fear or horror in order to qualify as trauma. However, we now know that this is not necessarily true, because traumatic events can also cause us to feel disconnected or dissociated from our bodies, emotions, and thoughts. They may also trigger incongruent emotional reactions (e.g. uncontrollable laughing), which may at the time seem inappropriate to the event, but are in fact not uncommon.

It is important to note, however, that the experience of trauma can be very subjective and personal. Often times, life events, even if they do not constitute a significant threat to our life, can be very traumatizing, for instance, the experience of a woman going through multiple cycles of IVF, where her body is exposed to constant changes, losses, and medical procedures infidelity or going through a divorce bullying at school being in a war zone or losing someone there even if not directly exposed to combat, multiple attachment disruptions for both children and adults, chronic exposure to poverty and hardship.

For some statistics of the prevalence of traumatic experiences, visit our main page here

Trauma vs. PTSD

Trauma does not necessarily result in PTSD, there are many other sequelae, and one may experience depression, anxiety, panic, relationship difficulties, etc., even if the symptoms do not add up to a diagnosis of PTSD. Therefore, it may be beneficial to work with a therapist who works from a trauma-informed perspective and has received additional training in trauma work even if you don’t have a diagnosis of PTSD. They will be best equipped to see your symptoms in context and may think to ask you questions and address other symptoms that a non-trauma informed therapist may not think about, e.g. the impact of traumatic events on the body and nervous system, the experience of dissociation (e.g., feeling like you are not fully here, spaced out, as if the world is not real, or as if you are disconnected from yourself or your body). For more on dissociation and its connection to trauma, you can visit the International Society for the Study of Trauma and Dissociation.

That being said, PTSD is one possible outcome of experiencing a traumatic event. We prefer to think of it as a reaction to trauma which fails to normalize over time, even if the traumatic event is no longer happening. Namely, most people who experience a traumatic event will have a response to it. This response may involve hypervigilance, nightmares, anxiety, low mood, hyper alertness, negative thoughts and self-doubts, intense emotional reactions and even bodily symptoms such as tenseness, tightness, heart racing, etc. All of these constitute a normal response in abnormal circumstances! We all will have some or all of them (and more) if we are exposed to a traumatic event. This is why we do not diagnose PTSD immediately after trauma, because you are expected to experience the above. It is the body’s natural reaction to something so out of the ordinary, something so scary or upsetting, that it sends us into a survival mode-type reaction.

You can think of PTSD as a combination of experiences, that can add up to feeling significant distress, which we then try to avoid at all cost. And, indeed, in many occasions, the cost is high. The general symptoms fall within several clusters. Please have in mind that you may not experience all of the symptoms in any given cluster. Only a few, usually one or two per cluster, are enough for a diagnosis.

Intrusive Symptoms Cluster

We call these symptoms of re-experiencing. They are internal experiences that feel as if they are keeping the memory of the trauma alive and our bodies and minds can lose track of time…as if the traumatic event is not in the past but in the present.

  • Intrusive memories that are unwanted—these can be throughs, images, sensations that are brought up by some stimuli in the environment, or even sometimes seemingly out of nowhere. You find yourself thinking about what happened, even though you do not want to be. They are different from flashbacks in that you don’t lose awareness of where you are, and yet cannot easily redirect your attention to other thoughts.
  • Flashbacks—you may feel like the traumatic event is happening to you over again. This may be a fleeting moment, when you see, hear, smell, or feel something and you are transported back to when the trauma occurred. Or it may be a longer episode in which you become disoriented and lose track of where you are, time becomes distorted, and you have to reorient yourself to your surroundings.
  • Nightmares—whether they are a repetitive nightmare, in which the trauma plays out over and over again, or more general bad dreams that leave you feeling anxious, angry, panicky, or generally off kilter
  • Emotional distress when reminders of the event are present—e.g. you become easily upset and have difficulty composing yourself again when any of the above happen, or when something in your environment reminds you of your trauma. For instance, if you experienced medical trauma, being in a hospital, or even watching a TV show that shows one can be upsetting.
  • Physical reactivity—when thinking about the event or perceiving triggers in the environment, you may feel your heart rate and blood pressure increase, experience heart palpitations, feel suddenly hot or cold, feel your palms get sweaty, have difficulty breathing or breathing shallowly, feel your head suddenly get foggy or heavy, or even feel physical tension and pain in certain areas. For instance, many survivors of sexual assault experience significant pain and discomfort in the pelvic area, which may fluctuate in intensity.

Changes in arousal and reactivity

Think of these symptoms as your nervous system’s reaction to trauma. During a traumatic event, your body will most likely experience a physiological stress response. When we have PTSD, it is as if our bodies never fully returned to normal functioning and are constantly living in a state of increased stress, as felt in:

  • Hypervigilance—constantly watching our back, scanning the environment for threats or cues that we may get hurt (both physically and emotionally)
  • Increased startle response—for instance, having a startle reaction to sudden movements or loud sounds, that would be more intense than or last longer usual
  • Engaging in risky behaviors—such as increased alcohol or drug use, reckless driving, increased spending, risky sexual behaviors, aggression and destructiveness
  • Difficulty concentrating—mind may be preoccupied with worries or overwhelmed, feeling scattered
  • Difficulty sleeping—either due to not being able to relax your mind and body enough, feeling unsafe to be in such a vulnerable state, or worrying about having nightmares
  • Irritability or aggression—finding yourself more on edge, engaging in more verbal or even physical arguments, feeling more easily overwhelmed by people’s demands on you and wanting to crawl out of your skin

Changes in cognition and mood

This cluster of symptoms can be thought of as the negative changes in our thoughts and emotions that develop as a result of trauma.

  • Global and general negative thoughts about yourself, others, or the world—for example thoughts that nobody can ever be trusted, that the world is all bad and hopeless, that you are not worthy of love or care. These are dangerous because they may subjectively feel true. For instance, if you experienced assault or abandonment, it may feel like nobody can ever be trusted. If you survived a natural disaster or witnessed atrocities of war, it may feel like the whole world and people in it are bad. But thinking in such absolute terms is a symptom of being traumatized and of having survived something very difficult, not an objective truth.
  • Excessively blaming yourself or others for the trauma—this is especially prominent when the trauma is losing someone you care about. Our brains tend to look for rhyme or reason, for explanations and responsibility. It is easier to accept a world where we are in control, albeit blaming ourselves, than a world in which sometimes tragedies happen. We are also often raised to believe in a fair world, one in which good things happen to good people and bad things to bad people. While we may know from experience this is not always the case, in the aftermath of trauma, it is hard to reconcile this belief with something bad happening to us. As with the above point, excessive self-blame (or other blame) is a symptom of our whole being experiencing a conflict between what we have been taught and something highly abnormal and traumatic happening to us.
  • Negative affect—frequently one or more of the following feelings: fear, horror, anger, guilt, shame having difficulty pulling yourself out from those emotional states
  • Anhedonia—loss or a decrease in positive affect. For instance, catching yourself in situations where you might think “this good thing happened, I should probably be feeling happy or joyful, or excited” but not being able to feel it
  • Losing interest in activities you previously liked—similarly as above, not being able to get enjoyment out of things that you used to enjoy or difficulty finding the motivation to even try
  • Forgetting some key parts of the traumatic event—feeling like you should be able to remember them, or maybe that if you really tried hard you could, but it is as if your brain is refusing to go there, or the time/scene is just lost in your memory
  • Feelings of isolation—becoming increasingly withdrawn, feeling like you can’t be close to anyone, or to very few people, but even then keeping them at a distance

Avoidance cluster

And finally, you can think of these symptoms as your attempts to cope with all of the above.

  • Avoiding trauma-related thoughts or feelings—while it may seem a little unclear what we mean by this, think of all the ways we try to avoid painful emotions: drinking and drugs, mechanically overeating, excessive exercise, aggression towards others because if we scare them the will stay away, leaving in the middle of arguments, numbing ourselves out through excessive TV watching…
  • Avoiding external trauma reminders—people, places, or things that in some way bring your mind back to what happen. Maybe you never drive over bridges, or never go out in the dark. Maybe you have not seen your doctor in years because of a fear of hospitals. Or maybe you have not even driven a car after the accident. Maybe you avoid talking to certain family members because they ask questions about your military service, or maybe you have not been to a family party in years because of the noise and chaos.

The distress caused by the symptoms described above can often feel overwhelming. We spend so much time and efforts to try to manage our anxiety and arousal, our bodily reactions of tenseness and pain, the constant emotional up and down roller-coaster, the intrusive memories, and unwanted thoughts. We pick up all the cues in the environment that remind us of what happened, songs, colors, places, people, TV programs, areas in our town, public transportation and crowded places, garbage pales on the side of the road, driving in traffic…

So eventually, we learn that if we avoid them, maybe we can manage ourselves a little better, feel a little less activated and always on edge. The avoidance comes naturally, sometimes to a point where we don’t realize we are mapping alternative routes, even if they take twice as long, that we are skipping medical appointments, that we haven’t seen friends in months. Avoidance cluster symptoms are ways of managing, but they also make our world very small.

A note on dissociation

Dissociation is a mental process, which can become very exaggerated during and after experiencing trauma. When diagnosing PTSD, clinicians will also pay attention to possible symptoms of dissociation, and the two types that serve as qualifiers for the PTSD diagnosis, if present: depersonalization and derealization. We will have a whole article on the dissociation and trauma in the future, but in the meantime, if interested, you can start by visiting the page of the International Society for the Study of Trauma and Dissociation

As scientists and clinicians, we are still learning about human resiliency and what factors contribute to why some people develop PTSD after a traumatic event and others do not. In fact, it is more accurate to say that most, if not all, people will have some type of trauma response to a traumatic event, but that a number of them will spontaneously recover after it, without long-lasting symptoms. About a third will not, and will go on to develop PTSD. (For an interesting review article on the matter, please click here)

What we do know is that there are a number of factors that may contribute to the development of PTSD after trauma:

  • chronic vs one-time trauma
  • preexisting mental illness or family history of mental illness
  • who the perpetrator is (someone known and trusted vs. a stranger)
  • social support
  • availability of resources such as medical and psychological care after the trauma
  • general level of stress and coping skills
  • type of trauma (e.g. sexual trauma vs natural disaster)

Overall, it appears that the higher the chronicity and intensity of the trauma, the more personal it is (e.g. natural disaster vs interpersonal violence), the more stressors and fewer support systems/resources the person has, the more likely they are to develop PTSD. Early trauma or adversity are also likely contributing factors, and so is family history of mental illness or already present mental illness in the trauma survivor. At the end of the day, it is especially important to remember that PTSD, or any other mental health issue following trauma, is not weakness, lack of desire to “just get better,” or “not trying hard enough.”

If you are interested in learning more about the impact of early childhood trauma and adversity, we recommend reading about the Adverse Childhood Experiences (ACEs) study.

Traumatic memories feel fresh in our minds, often times as if they are happening all over again. There is no easy answer to this question, because at the end of the day, it is this stuckness that is causing you significant distress. One way to understand the re-experiencing cluster of symptoms (see Question 2) is through the lens of what function they serve. During a traumatic event, your whole body is mobilized for survival (see fight/flight/freeze response).

Reexperiencing has a purpose

In that sense, reexperiencing, which triggers all of the other symptom clusters, ensures that you remain vigilant even in the present moment. It ensures that you cannot fall asleep and thus be in a vulnerable position, that you stay irritable or angry (or in a constant state of anxiety/panic) so that you can fight or flee, should a danger present itself. In a way, your mind and brain are trying to stay constantly on stand-by. The problem is that this constant stand-by, constant state of activation, is no longer applicable, because you are no longer in the traumatizing situation that caused this in the first place. But you keep reacting to the world as if you are.

Traumatic events have a way of “getting stuck” in our bodies and minds. But they can also be released. Therapy addresses some of this through teaching relaxation strategies and coping skills, but also through allowing you to address the ways in which trauma has impacted you in a safe environment. Trauma-informed therapists are also knowledgeable in how to help you with the physiological components of how trauma is lodged in your body and its emotional core.


Children are incredibly resilient! Often times, they are able to cope with difficult and challenging events better than we anticipated. We are often in awe of how they use their creativity, imagination, and inner strength to combat sadness, anxiety, and anger.

However, at times difficulties can overwhelm their inner resources. There are a number of behaviors and signs that your child may be experiencing a traumatic reaction to an event or events. Sometimes, you may know that something happened (e.g. bullying, a natural disaster) and be vigilant about how child is coping. Other times, you may not know that your child has been exposed to a traumatic event, but a change in their behavior, sleep and play patterns, concentration, and mood may be a good indication that your child is hurting:

  • Changes in sleep or appetite
  • Persistent nightmares or difficulties falling and/or staying asleep
  • Anger or rage
  • Difficulty being soothed
  • Unreasonable fear
  • Regressing to a previous developmental stage (e.g. wetting bed after that had stopped)
  • Unusually strong startle response
  • Sudden difficulties at school, grades decreasing
  • Lethargy
  • Withdrawal from previously trusted adults
  • Clinginess or intense anxiety when separated from parent
  • Frequent stomach aches and/or headaches
  • Unusual shyness or acting out in social situations

Regression

Of the above, several are particularly telling of when a child is coping with a traumatic event. One of those is regression, i.e. returning to a previous stage of development. This can be emotionally, when a child who had achieved a level of independence is suddenly much more clingy and starts asking of their parents to perform tasks/chores/responsibilities that the child had mastered. Or it could be through regressing in bodily control, such as sudden enuresis (bed wetting) or encopresis (bed soiling alternatively, some children may signal distress through withholding their bowel movements), suddenly forgetting how to talk, or regressing in other already achieved milestones.

Loss of imaginative play

Most children, unless they are experiencing neuro-developmental delays, show signs of imaginative play early in childhood. As they progress through the developmental stages, their play becomes more and more complex, with whole stories and characters existing only in their rich imaginations.

Because traumatic events overwhelm our emotional resources, directing all efforts and attention towards coping with their aftermath, children in particular can struggle to remain playful and imaginative after trauma. If you are noticing that your child’s play is repetitive, unimaginative, and even has a perseverative quality to it, or if your child is enacting a traumatic event over and over in their play, this may be a sign that they are struggling to process the event and recover from it. A skilled child therapist will be able to help them utilize their play to “digest” the difficult event and heal from it.

Most of us are by now familiar with the fight/flight response to danger. They are evolution’s gift to us, to ensure our physical survival. A neighbor cave man tries to steal our meat, we beat them up with a stick. The truth is, in a traumatic situation (read: one that we perceive as physically or emotionally dangerous), we cannot say for sure which one will kick in.

In therapy, we hear many people express self-blame for a third type of reaction – freezing. They report becoming paralyzed and then experiencing crushing shame that “I didn’t run away, or scream, or push the attacker away,” “I did not report what happened,” “I couldn’t move and save these people.” However, freezing, just like fight or flight, is an evolution-determined response of the nervous system. It is not more or less likely than its two counterparts, nor is it a choice that you make during the experience of trauma. Just like fighting or fleeing, in certain dangerous situations, it may ensure your survival, and even if you are not “playing dead” in front of a bear, your body may still freeze in the face of other traumas. We believe this video may be interesting to you, if you wish to learn more about the freeze response:

Protective factors – The power of connection

As we discussed earlier, you are expected to feel some distress after experiencing a traumatic event. Not much is yet known about what factors are at that critical time most effective in protecting from PTSD. Further, each person will move through those first days and weeks at their own pace, having their own unique emotional experienced and coping strategies.

What we do know, however, is that traumatic events can feel very isolating. As a result, we tend to withdraw and often distance ourselves from others. In contrast, it seems that people who, in the aftermath of a traumatic event, are able to reach for and accept help, support, and care from others fare off better. There is very little empirical support for any psychological or crisis first aid interventions being especially effective in the immediate aftermath of traumatic events. This may be because, in general, for therapy to work, a good, trusting, and collaborative relationship between patient and therapist is essential. In the immediate days after a traumatic event, we may be too activated, in shock, or in crisis, to be establishing new connections. Therefore, leaning on those who are already there, such as friends, family, social circle, appears to be immensely helpful. It seems that feeling connected with others produces hormones that make our immune systems stronger to withstand adversity.

For an excellent book on this subject, we recommend Sebastian Junger’s book “Tribe: On Homecoming and Belonging”

In contrast, avoidance seems to be correlated with a higher likelihood of developing PTSD. The more you try to tell yourself to ignore it, the more you risk having longer-term symptoms, as trauma becomes lodged in the body, which has no way of releasing it. Disclosing the trauma to loved ones, on the other hand, appears to be beneficial.

Treating PTSD

Each person will progress through treatment of trauma-related symptoms and/or PTSD at their own pace. One of the most important factors in therapy, it is worth repeating, is a sense of comfort and feelings of trust and safety with your therapist. From there on, your therapist will work with you on creating a treatment plan that is best fit for you, based on type and severity of symptoms, current stressors, and other factors.

There are a variety of treatment approaches to trauma. APA’s guidelines for the treatment of Post-Traumatic Stress Disorder (click here) recommend Cognitive Therapy (CT) or Cognitive Behavioral Therapy (CBT) as effective modalities, as well as several varieties of CBT, such as Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE). These therapies are highly structured and promise results within a limited number of sessions (usually 12 to 18). However, they may not be suitable for some people. For instance, recent brain imaging research (click here) suggests that only certain patients may benefit from Prolonged Exposure, for instance.

The APA guidelines also suggest that several other types of therapy, e.g. ones combining CBT and psychodynamic interventions, as well as Eye Movement Desensitization and Reprocessing (EMDR) and Narrative Exposure Therapy may work with good effect as well.

Treating the whole body

It is also important to remember that other methods of treatment can be effective, either on their own or in combination with the above modalities. They have not been included in these guidelines not due to their ineffectiveness, but often because conducting clinical research trials is an expensive and time consuming, not to mention difficult, undertaking and there is simply not enough well-regulated studies out there to support their inclusion in guidelines.

As clinicians, we know that there is also a bodily component to trauma (see Question 4, for example). Therefore, it is essential to include a component of relaxation, somatic work, art work, perhaps even meditation and trauma-sensitive yoga practices, as adjunct to treatment. Therapies like Somatic Experiencing and Sensorimotor Psychotherapy have shown great results in treating complex traumatic reactions.

In children, Trauma-Focused CBT has a wide foundation of empirical support. It combines elements of traditional CBT therapist with a narrative component, as well as a module in teaching children how to relax their bodies and manage heightened emotional states.

Ideally, your therapist will have background in at least a few (or many) of the above and be able to combine interventions from them to best fit your needs.

The very short answer is NO, it is not too late. Just like with any other chronic affliction, when untreated, PTSD can last a lifetime. Studies (like this one) with Vietnam-era veterans have found that untreated symptoms persisted 40 years after the service members’ return from war.

If you have been suffering from PTSD symptoms for a long time, by now you probably realize the many ways in which they have affected your life, from relationship difficulties, to troubles sleeping, to becoming emotionally upset at the sight/smell/sound of certain triggers, to panic and anxiety (for a full list, see Question 2).

However long you have been experiencing these symptoms, treatment with a caring, understanding, and trauma-competent clinician can help tremendously improve your symptoms and quality of life. You may wonder how this could happen if therapy can’t take the memories away. But there is a difference between curing (eliminating all signs of an illness) and healing (becoming whole again). While we cannot cure PTSD in the sense that we cannot eliminate all traces of the trauma (e.g. the memories), we can help you heal and feel whole again through lessening the power that those memories have over you, your emotions, and your body.

As we discussed above (in Question 8), the impact of trauma can last for many years, even decades, if untreated. Also, avoidance is one of the primary symptoms of PTSD. We simply do not want to talk about and relive the traumatic event. Most of the time, we already spend so much effort and mental resources to manage our internal struggle, that it seems unbearable to talk about what is causing us to feel this way in the first place. And then there can also be feelings of shame, which can develop as a result of the trauma. They make it even more difficult to talk about it, for fears of being judged, seen as damaged or broken, or being blamed for what happened.

However, we know that the more we avoid talking about the trauma or doing anything about our symptoms, the longer they are likely to persist. Avoidance has a way of “encapsulating” the trauma in our minds and bodies. We may think that not addressing what happened or our symptoms will make them lessen or go away overtime, but in reality, avoidance makes our world much smaller, albeit seemingly more predictable. The truth it, triggers in the environment are unpredictable. If we don’t learn how to better manage our symptoms, memories, and emotional reactions, we are constantly at the mercy of our environment and the triggers in it.

That being said, there are many ways to approach the treatment of symptoms following stressful and traumatic events. Some treatment modalities will require talking at length about what happened, and others do not. A good therapist, trained in working through a trauma-informed lens, will work with you at your own pace and selecting treatment approaches that work for you. It is important that you express your needs and worries, and that you feel comfortable with your therapist, so that you can begin this journey towards healing armed with the knowledge that they have your back!

PTSD has only existed as a diagnosis in the DSM since 1980, and only in the last version of the DSM did it become separated from the Anxiety Disorders cluster of diagnoses. This change finally granted it a recognition it did not before have, acknowledging that PTSD is not just another variation of an anxiety dysregulation and that its symptoms are rather unique. While this is a significant change, PTSD and trauma treatment in general, are still in the beginning stages of empirical study. There is little in the scientific literature that empirically traces what PTSD recovery looks like.

The National Center for PTSD, recognizes four stages of PTSD recovery: Impact, Immediate, Intermediate, and Long-term.

Impact Phase

These are the very first hours, days, and weeks after a traumatic event. During those, everyone is expected to experience some kind of trauma response (shock, feelings of helplessness, fear, powerlessness, guilt, panic, dissociation). Additional stressors, like separation from loved ones, medical trauma, loss of a loved one, and many others may further contribute to these feelings.

However, many of us have experienced multiple traumatic events. When trauma is chronic, we learn to adapt to it in ways that may keep us alive, but have a high psychological cost. If the dangerous or hurtful event is ongoing, or if we continue to be exposed to hardship, our minds and bodies will summon all resources to ensure physical (and psychological) survival, but the recovery stages will look different, as will the steps that need to be made to ensure safety. Recovery from what is frequently called Complex PTSD, then, will not necessarily follow these stages exactly.

Immediate (Rescue) Phase

This is described as the phase in which “there is reckoning with what has happened.” We now know that during this phase, people may exhibit significant resilience in coping, as they attempt to get their life back together and deal with the aftermath, support other loved ones, and work on achieving stability again.

However, many may experience delayed emotional reactions. They will often report that keeping busy in the first months after a traumatic event (e.g. after returning from deployment, or after surviving a natural disaster) has kept the feelings at bay, but as life starts to settle in, waves of emotional and somatic/physical reactions may begin to appear including: denial or shock, sadness, anger, fear, numbness, feeling overwhelmed, complex grief responses, flashbacks and nightmares, feelings of despair and hopelessness, loss of purpose or meaning.

Intermediate (Recovery) Phase

During this phase is when we start to adjust to the new normal and begin to try to achieve equilibrium. This may be the phase when we start seeking treatment, or begin acknowledging that perhaps there are psychological needs that need to be addressed. Recovery can be complicated by additional stressors, of course, but the core of the problem begins to be more recognizable. For instance, this is when nightmares or intrusive memories, which we thought would go away, continue to persist. Or we find ourselves withdrawing more from the loved ones around us. We realize that we have new anxieties or anger that were not there before, or certain things that did not matter before bother us more. We can become disillusioned or begin experiencing also more physical symptoms and illness. Stress we are experiencing can begin to impact our relationships and work.

In this recovery stage, it is important that we address the impact of trauma on our nervous system, bodily reactions, and reexperiencing symptoms, as well as learn to regulate our emotional reactivity and intensity. Recovery will begin by starting to establish safety, recognizing the triggers in the environment that now remind us of the trauma and cause us to feel unsafe, anxious, or angry. We learn coping skills for our anxiety, and we learn to relax our bodies enough so that they can progress to the next phase, Restructuring or Long-term Recovery, which would be difficult if we become panicky, shut down, or hyperactivated every time that the trauma is mentioned or when our emotions are easily dysregulated.

Long-term (Reconstruction) Phase

This is the meaning-making phase of recovery. Once you are able to address the traumatic event and its impact, you can become examining the deeper-held beliefs that it may have left in its aftermath. Beliefs related to the world, others, or yourself. Beliefs that tell you that nobody can be trusted, or that it is your fault for taking too long to recover and heal, or that you cannot ever trust your mind or your body to protect you, or that since help was unavailable at the time, nobody would ever be there for you to help.

Those are only a small sample of the insidious negative thoughts that result from those first moments of feeling powerless, helpless, and terrified during a traumatic experience, or the longer-term distrust in the world and others or oneself that chronic trauma can cause.

One of the most challenging but rewarding tasks of this stage is making meaning of what happened and integrating it into your story of who you are, where you came from, and who you want to become. This also helps in reestablishing a sense of control over your life goals and course, and finding a sense of purpose again, and learning to trust your judgment and abilities to overcome adversity. Some do this through acts of altruism, while others work on rebuilding a sense of a stronger self as a survivor.


What Is PTSD?

Post-traumatic stress disorder (PTSD) is a mental health condition caused by an intensely fearful situation, such as participating in active combat, being in a car accident, or surviving domestic violence. A diagnosis of PTSD requires a specific trigger that led to the development of certain related symptoms.

The core symptoms of PTSD include avoidance, intrusive memories, emotional reactivity or numbness, sleep disturbances, panic attacks, hypervigilance, and dissociation. These symptoms may also lead to chronic low mood states and negative thinking patterns. PTSD symptoms can range from mild to severe and can get in the way of the person&rsquos ability to lead a normal and fulfilling life. These symptoms indicate that the brain's fear response system has become effectively "stuck" in the on position, perceiving threats from relatively harmless stimuli and firing false alarms.

While not everyone will develop PTSD in the aftermath of a trauma, it is a common condition that affects up to 14 million adults in America. We're still learning exactly what leads to certain people developing the condition and not others. It appears to be partially related to genetics and individual vulnerabilities in certain brain structures.

Hyperactivity in certain parts of the brain, especially the amygdala, may put a person at risk for developing PTSD in the aftermath of a trauma. Dopamine, usually considered a chemical promoting reward and motivation, may also play a role in promoting anxiety and recognizing fear. Dysregulation in this area needs further investigation to understand its role in PTSD and other mental health conditions.

PTSD was added to the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980, though its symptoms had been recognized for decades before. Interestingly, while men are statistically more likely to have PTSD at some point in their lifetime than women, women are more likely to seek treatment.

For some people, psychotic disorders may occur secondary to PTSD symptoms. While the link between the two conditions is still being investigating, there is evidence of a connection.

What Is Psychosis?

Psychosis refers to a collection of symptoms that cause an individual to be disconnected from reality. Psychotic symptoms are grouped into two distinct categories: positive symptoms and negative symptoms.

Positive symptoms are the addition of thoughts, behaviors, and mental states. The person may have the awareness that these symptoms represent things that are not real (referred to as "insight") or, in more severe cases, may not be able to differentiate between what is real and what isn't. Positive symptoms of psychosis include:

  • Paranoia:Paranoia refers to anxious thoughts that involve suspicion and distrust of other people, including people that the individual is close to, like family members and friends. You may feel like someone or something is out to get you. You may think you're being followed or listened to, or you may have obsessive thoughts that someone is trying to conspire against you.
  • Hallucinations:A hallucination is the perception of something that is not real. Hallucinations can be visual, auditory, tactile (physical), or even a smell or taste. You may hear voices when there's no one around, smell a scent with no apparent source, or see shadowy figures that don't exist.
  • Delusions:A delusion is a belief that you hold on to despite evidence showing it is not true. An example of a delusion is if you believe that you can communicate with the characters on a TV show or that someone in the government has put a tracker in your car. Delusions can also be present on a smaller scale, such as the feeling that someone is watching you at all times.

Other positive symptoms are sometimes apparent, including racing thoughts, agitation, aggression, and fast speech.

Negative symptoms, on the other hand, represent a loss of functioning for the individual. Negative symptoms include a severe loss of motivation, emotional withdrawal, dissociation, apathy, social withdrawal, and other symptoms. Negative symptoms are seen less frequently with PTSD, but their presence can complicate the progress of treatment.

The Connection Between PTSD And Psychosis

Over the last few decades, research has begun to piece together the connection between PTSD and psychotic disorders. Lifetime rates of comorbid psychotic disorders in those living with PTSD are estimated at 30%, versus less than 8% in the general population. One study of over 5000 people in the U.S. showed 52% of correlated PTSD and psychotic symptoms.

Positive symptoms are most frequently identified as being connected to PTSD, although negative symptoms are sometimes reported in patients who have had PTSD for an extended period.

Trauma could be a risk factor for both conditions, especially if the trauma occurred early in life. Childhood trauma has a strong connection with both PTSD and psychotic disorders.

Trauma can trigger an actual episode of psychosis or comparatively milder, transient psychotic symptoms. Symptoms may come and go and be related to the trauma in some fashion. Fear and anxiety are often reported to be direct triggers of positive psychotic symptoms.

Paranoia can cause an individual to lose trust in others and withdrawal socially, which can have a circular effect on symptoms of PTSD. Paranoia can make reaching out to others difficult. You may constantly overanalyze the motivations of other people and question whether they are telling you the truth. Paranoia can damage relationships and cause you to become isolated.

Hallucinations

Perhaps the most common symptom of PTSD related to psychosis is hallucinations. You may feel like you see or hear things that aren't there, but that are related to the trauma. Hallucinations can be correlated with, but are distinct from, flashbacks. These are episodes in which you feel like you're reliving the trauma.

Dissociation can also be related to these types of experiences, where you perceive a disconnect between yourself and the world around you.

Paranoia can become severe enough to become full-blown delusions. Delusions are usually related to the trauma in some fashion and can keep a person feeling as though they can't move on from the past. Delusions can be debilitating and difficult to let go of once they have become established.

Diagnosis by a qualified professional is essential to receiving proper treatment. A diagnosis will give you a clear picture of your condition and help you receive the best treatment.

How To Treat PTSD With Psychotic Symptoms

PTSD with comorbid psychosis may often indicate a certain level of severity. If the psychotic disorder is secondary to the PTSD, the latter is usually treated first. Seeking treatment is often the first hurdle to overcome at the start of recovery.

Preliminary research has shown that atypical antipsychotics may help alleviate symptoms of psychosis when comorbid with PTSD, but more investigation is needed to make a definitive statement on the effectiveness of this type of medication. Please consult with your doctor or primary care physician before considering any medication options.

The presence of psychotic symptoms with PTSD may also be associated with a higher risk of depression. Depression is commonly treated with selective serotonin reuptake inhibitors (SSRIs).

Both PTSD and psychotic disorders can persist for a long time on a chronic basis. Treatment can help you effectively manage these conditions.

The Role Of Therapy

Psychotherapy is considered the first-line approach for PTSD, including that with comorbid psychosis. Cognitive behavioral therapy (CBT) has so far been found to be the most effective form of therapy for PTSD. A meta-analysis of CBT for schizophrenic patients found it to be effective at managing symptoms of psychosis.

Various types of CBT have been used to help patients with PTSD treat their symptoms, with varying degrees of evidence to support their effectiveness.

Research shows that online counseling can be a powerful tool in reducing PTSD. This study, for example, found that online therapy is a useful option for people with PTSD and more efficient than face-to-face treatment. Web-based therapy can still maintain the important therapeutic relationship found in more traditional therapy treatment settings, which means you will still have the opportunity to develop a strong connection to your counselor.

Every person needs to feel comfortable with their therapist, but it is particularly important for those living with PTSD. BetterHelp will work to match you with a therapist who makes you feel safe and who you can trust. When you meet with an online counselor who specializes in trauma and recovery, you can be sure that you're in a secure space where you can speak your truth and begin to process what you've been through. The excellent counselors at BetterHelp aren't here to judge but rather to help you treat your scars and traumatic experiences. BetterHelp therapists will also let you go at your own pace. There's no timeline on healing from trauma, and your counselor understands this. You can take all the time in the world to sort through your concerns. Read below for some reviews of BetterHelp counselors.

"Jessica is amazing!! She is so understanding and empathetic. She has done a great job helping me work through my trauma while providing a safe environment that I feel comfortable in. I would recommend her to anybody and everybody!&rdquo

&ldquoCarmen is really insightful and listens to me, and acknowledges my experience and challenges with PTSD. I feel heard and supported. It&rsquos been only a short amount of time but I am confident in her ability to help me.&rdquo

  • Cognitive Processing Therapy (CPT):CPT involves examining feelings, thoughts, and emotions related to the trauma. This information is processed with the support and guidance of the therapist.
  • Prolonged Exposure (PE):During PE, memories of the trauma are processed in the present in a safe environment with the therapist. The patient works on desensitizing the effect of certain triggers in incremental steps.
  • Behavioral Activation:This type of therapy, instead of focusing on processing and relieving the trauma, encourages activating positive behaviors with the idea that your feelings and thought patterns would change accordingly.

Another type of therapy that is gaining attention for treating PTSD, among other conditions, is Eye Movement Desensitization and Reprocessing (EMDR). EMDR involves processing traumatic memories while performing certain eye-movement exercises that encourage positive brain stimulation. Once controversial, promising research has shown EMDR to be effective in improving the symptoms of PTSD.

BetterHelp can connect you with a therapist that will help you determine the best type of therapy to treat your particular condition. BetterHelp's professional online therapy is available whenever you need support to help guide you through the process of moving forward. A therapist can be your partner in navigating the journey to have a more fulfilling life.


The Effects of Post Traumatic Stress Disorder (PTSD) on the Officer and the Family

The following letter is from an officer who wrote it in the Guestbook and kindly gave me permission to use it in an article in the hope that his experience will help others. He describes many of the classic symptoms of police PTSD, or post traumatic stress disorder. In fact, every distressing thought, feeling and behavior he relates below is a symptom of PTSD.

I am a (10 plus)-- year police veteran and (30 plus)-- years of age. I have become seriously concerned with some of the events that have been taking place in my life for the past two years. I have started having nightmares frequently and have great difficulty going to sleep at night. There is always a feeling of uneasiness at night and I have started to develop some unnatural habits associated with these uneasy feelings. At the slightest sound, I have to get out of the bed and check every room in the house.

I have two children who live with me and my wife and I have gotten to the point that I almost always make them come into my room at night because of the feelings I have. If I am the first one in the house to go to sleep, I am ok, but otherwise, the feelings surface about 0:00 pm. I usually end up passing out somewhere between 3 and 5 AM. I get up for work at 7 am and this has started causing me a great deal of problems in my job. I often find myself in a trance thinking about traumatic events that have taken place in my career and always find myself in a very disheartened state afterwards. During the recollection of these events, I often experience a shortness of breath and fear. I feel sad often and one specific event makes me feel very guilty. I know that I could have stopped a murder if I had taken other steps at the time of this incident. I often think about things while driving and end up going in the wrong direction before I realize where I am at.

Certain events that I have experienced cause me a great deal of emotion l distress when I think or communicate about them. My hands are shaking here at 1:06 AM as I write this letter. I have recently found myself to be very irritable, and my wife and I often argue because I don't want to go to social gatherings with her. I am not being anti-social, I just don't like to be around people. I just like being with my kids and taking care of them. I feel bad about some things that are happening to me. My daughter came into my room four nights ago and kissed me on the cheek while I was sleeping. I jumped and scared her to death. My wife came to bed one night and when she walked up to the bed, I drew my fist back to hit her. I get up all hours of the night and check the house over and over. I don't even know what I am looking for. I was asleep about a month ago, and I just knew that someone had fired a gun in my living room. I hear people pound on my door in the middle of the night, when in fact there was never anyone there to my knowledge. One night I got up out of the bed and got my gun. I was about half-asleep. I don't know what I was looking for, but on my way through the house, I cocked my weapon. On the way through the house, the .357 discharged and shot a hole through my floor. Some of the incidents that I remember the most seem vague. I remember every aspect of a shooting where I held the victim as he died. I can't remember what he looked like. We do not have counselors to speak to about these things and I feel that the average doctor would not be able to understand what I am talking about. I Know I need help, but I have dealt with it for the past two years. It is getting harder to deal with.

An officer may develop PTSD after experiencing an critical incident, or being exposed over a period of time to stress that he was unable to alleviate. These are two basic causes of PTSD with police officers:

The first is what the public envisions when police PTSD is brought up, especially after 9-11. These are the single event traumas. Perhaps someone shot him (or, throughout him = and/or her), or maybe he had to kill someone himself. Or perhaps both. The critical incident stress management team might have made every effort possible to debrief the officer. They could have been skilled, they could have been novices. Everyone paid attention at the time, but their lives are like everyone else's lives, and after a while they go about their business and while they still cared, the officer and his family are their own. Hopefully everything worked out and there were no lingering effects. Post traumatic stress disorder can sometimes be avoided even when an individual has the most traumatic, life threatening and life changing experience. Sometimes officers don't get any treatment at all and never develop it. Other times they get what seems like the best treatment and they do.

But sometimes intervention isn't as good as it should be. And other times even the best intervention doesn't work. As far as CISM and CISD*, look at it like a vaccine that is effective a certain percentage of the time. You don't not want to be inoculated, but you have to realize the preventative measure isn't 100%. So it is with critical incident stress management and debriefing. It doesn't always prevent PTSD. Nobody really knows why, except that knowing this there's no excuse for law enforcement administrators not to making sure officers are followed closely for at least two years after an incident. I would recommend at least a monthly half hour session with a good therapist and every other month a meeting which includes the spouse if there is one. Sometimes the individual doesn't see his own symptoms. Either he is denying them or really doesn't recognize how he's changed. Or maybe he kind of sees how he's different but it's too painful to think about it for very long.

The second kind of trauma is addressed, in part, in some of the article list in the "Politics" section of Police Stressline, where the stress is caused by an aspect of the job over a long period of time that undermines the officers self-esteem, confidence and trust in his superiors and/or coworkers. This may occur where there is racial or sexual discrimination. It may occur with an honest officer in a less than honest department. It may occur in an officer that believes in proactive policing in a caretaker reactive department. It can occur in a department where decisions are made on the basis of favoritism, politics and ego. The term "hostile work environment" is generally used to describe this kind of internal police department atmosphere. Of course prolonged trauma that builds up and leads to PTSD can be caused by having to work day after day with an unappreciative or hostile public and being exposed to the worst aspects of the human condition.

Mild PTSD can disrupt a life, but moderate to severe PTSD is a nasty condition. For one thing, it involves a combination of psychological and physiological changes in a person. On the psychological side, it can shake a person's very belief system to the core. It can produce overwhelming, if illogical, guilt feelings. It can lead to an "I don't give a crap" attitude. It can make a police officer question whether the job has any meaning or value. It can make someone so vigilant he becomes paranoid, unable to trust or let his guard down even when he's completely safe. It can lead to suicidal thoughts and in rare instance actual suicides. On the physiological side, as noted in other articles here, it can produce anxiety, irritability, depression, insomnia and a host of physical problems from headaches to digestive problems.

But in the interpersonal realm, there's where the family is really effected. PTSD can cause the sufferer to become emotionally withdrawn and distant from family members. The sex drive can go out the window. He can become overly needy and dependent, or on the other hand outrageously demanding and impatient. He can revert back to old habits like smoking or drinking, or become a newly hatched adolescent and engage in reckless, sometimes life threatening, hobbies. Sometimes hobbies like motorcycling can border on suicidal when officers test the limits of speed and good sense. I hate to say it, but PTSD can contribute to an officer thinking, "what the hell, I might as well have an affair." He may not do it, but thinking it can be very distressing, and the spouse may pick up signs her mate is thinking of straying.

Needless to say, if an officer has turned into a devil-may-care adolescent or become sullen and melancholy, and his personality is different, he might as well be a different person than he was before the critical incident and the onset of PTSD. The family becomes the secondary victim. Loyalty is tested in the extreme. So spouses and kids ask themselves, "if husband or Dad isn't the person he used to be, if sometimes it seems I hardly know him, what am I doing sticking with him?" Of course the families know when the changes occurred and why, and Dad was probably a hero, made the newspaper, got a distinguished officer award. So they stand by him, but the unhappiness is incredible.

What can the family do? First of all, make sure that nothing was missed as far as treatment goes. Especially whether or not there ever was or still is a need for medication. Sometimes law enforcement officers, especially men, are loathe to take meds. But they need to understand that PTSD may actually irrevocably alter the way their brain functions. Research into this is fairly new, but this is what the evidence suggests. Most people reluctantly accept when they've had a serious injury, say to their back, that they may never quite be the same again. But to think that the stress of a critical incident can essentially injure the brain so it will never return to optimal functioning is a horrendous thought. And it may be true.

We know that the efficacy of serotonin in the brain is drastically effected by stress, and by PTSD, which alters the receptor nerve cells. Medications like Prozac, Zoloft, Paxil, Wellbutrin, Celexa, and more recently Lexapro are often recommended and used very effectively to help people through rough times. They help the brain return to normal by making the neurotransmitters work the way they're supposed to. If the officer was on them after the incident and they seemed to help, but he stopped using them in the hopes he wouldn't need them anymore, and the symptoms returned, he should probably start using them again. And if he never was on them, family members should urge him to see his doctor to discuss a trial of at least two months.

The treatment of choice for PTSD is generally a combination of psychotherapy and medication. Officers should be advised that PTSD does not mean post traumatic stress distress. The "D" stands for disorder, and this indicates that one is having a serious reaction to a single incident or to a prolonged trauma.

In addition to finding a sympathetic and knowledgeable physician or psychiatrist, the officer will need to seek out a therapist who works well with police (or correction) officers. Any law enforcement therapist has seen officers who have developed PTSD after a critical incident or after exposure to prolonged trauma.

I wouldn't recommend any drastic life or career changes for an officer until he (and again, it could be a female officer too) has had some therapy, and when appropriate some couple sessions with the spouse. Some officers do quite well when they move out of law enforcement into something completely different following a critical incident that resulted in PTSD, but because law enforcement is as much of a "calling" as medicine or the clergy (or therapy), it is not a decision to be taken lightly. And it is never too late to start.

In closing, the good news for those who suffer directly from it, and those family members who suffer indirectly, is that PTSD is very treatable like most police stress.

Published by the American Academy of Experts in Traumatic Stress - 2020


Clinical trials are research studies that look at new ways to prevent, detect, or treat diseases and conditions. Although individuals may benefit from being part of a clinical trial, participants should be aware that the primary purpose of a clinical trial is to gain new scientific knowledge so that others may be better helped in the future.

Researchers at NIMH and around the country conduct many studies with patients and healthy volunteers. Talk to your health care provider about clinical trials, their benefits and risks, and whether one is right for you. For more information, visit NIMH's clinical trials webpage.


PTSD and Co-Occurring Mental Health Conditions

People with PTSD are 80% more likely to have a comorbid mental health concern than those without the condition. Depression, substance abuse, and anxiety often co-occur with PTSD. Children with PTSD are likely to have comorbid oppositional defiant behavior and separation anxiety. Veterans with PTSD are 48% likely to also have a mild traumatic brain injury.

Other mental health issues can exacerbate PTSD symptoms. They may lower mood, disrupt concentration, or bring out aggressive tendencies. These complicating issues can prevent individuals from seeking help. They may isolate themselves from loved ones or avoid treatment resources. If someone with PTSD has a comorbid condition, it can be quite difficult for them to get necessary care.

A therapist can identify if co-occurring conditions are contributing to PTSD. Therapy can help someone reduce symptoms from PTSD and any other diagnoses. There is no shame in seeking help.


Links Between Trauma, PTSD, and Dissociative Disorders

Carly Snyder, MD is a reproductive and perinatal psychiatrist who combines traditional psychiatry with integrative medicine-based treatments.

There is a very strong link between trauma (especially childhood abuse and/or neglect) and dissociative disorders, and the relationship is important in both directions.   It's thought that long-term trauma is a root cause of dissociative disorders, with dissociation occurring as a coping strategy that allows people to distance themselves from a trauma that may otherwise be unbearable.

When dissociation continues when real danger no longer exists, however, it can prolong or even prevent recovery from abuse and neglect. There is also a connection between dissociation and post-traumatic stress disorder (PTSD).   Changes in brain function may further explain the connections among these causes and conditions.


1. Only soldiers are affected.

Photo by British Library on Unsplash

While the biggest concern surrounding combat is the development of PTSD, soldiers are not the only group susceptible to it. Anyone who has experienced a traumatic event, first or secondhand, such as death, violence, abuse, etc. and does not receive proper support or care to process it, can experience long-lasting post-traumatic stress. Both children and adults are susceptible to it.


Understanding OCD

While many people have repetitive behaviors or driven thoughts, the thoughts and behaviors of a person with OCD are persistent and disruptive to daily functioning.

Obsessions

Obsessions are recurring and persistent thoughts, impulses, and/or images that are viewed as intrusive and inappropriate. The experience of obsessions causes considerable distress and anxiety for a person.

It's important to understand that the obsessions in OCD are not just worries about real-life problems.

People will try (often unsuccessfully) to ignore or "push away" these recurrent thoughts, impulses, or images, usually knowing that they are unreasonable and from their own mind. Yet people with OCD cannot suppress or ignore their obsessions.

Compulsions

Compulsions are repetitive behaviors (for example, excessive hand washing, checking, hoarding, or constantly trying to put things around you in order) or mental rituals (for example, frequently praying, counting in your head, or repeating phrases constantly in your mind) that someone feels like they have to do in response to the experience of obsessive thoughts.

Compulsions are focused on trying to reduce or eliminate anxiety or prevent the likelihood of some kind of dreaded event or situation. Like obsessions, a person with OCD knows that these compulsions are illogical, which causes further distress.

Diagnosing OCD

To be diagnosed with OCD, a person must experience more than one hour per day of intrusive and uncontrollable obsessions and/or compulsions. In addition, these obsessions and/or compulsions must cause considerable distress and impair functioning such as at work, school, or spending time with friends.


Do I Have It?

To figure out if you have it, your doctor will talk to you about the trauma and see if your reactions fit into the American Psychiatric Association’s criteria for PTSD. You must meet all eight of them in order to be diagnosed with PTSD. Here are the criteria:

Criterion A: You must have been exposed to or threatened with death. Or, you must have had an actual or serious injury, or actual or threatened sexual violence. You must have experienced at least one of these things in the following ways:

  • First-hand experience
  • Witnessing the event
  • Learning that a close friend or relative experienced it or was threatened
  • You’re regularly exposed to other people’s trauma, maybe for your job

Continued

Criterion B: You experience the trauma over and over through at least one of the following:

  • Flashbacks
  • Thoughts you can’t control
  • Emotional distress
  • Physical symptoms when thinking about the event

Criterion C: You avoid things that remind you of the trauma. To meet this criterion, you must do one of these things:

  • Avoid thoughts or feelings related to the trauma. For example, you might refuse to talk about war if war was the cause of your symptoms.
  • Avoid things that remind you of the trauma. You might not watch war movies for fear of triggering painful feelings, for instance.

Criterion D: You have negative thoughts or feelings that started or got worse after the trauma. To meet this criterion, at least two of these must be true for you:

  • You remember little about the event
  • You’re overly negative about yourself or the world
  • You blame yourself or others for the trauma, even if it’s not true
  • You lack interest in activities you used to enjoy
  • You feel lonely and isolated
  • You find it hard to be positive or experience joy

Continued

Criterion E: Your symptoms started or got worse after the traumatic event. At least two of these things must be part of your experience:

  • You’re often irritable or angry
  • You constantly feel on guard, or you’re easily startled
  • You engage in risky or dangerous behavior
  • You have trouble sleeping
  • You have trouble staying focused

Criterion F: You meet this criterion if any of your symptoms have lasted for more than a month.

Criterion G: Your symptoms make it hard to work or keep up with daily life.

Criterion H: Your symptoms aren’t caused by medicines, illegal drugs, or another illness.

If you meet all of these standards, your doctor will diagnose you with PTSD. Next step: treatment.


Can PTSD be mild? Do the traumas have to be of a certain kind? - Psychology

National Association of Adult Survivors of Child Abuse

Recovery from child abuse is available, if we work for it

There are many paths to recovering from child abuse, and some of them cost almost no money. Then, too, there are benefits from getting assistance from the professional community trained to assist us.

Trauma specialists believe that "what is most tragic about child abuse and neglect is the exploitation of the child's attachment to the parent." To be sure, it is far easier to abuse one's own children, precisely because their love and loyalty to the parent render them much more compliant than they would be to a stranger. It is exactly this attachment exploitation that teaches children they are not safe in a relationship to other human beings.

Children are born into the world absolutely dependent and helpless. They depend on others for food, warmth, cleanliness and protection from threat. Children's natural and healthy helplessness is transformed into terror and dispair when those needs are ignored, or when a parent plays "let's make a deal" with those needs.

Childhood should be a time of no-risk dependency. Many children, in desperation, learn to care prematurely for themselves. at the expense of trust in others, emotional growth and self-acceptance. Unfortunately, try as they might, such children can never absolutely ensure their survival, simply because it is never absolutely within their control.

Try as they might, parents cannot always protect their children from trauma. A relative dies. The house burns down. The child witnesses a fatal car accident. The child is molested by someone outside the family and terrorized into keeping the secret. Yet, children can survive intact emotionally if adults provide them with a sense of safety and well-being in the aftermath of traumatic events.

Realistic, protective and compassionate treatment by adults can become more meaningful than the trauma itself, thus lessening its after-effects. However, when the source of the trouble is within the family, realism, protection and comapssion are usually in short supply. It is often not so much what actually happened that causes the "persistant negative effects" of trauma, as it is the absence of healing responses. what didn't happen afterward.

Suppose that in the midst of a tornado a child sought comfort and protection from his parents and was told, "What tornado? It's a beautiful day. Go outside and play." That's how crazy and unsafe the world seems to some children. Some survivors have tried to tell the truth about the abuse and were called liars or accused of being responsible for the abuser's behavior.

When a victim or survivor is disbelieved, shamed, threatened into silence, or when the disclosure is minimized or becomes cause for punishment, the trauma inflicted by willful ignorance compounds the original trauma. Children can withstand a lot with the help of other people conversely, the denial or rejection of children's normal thoughts and feelings about trauma can cause as much pain as the original trauma.

To minimize the damage of trauma, children also need protection from further harm. But in troubled families it is not in the abuser's best interest to teach the child how to prevent further abuse. The nonprotective parent who denies or minimizes the abuse is usually passive. The child is usually left on his own to figure out the best way to protect himself.

Survivors rarely, if ever, benefitted from the compassionate and reasonable reactions that would have lessened the effects of their troubled childhoods. Given the enormity of what didn't happen after their traumas, it isn't surprising that they entered adulthood numb and anxious, or both. Protective numbing and reactive anxiety are, after all, normal reactions to abnormal situations.

Clearly, people were not meant to be physically or sexually abused. Human beings are not equipped to understand abuse as it happens, not to feel the full force of their physiological response at the time. And they cannot, at that moment, find meaning in the experience of the abuse. Each of these important elements of accomodation can only happen later, in distinct stages.

Survivors commonly speak of how they endured trauma by pretending that their mind and spirit had gone to a safer place, leaving the body behind to endure the abuse.

Abused children abandon reality, dissociating mind from body so they won't be overwhelmed and their ability to cope won't be shattered. Even a relatively minor trauma can provoke dissociation until a person is later able to integrate the experience. "Later", in the case of chronic abuse, particularly where the child has no support, may mean years later.

In the short run, dissociation is a very effective defense, walling off what cannot be accomodated. Sometimes the actual memory of the abuse goes into deep freeze. An incident in the present may trigger strong feelings that really belong to an incident in the past. The survivor may become enraged by what merely annoys others, devastated when others are momentarily sad, panicked when others are just worried. Present events tap into a deep well of feelings whose source remains alusive.

When asked what the worst memory from their childhood is, many survivors reply, "My worst memory has yet to surface."

Sometimes only the feelings go into deep freeze. Some suvivors have perfect, excruciating detailed recall of the abuse itself, but are numb to their feelings. Their hearts are in deep freeze. They do fine when they are not provoked to feel too much. They may avoid friendships and romance, or enter into them only on their own terms. They believe their feelings are as troublesome and overwhelming today as their parents once told them they were. They are numb to feelings as a way to keep control.

Many survivors ask, "If I don't remember the trauma, or if I don't have strong feelings about it, isn't that better?" Dissociation eventually takes far more effort than it is worth. The more we try not to, the more feelings and thoughts assert themselves, unconsciously demanding our attention. It takes an enormous toll to keep perfectly legitimate memories and feelings about childhood trauma in deep freeze. In the long run, one is better letting the thaw happen, and with the support of others, participating in some manner of "cure" that will allow life to go on.

Some survivors don't know they have a highly recognizable and treatable anxiety disorder called Post Traumatic Stress Disorder (PTSD), which has been associated with survivors of the Vietnam War, the Holocaust, mass murders, natural disasters, rape, kidnapping, accidents, torture, and other extraordinary events.

People with PTSD often re-experience the trauma in their minds. When the memory brings on a physiological response or feeling this is called an abreaction. (The release of emotional tension through the recalling of a repressed traumatic event.) Often the situation that brings on the abreaction is reminiscent of the original trauma.

An abreaction could be triggered by something someone says, circumstances such as the press of a crowd, being left totally alone, a darkened room. or even a particular time of the year, smells, touch, tastes. or other things associated with the trauma. Suddenly, the survivor is transported as if in a time machine to the event of the original trauma and reacts with the emotional intensity that would have been appropriate then, though not now. During an abreaction it is difficult to distinguish "what was" from "what is".

Herein lies the Achilles Heels for survivors. They function well in many aspects of life until they encounter the events or circumstances that are likely to trigger abreactions: emotional vulnerability, physical illness or evasive medical procedures, struggles with authority figures, cultural oppression or abandonment, to name a few.

A person with PTSD lives with a persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness. Survivors with PTSD may avoid any intimate connection, often resulting in feelings of detachment or estrangement from others. Survivors often have highly developed social skills and may seem to be extremely extroverted, but their dealings with others may preclude vulnerability. They can talk about movies or work or the weather, but they have difficulty expressing their feelings. Or, they may have constricted feelings. They may be unable to identify and express a wide range of emotions, particularly the anger, fear and sadness so closely associated with the original traumatic events.

Certain circumstances can make the disorder longer lasting and more severe. If a trauma is repeated, for instance, as in chronic physical or sexual abuse, then the disorder might persist more than it would after only one incident. Repitition does not make one immune to the consequences of trauma. Rather, it has a cumulative effect, as unresolved trauma is layered upon unresolved trauma.

Traumatic events that are human in origin seem to have more severe after-effects than natural disasters. Hurtful and frightening as it is to be raped by a stranger, or to be in the path of a natural disaster, the creation of a personal disaster by a loved one is vastly more bewildering and overwhelming.

Another circumstance that contributes to the persistance of PTSD is the victim's age. The younger the victim, the more vulnerable he is. The more developmental skills and life experiences uncontaminated by trauma a child has, the more he has to draw on in the face of trauma. When life goes well, and children are loved and protected, each day is like a deposit in a savings account. Neglect, repeated physical abuse or sexual assault. or other life-threatening events, make huge withdrawals on the account. The more a child has in the bank when the trauma occurs, the better the prognosis for a quick recovery. Small children who are repeatedly traumatized usually have few deposits and easily become emotionally bankrupt.

When the survivor is ready to deal with it, memories and feelings begin to reconnect. He or she remembers, with the mind and feelings, instead of dismembering through dissociation.

The beginning of reconnection is usually attibuted to the fortuitous occurence of a trigger - an event or circumstance obviously associated with or reminiscent of the original trauma. There must also always be the simultaneous occurence of a positive trigger before the reconnection can begin. For instance, the survivor may have found someone trustworthy to talk to (therapist, friend, partner, support group) and may finally feel safe and sane enough to explore and accept her feelings.

The pain and disorientation can be balanced by focusing on the positive trigger. During this process, survivors should ask themselves, "Why now? Why didn't I remember this two years ago? Five years ago?" The answer lies in the conjunction of this trigger, along with the negative one, which tells the survivor "you can afford to reconnect now. you have the power, judgement, insight and support that you truly did not have as a child. It is safe enough."

Walling off parts of the trauma was once the solution to an unbearable situation. Eventually, it causes problems in the mind, heart and spirit, in one's relationships with the child within and others, and in one's work. Trauma, if left unresolved, is destined to be re-enacted in one of those vital aspects of the self.

To recognize that a mother is exploiting you for her own ends, or that a father is unjust and tyrannical, or that neither parent ever wanted you, is intensely painful. Moreover, it is frightening. Given any loophole, most children will seek to see their parent's behavior in some more favorable light. This natural bias of children is easy to exploit.

It is not just the child's body that is abused or neglected. Troubled families mess with a child's mind. Virtually all survivors believe that their ability to think, to intellectually master the challenges in their lives, was of of their greatest strengths as children. Like other coping mechanisms, their over-reliance on rationality fell into obsolesence and became one of their greater weaknesses.

Children struggle to make some sense of a loved one's abusive and neglectful treatment. If the child understood what abuse really was, a random and violent imposition of another's will onto a relatively helpless person, he would despair at such hopelessness and betrayal. Therefore, he uses every mental effort to make himself seem in greater control while transforming the abusive parent into the safe and loving caretaker he so desperately needs. Such lies of the mind require mental gymnastics.

Children don't do this thinking in a vacuum. In some situations they are told what to think. In most cases they are influenced by the abuser's faulty thinking and by the rationalization of the adults who passively enable the abuse to go on. Children hear what those powerful adults say and what they don't say.

On top of the abuse and neglect, denial heaps more hurt upon the child by requiring the child to alienate herself from reality and her own experience. In troubled families, abuse and neglect are permitted it's the talking about them that is forbidden.

Minimization is a thinking error designed to protect the injured self, making one seem a little less injured. The need for it can lessen as the survivor can afford to embrace the full reality of the past. (Refraining from denial is an act of courage for survivors. They have to choose quite literally between being alienated from themselves and reality. or being alienated from family members who still deny abuse.)

In troubled families, the thinking around who is responsible is convoluted at best. Abusive parents externalize, blaming other people, places and things for their behavior. They compensate by controlling everyone around them. But. in their heart of hearts. they feel out of control. They must blame others because it is too painful to take responsibility for their unhappiness. Children are easy targets because they cannot challenge their parent's thinking errors. Few children can argue when facing an enraged mother. Hearing accusations often enough, children come to believe that they are responsible for their parent's troubled behavior.

Unfortunately, children receive an internal psychological payoff when they believe the abuse is their fault. a false sense of power. The child can let the unfairness and danger of the violence shatter him, or he can tell himself, "I'm not frightened or angry or sad or helpless or innocent. There is nothing wrong with this situation. This is happening to me for a good reason. This is happening to me because I deserve it, because I provoked it, because I was put here on Earth to endure such things. There is really nothing out of the ordinary about this."

The child is doing the best he or she can do to make sense out of the abuse or neglect, by feeling guilty and responsible, thereby holding on to the illusion that he or she is in control of what is truly out of control. This illusion of power seems better than acknowledging that one has no power at all. Such pseudologic quells feelings of hurt, rage, terror, confusion or sadness. rationalizing them into a deep freeze.

The child's sense of guilt and responsibility is useful to the abusive parent, who believes he isn't abusive..that it is the child who forces him into being abusive. The nonprotective adults want the child to bear the guilt so they won't have to face the harm their neglect is causing. So. the dance of the violent family begins: Children are responsible for adult's behavior. adults are responsible for nothing.

Faced with random, senseless abuse, a child begins to think herself as inherently unlovable.

Believing oneself to be guilty, responsible, or in control of others' hurtful behavior can be a tenacious habit. Many survivors deal with any overwhelming experience - physical illness, abandoment by a friend or spouse, academic or job demands - by "comforting" themselves with the illusion that they are in fact in control and to blame. An enormous amount of energy is sapped by this irrational guilt.

Rarely do survivors see themselves as so powerful over the good in their own lives. Here, their parent's constant projection has left it's mark. Many survivors, convinced of their inherent worthlessness and inadequacy, look to other people, places and things for salvation. Only when they have the "perfect intimate partner, their dream house, or public recognition for their work" will they be redeemed. Of course, anything so powerful to save their lives might also destroy their lives, which brings the survivor back full circle to his original feeling of powerlessness. Reasponsible for all the pain in the world. he is inept at enjoying his own happiness.

Fantasy, as a coping mechanism can also be a weakness. Too often fantasies become more real than relationships. Survivors may fantasize a lot about what other people think or feel about them.

Trauma influences our ways of organizing in our minds what goes on out in the world. Survivors who have not fared well in life tend to think in sweeping generalities. people are either good or bad, with no gray area in between. Everything is "always" or "never", with no room for "doesn't matter much." In contrast, some survivors have thinking that is highly compartmentalized.

Children simply do not have the cognitive development or life experience for clear thinking in the face of trauma. Their thinking errors reflect their best attempt to comprehend the incomprehensible. when the truth wasn't offered or allowed. A first step to recovery, then, is to examine, challenge, and change these old ways of thinking about trauma.

The goal of sorting through the lies of the mind is to learn to take the abuse less personally, and thereby to feel safer. By looking back, the powerful adult mind can more objectively measure the powerlessness of the traumatized child.

Thinkly clearly may not be the entire answer, but it is an excellent and necessary beginning. Emerson wrote: "It is the oyster who mends its shell with pearls." But, unlike oysters, we are not solitary creatures. We mend one another as well as ourselves. Pearls of wisdom help us to take the next step. to heal in the company of other people, feeling the effects of the trauma while we hold onto our life rafts.

Feelings begin in the body, not in the mind. Many survivors say, "I know what happened wasn't my fault, but I still feel somewhat unlovable and damaged. My self-worth is measured by how other people see me. My head knows that is wrong, but my heart feels differently. Thinking comes much more easily to me. it's still a big risk to feel. If I ever started to cry, I'd cry a river. If I ever felt the terror of it all, I'd disintegrate into nothingness."

Children don't innately know how to repress their spontaneous responses. They have to be taught, and troubled parents are perhaps the best teachers of all. There are three iron-clad rules in the abusive home: Don't talk. Don't trust. Don't feel. To break any of them means risking rejection or punishment.

One of the few predictable aspects of a violent family is the unpredictablity of the parent's responses. Every time the child cries, he gets a different response. Soon he realizes that it is unsafe to cry. After a while, he keeps his feelings to himself and perhaps loathes spontaneity because it causes so much trouble.

Young children offer their feelings to adults as gifts, as their currency of exchange in intimacy. All they can do to be close to adults is to offer their feelings. When their feelings are ignored or rejected as wrong, bad, troublesome, sick, crazy or stupid. they feel rejected. The young mind reasons "since my feelings are unacceptable, I must be unacceptable, too."

Beyond teaching children to recognize and articulate their feelings, parents help children to contain and express feelings constructively. When children do not learn how to do this they may become overwhelmed by them, experiencing them as floods. They may come to fear or loathe their feelings.

Adults from abusive homes can also become pain-avoidant. Survivors attempt to control the people and events around them so that they will never feel pain again.

What is most tragic about pain-avoidant behavior is that it is a defense against something that has already happened and cannot be undone. A survivor cannot live fully in the present until he or she has the past in perspective. Sometimes being preoccupied and defensive about the pain waiting in the future is just a distraction from addressing the real pain in the past.

To be intimate is to risk pain. There are no guanantees. To miss years of loving to avoid the pain of loss is too high a price to pay.

Survivors attempt to flee from feelings about having been abused, from normal reactions to an abnormal situation. Because that situation was life-threatening in the past, some survivors mistakenly believe that to experience those feelings today would also be life-threatening, would bring on an emotional breakdown, a falling apart akin to death. They do not understand that the breakdown has already happened, when their feelings were preempted by shame.

A survivor can afford to look that "death" squarely in the face when he has people who will stand by him, as well as the insight and power he did not have as a child. When it is finally safe enough, the survivor will remember the memories and feel the feelings about the trauma. Such a "thawing out" is a second chance, an emotional reincarnation. Still. the first sensations that have been repressed or avoided all of one's life can feel like a tidal wave.

When he is ready, the thoughts and feelings return. In response to what has been uncovered, he often feels great anger at the betrayal itself and the injustice and randomness of the violence.

Underneath that anger is a terror and helplessness that is more difficult to experience than the anger. ("Maybe it wasn't as bad as I remember. Maybe I'm just exaggerating.") This can go on for a long time, but with the help of others, the survivor will eventually accept that the trauma was as bad as he knows it was.

Profound sadness follows. This compassionate acceptance of "poor me" and the mourning of the losses that the trauma created eventually lead to resolution.

When the losses engendered by trauma are fully mourned, the trauma loses its power over the survivor. Instead of the emotional breakdown they feared. survivors experience an emotional breakthrough! Completing the grieving process means divorcing the trauma from one's sense of identity and self-worth.

This was written by me around 1990-1991. I had been in a psychiatric hospital for the first time for a couple weeks, and part of my therapy after being discharged was to keep a journal.

This came from that journal.

If I ever let out the scream inside me, it will be heard for miles. It will echo across acres of land and tens of years. It will be a scream of rage and hurt and violation and of things wrongfully taken. It will put fear into the hearts of wild beasts, topple mountains and shatter the calm. It will ripple and grow and turn in upon itself as it simultaneously devours everything in its path.

If I ever let out the scream inside me, it will come from the very depths of my soul. It will start at my toes, explode through my heart, spring out through my tears. It will freeze my face in an expression of terror and pain. It will rip through the essence of my being. It would convulse my body into spasms of anguish and sorrow.

I would know, at that instant, how murders happen, how suicides are excused or explained. how vulnerable each of us really are.

I would scream the rage for myself and every other child throughout time that has been hurt, abused, neglected, afraid, abandoned or forgotten. I would scream the rage for myself and every other child throughout time that has sought comfort and been turned away or ignored, that looked for answers without knowing the questions.

If I ever let out the scream inside me it would be an emotional vomiting of things rotten and diseased, of things soured and spoiled. contaminated things that sit and churn and cannot be purged by any other means than an immense, sudden and explosive release. For the feelings behind the scream are volatile. and pressurized.

If I ever let out the scream inside me, I will have to do it alone, for I was alone when it was forced upon me in the first place. The scream is mine and mine alone. It is one of the few things I was allowed to keep. Most everything else was taken.

But now the scream wants to be set free. it doesn't want to be mine anymore. It demands release. How can I expect anyone to hold me near? I don't even want to be here. Hide, hide! Go to sleep! Maybe it will fade away. Maybe it will stay. I don't think so. I think it wants out.

It hurts! It swells and presses outward. but I can't let it go. I am paralyzed by it. It's got ME captive instead of the other way around.


PTSD and Co-Occurring Mental Health Conditions

People with PTSD are 80% more likely to have a comorbid mental health concern than those without the condition. Depression, substance abuse, and anxiety often co-occur with PTSD. Children with PTSD are likely to have comorbid oppositional defiant behavior and separation anxiety. Veterans with PTSD are 48% likely to also have a mild traumatic brain injury.

Other mental health issues can exacerbate PTSD symptoms. They may lower mood, disrupt concentration, or bring out aggressive tendencies. These complicating issues can prevent individuals from seeking help. They may isolate themselves from loved ones or avoid treatment resources. If someone with PTSD has a comorbid condition, it can be quite difficult for them to get necessary care.

A therapist can identify if co-occurring conditions are contributing to PTSD. Therapy can help someone reduce symptoms from PTSD and any other diagnoses. There is no shame in seeking help.


The Effects of Post Traumatic Stress Disorder (PTSD) on the Officer and the Family

The following letter is from an officer who wrote it in the Guestbook and kindly gave me permission to use it in an article in the hope that his experience will help others. He describes many of the classic symptoms of police PTSD, or post traumatic stress disorder. In fact, every distressing thought, feeling and behavior he relates below is a symptom of PTSD.

I am a (10 plus)-- year police veteran and (30 plus)-- years of age. I have become seriously concerned with some of the events that have been taking place in my life for the past two years. I have started having nightmares frequently and have great difficulty going to sleep at night. There is always a feeling of uneasiness at night and I have started to develop some unnatural habits associated with these uneasy feelings. At the slightest sound, I have to get out of the bed and check every room in the house.

I have two children who live with me and my wife and I have gotten to the point that I almost always make them come into my room at night because of the feelings I have. If I am the first one in the house to go to sleep, I am ok, but otherwise, the feelings surface about 0:00 pm. I usually end up passing out somewhere between 3 and 5 AM. I get up for work at 7 am and this has started causing me a great deal of problems in my job. I often find myself in a trance thinking about traumatic events that have taken place in my career and always find myself in a very disheartened state afterwards. During the recollection of these events, I often experience a shortness of breath and fear. I feel sad often and one specific event makes me feel very guilty. I know that I could have stopped a murder if I had taken other steps at the time of this incident. I often think about things while driving and end up going in the wrong direction before I realize where I am at.

Certain events that I have experienced cause me a great deal of emotion l distress when I think or communicate about them. My hands are shaking here at 1:06 AM as I write this letter. I have recently found myself to be very irritable, and my wife and I often argue because I don't want to go to social gatherings with her. I am not being anti-social, I just don't like to be around people. I just like being with my kids and taking care of them. I feel bad about some things that are happening to me. My daughter came into my room four nights ago and kissed me on the cheek while I was sleeping. I jumped and scared her to death. My wife came to bed one night and when she walked up to the bed, I drew my fist back to hit her. I get up all hours of the night and check the house over and over. I don't even know what I am looking for. I was asleep about a month ago, and I just knew that someone had fired a gun in my living room. I hear people pound on my door in the middle of the night, when in fact there was never anyone there to my knowledge. One night I got up out of the bed and got my gun. I was about half-asleep. I don't know what I was looking for, but on my way through the house, I cocked my weapon. On the way through the house, the .357 discharged and shot a hole through my floor. Some of the incidents that I remember the most seem vague. I remember every aspect of a shooting where I held the victim as he died. I can't remember what he looked like. We do not have counselors to speak to about these things and I feel that the average doctor would not be able to understand what I am talking about. I Know I need help, but I have dealt with it for the past two years. It is getting harder to deal with.

An officer may develop PTSD after experiencing an critical incident, or being exposed over a period of time to stress that he was unable to alleviate. These are two basic causes of PTSD with police officers:

The first is what the public envisions when police PTSD is brought up, especially after 9-11. These are the single event traumas. Perhaps someone shot him (or, throughout him = and/or her), or maybe he had to kill someone himself. Or perhaps both. The critical incident stress management team might have made every effort possible to debrief the officer. They could have been skilled, they could have been novices. Everyone paid attention at the time, but their lives are like everyone else's lives, and after a while they go about their business and while they still cared, the officer and his family are their own. Hopefully everything worked out and there were no lingering effects. Post traumatic stress disorder can sometimes be avoided even when an individual has the most traumatic, life threatening and life changing experience. Sometimes officers don't get any treatment at all and never develop it. Other times they get what seems like the best treatment and they do.

But sometimes intervention isn't as good as it should be. And other times even the best intervention doesn't work. As far as CISM and CISD*, look at it like a vaccine that is effective a certain percentage of the time. You don't not want to be inoculated, but you have to realize the preventative measure isn't 100%. So it is with critical incident stress management and debriefing. It doesn't always prevent PTSD. Nobody really knows why, except that knowing this there's no excuse for law enforcement administrators not to making sure officers are followed closely for at least two years after an incident. I would recommend at least a monthly half hour session with a good therapist and every other month a meeting which includes the spouse if there is one. Sometimes the individual doesn't see his own symptoms. Either he is denying them or really doesn't recognize how he's changed. Or maybe he kind of sees how he's different but it's too painful to think about it for very long.

The second kind of trauma is addressed, in part, in some of the article list in the "Politics" section of Police Stressline, where the stress is caused by an aspect of the job over a long period of time that undermines the officers self-esteem, confidence and trust in his superiors and/or coworkers. This may occur where there is racial or sexual discrimination. It may occur with an honest officer in a less than honest department. It may occur in an officer that believes in proactive policing in a caretaker reactive department. It can occur in a department where decisions are made on the basis of favoritism, politics and ego. The term "hostile work environment" is generally used to describe this kind of internal police department atmosphere. Of course prolonged trauma that builds up and leads to PTSD can be caused by having to work day after day with an unappreciative or hostile public and being exposed to the worst aspects of the human condition.

Mild PTSD can disrupt a life, but moderate to severe PTSD is a nasty condition. For one thing, it involves a combination of psychological and physiological changes in a person. On the psychological side, it can shake a person's very belief system to the core. It can produce overwhelming, if illogical, guilt feelings. It can lead to an "I don't give a crap" attitude. It can make a police officer question whether the job has any meaning or value. It can make someone so vigilant he becomes paranoid, unable to trust or let his guard down even when he's completely safe. It can lead to suicidal thoughts and in rare instance actual suicides. On the physiological side, as noted in other articles here, it can produce anxiety, irritability, depression, insomnia and a host of physical problems from headaches to digestive problems.

But in the interpersonal realm, there's where the family is really effected. PTSD can cause the sufferer to become emotionally withdrawn and distant from family members. The sex drive can go out the window. He can become overly needy and dependent, or on the other hand outrageously demanding and impatient. He can revert back to old habits like smoking or drinking, or become a newly hatched adolescent and engage in reckless, sometimes life threatening, hobbies. Sometimes hobbies like motorcycling can border on suicidal when officers test the limits of speed and good sense. I hate to say it, but PTSD can contribute to an officer thinking, "what the hell, I might as well have an affair." He may not do it, but thinking it can be very distressing, and the spouse may pick up signs her mate is thinking of straying.

Needless to say, if an officer has turned into a devil-may-care adolescent or become sullen and melancholy, and his personality is different, he might as well be a different person than he was before the critical incident and the onset of PTSD. The family becomes the secondary victim. Loyalty is tested in the extreme. So spouses and kids ask themselves, "if husband or Dad isn't the person he used to be, if sometimes it seems I hardly know him, what am I doing sticking with him?" Of course the families know when the changes occurred and why, and Dad was probably a hero, made the newspaper, got a distinguished officer award. So they stand by him, but the unhappiness is incredible.

What can the family do? First of all, make sure that nothing was missed as far as treatment goes. Especially whether or not there ever was or still is a need for medication. Sometimes law enforcement officers, especially men, are loathe to take meds. But they need to understand that PTSD may actually irrevocably alter the way their brain functions. Research into this is fairly new, but this is what the evidence suggests. Most people reluctantly accept when they've had a serious injury, say to their back, that they may never quite be the same again. But to think that the stress of a critical incident can essentially injure the brain so it will never return to optimal functioning is a horrendous thought. And it may be true.

We know that the efficacy of serotonin in the brain is drastically effected by stress, and by PTSD, which alters the receptor nerve cells. Medications like Prozac, Zoloft, Paxil, Wellbutrin, Celexa, and more recently Lexapro are often recommended and used very effectively to help people through rough times. They help the brain return to normal by making the neurotransmitters work the way they're supposed to. If the officer was on them after the incident and they seemed to help, but he stopped using them in the hopes he wouldn't need them anymore, and the symptoms returned, he should probably start using them again. And if he never was on them, family members should urge him to see his doctor to discuss a trial of at least two months.

The treatment of choice for PTSD is generally a combination of psychotherapy and medication. Officers should be advised that PTSD does not mean post traumatic stress distress. The "D" stands for disorder, and this indicates that one is having a serious reaction to a single incident or to a prolonged trauma.

In addition to finding a sympathetic and knowledgeable physician or psychiatrist, the officer will need to seek out a therapist who works well with police (or correction) officers. Any law enforcement therapist has seen officers who have developed PTSD after a critical incident or after exposure to prolonged trauma.

I wouldn't recommend any drastic life or career changes for an officer until he (and again, it could be a female officer too) has had some therapy, and when appropriate some couple sessions with the spouse. Some officers do quite well when they move out of law enforcement into something completely different following a critical incident that resulted in PTSD, but because law enforcement is as much of a "calling" as medicine or the clergy (or therapy), it is not a decision to be taken lightly. And it is never too late to start.

In closing, the good news for those who suffer directly from it, and those family members who suffer indirectly, is that PTSD is very treatable like most police stress.

Published by the American Academy of Experts in Traumatic Stress - 2020


What Is PTSD?

Post-traumatic stress disorder (PTSD) is a mental health condition caused by an intensely fearful situation, such as participating in active combat, being in a car accident, or surviving domestic violence. A diagnosis of PTSD requires a specific trigger that led to the development of certain related symptoms.

The core symptoms of PTSD include avoidance, intrusive memories, emotional reactivity or numbness, sleep disturbances, panic attacks, hypervigilance, and dissociation. These symptoms may also lead to chronic low mood states and negative thinking patterns. PTSD symptoms can range from mild to severe and can get in the way of the person&rsquos ability to lead a normal and fulfilling life. These symptoms indicate that the brain's fear response system has become effectively "stuck" in the on position, perceiving threats from relatively harmless stimuli and firing false alarms.

While not everyone will develop PTSD in the aftermath of a trauma, it is a common condition that affects up to 14 million adults in America. We're still learning exactly what leads to certain people developing the condition and not others. It appears to be partially related to genetics and individual vulnerabilities in certain brain structures.

Hyperactivity in certain parts of the brain, especially the amygdala, may put a person at risk for developing PTSD in the aftermath of a trauma. Dopamine, usually considered a chemical promoting reward and motivation, may also play a role in promoting anxiety and recognizing fear. Dysregulation in this area needs further investigation to understand its role in PTSD and other mental health conditions.

PTSD was added to the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980, though its symptoms had been recognized for decades before. Interestingly, while men are statistically more likely to have PTSD at some point in their lifetime than women, women are more likely to seek treatment.

For some people, psychotic disorders may occur secondary to PTSD symptoms. While the link between the two conditions is still being investigating, there is evidence of a connection.

What Is Psychosis?

Psychosis refers to a collection of symptoms that cause an individual to be disconnected from reality. Psychotic symptoms are grouped into two distinct categories: positive symptoms and negative symptoms.

Positive symptoms are the addition of thoughts, behaviors, and mental states. The person may have the awareness that these symptoms represent things that are not real (referred to as "insight") or, in more severe cases, may not be able to differentiate between what is real and what isn't. Positive symptoms of psychosis include:

  • Paranoia:Paranoia refers to anxious thoughts that involve suspicion and distrust of other people, including people that the individual is close to, like family members and friends. You may feel like someone or something is out to get you. You may think you're being followed or listened to, or you may have obsessive thoughts that someone is trying to conspire against you.
  • Hallucinations:A hallucination is the perception of something that is not real. Hallucinations can be visual, auditory, tactile (physical), or even a smell or taste. You may hear voices when there's no one around, smell a scent with no apparent source, or see shadowy figures that don't exist.
  • Delusions:A delusion is a belief that you hold on to despite evidence showing it is not true. An example of a delusion is if you believe that you can communicate with the characters on a TV show or that someone in the government has put a tracker in your car. Delusions can also be present on a smaller scale, such as the feeling that someone is watching you at all times.

Other positive symptoms are sometimes apparent, including racing thoughts, agitation, aggression, and fast speech.

Negative symptoms, on the other hand, represent a loss of functioning for the individual. Negative symptoms include a severe loss of motivation, emotional withdrawal, dissociation, apathy, social withdrawal, and other symptoms. Negative symptoms are seen less frequently with PTSD, but their presence can complicate the progress of treatment.

The Connection Between PTSD And Psychosis

Over the last few decades, research has begun to piece together the connection between PTSD and psychotic disorders. Lifetime rates of comorbid psychotic disorders in those living with PTSD are estimated at 30%, versus less than 8% in the general population. One study of over 5000 people in the U.S. showed 52% of correlated PTSD and psychotic symptoms.

Positive symptoms are most frequently identified as being connected to PTSD, although negative symptoms are sometimes reported in patients who have had PTSD for an extended period.

Trauma could be a risk factor for both conditions, especially if the trauma occurred early in life. Childhood trauma has a strong connection with both PTSD and psychotic disorders.

Trauma can trigger an actual episode of psychosis or comparatively milder, transient psychotic symptoms. Symptoms may come and go and be related to the trauma in some fashion. Fear and anxiety are often reported to be direct triggers of positive psychotic symptoms.

Paranoia can cause an individual to lose trust in others and withdrawal socially, which can have a circular effect on symptoms of PTSD. Paranoia can make reaching out to others difficult. You may constantly overanalyze the motivations of other people and question whether they are telling you the truth. Paranoia can damage relationships and cause you to become isolated.

Hallucinations

Perhaps the most common symptom of PTSD related to psychosis is hallucinations. You may feel like you see or hear things that aren't there, but that are related to the trauma. Hallucinations can be correlated with, but are distinct from, flashbacks. These are episodes in which you feel like you're reliving the trauma.

Dissociation can also be related to these types of experiences, where you perceive a disconnect between yourself and the world around you.

Paranoia can become severe enough to become full-blown delusions. Delusions are usually related to the trauma in some fashion and can keep a person feeling as though they can't move on from the past. Delusions can be debilitating and difficult to let go of once they have become established.

Diagnosis by a qualified professional is essential to receiving proper treatment. A diagnosis will give you a clear picture of your condition and help you receive the best treatment.

How To Treat PTSD With Psychotic Symptoms

PTSD with comorbid psychosis may often indicate a certain level of severity. If the psychotic disorder is secondary to the PTSD, the latter is usually treated first. Seeking treatment is often the first hurdle to overcome at the start of recovery.

Preliminary research has shown that atypical antipsychotics may help alleviate symptoms of psychosis when comorbid with PTSD, but more investigation is needed to make a definitive statement on the effectiveness of this type of medication. Please consult with your doctor or primary care physician before considering any medication options.

The presence of psychotic symptoms with PTSD may also be associated with a higher risk of depression. Depression is commonly treated with selective serotonin reuptake inhibitors (SSRIs).

Both PTSD and psychotic disorders can persist for a long time on a chronic basis. Treatment can help you effectively manage these conditions.

The Role Of Therapy

Psychotherapy is considered the first-line approach for PTSD, including that with comorbid psychosis. Cognitive behavioral therapy (CBT) has so far been found to be the most effective form of therapy for PTSD. A meta-analysis of CBT for schizophrenic patients found it to be effective at managing symptoms of psychosis.

Various types of CBT have been used to help patients with PTSD treat their symptoms, with varying degrees of evidence to support their effectiveness.

Research shows that online counseling can be a powerful tool in reducing PTSD. This study, for example, found that online therapy is a useful option for people with PTSD and more efficient than face-to-face treatment. Web-based therapy can still maintain the important therapeutic relationship found in more traditional therapy treatment settings, which means you will still have the opportunity to develop a strong connection to your counselor.

Every person needs to feel comfortable with their therapist, but it is particularly important for those living with PTSD. BetterHelp will work to match you with a therapist who makes you feel safe and who you can trust. When you meet with an online counselor who specializes in trauma and recovery, you can be sure that you're in a secure space where you can speak your truth and begin to process what you've been through. The excellent counselors at BetterHelp aren't here to judge but rather to help you treat your scars and traumatic experiences. BetterHelp therapists will also let you go at your own pace. There's no timeline on healing from trauma, and your counselor understands this. You can take all the time in the world to sort through your concerns. Read below for some reviews of BetterHelp counselors.

"Jessica is amazing!! She is so understanding and empathetic. She has done a great job helping me work through my trauma while providing a safe environment that I feel comfortable in. I would recommend her to anybody and everybody!&rdquo

&ldquoCarmen is really insightful and listens to me, and acknowledges my experience and challenges with PTSD. I feel heard and supported. It&rsquos been only a short amount of time but I am confident in her ability to help me.&rdquo

  • Cognitive Processing Therapy (CPT):CPT involves examining feelings, thoughts, and emotions related to the trauma. This information is processed with the support and guidance of the therapist.
  • Prolonged Exposure (PE):During PE, memories of the trauma are processed in the present in a safe environment with the therapist. The patient works on desensitizing the effect of certain triggers in incremental steps.
  • Behavioral Activation:This type of therapy, instead of focusing on processing and relieving the trauma, encourages activating positive behaviors with the idea that your feelings and thought patterns would change accordingly.

Another type of therapy that is gaining attention for treating PTSD, among other conditions, is Eye Movement Desensitization and Reprocessing (EMDR). EMDR involves processing traumatic memories while performing certain eye-movement exercises that encourage positive brain stimulation. Once controversial, promising research has shown EMDR to be effective in improving the symptoms of PTSD.

BetterHelp can connect you with a therapist that will help you determine the best type of therapy to treat your particular condition. BetterHelp's professional online therapy is available whenever you need support to help guide you through the process of moving forward. A therapist can be your partner in navigating the journey to have a more fulfilling life.


The top 10 questions about trauma, PTSD, and psychotherapy our patients ask: answered honestly

As psychotherapists specializing in treating the impact of traumatic events and chronic adversity, we are often asked a number of questions about trauma, PTSD, and psychotherapy.

Here, we have compiled the most common of these questions in order to help you, the brave reader seeking help for yourself or someone you love, better understand the effects of trauma on us all, the similarities and differences between how we may respond to experiencing/witnessing traumatic events, what it takes to heal from their impact, and what you can expect in therapy.

Have you have ever wondered why, for instance, some people develop Post-Traumatic Stress Disorder after traumatic events and others do not? Do you worry if the panic, pain, shame, or nightmares will go away on their own or how long it would take? If you will ever feel safe again? Have you wondered what psychotherapy for healing from traumatic events looks like? Then read on, we are here to help! (This article is going to be long…we wanted to provide an exhaustive list of questions and answers, feel free to scroll down to the ones you are most interested in)

The Definition of Trauma

According to the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a traumatic event is an event or situation which may involve:

This definition is expanded, however, from past definitions. Nowadays, we know that a traumatic reaction can be experienced after more indirect exposure to traumatic events, such as:

  • witnessing someone go through such event, or
  • learning about a situation in which a loved one experienced violent or accidental death, or
  • chronic exposure to or witnessing of distressing events, like through one’s job as a correspondent in a war-torn country, police officer or firefighter, is also recognized as trauma.

The Experience of Trauma

In previous editions, the DSM had also required that the event cause one significant feelings of fear or horror in order to qualify as trauma. However, we now know that this is not necessarily true, because traumatic events can also cause us to feel disconnected or dissociated from our bodies, emotions, and thoughts. They may also trigger incongruent emotional reactions (e.g. uncontrollable laughing), which may at the time seem inappropriate to the event, but are in fact not uncommon.

It is important to note, however, that the experience of trauma can be very subjective and personal. Often times, life events, even if they do not constitute a significant threat to our life, can be very traumatizing, for instance, the experience of a woman going through multiple cycles of IVF, where her body is exposed to constant changes, losses, and medical procedures infidelity or going through a divorce bullying at school being in a war zone or losing someone there even if not directly exposed to combat, multiple attachment disruptions for both children and adults, chronic exposure to poverty and hardship.

For some statistics of the prevalence of traumatic experiences, visit our main page here

Trauma vs. PTSD

Trauma does not necessarily result in PTSD, there are many other sequelae, and one may experience depression, anxiety, panic, relationship difficulties, etc., even if the symptoms do not add up to a diagnosis of PTSD. Therefore, it may be beneficial to work with a therapist who works from a trauma-informed perspective and has received additional training in trauma work even if you don’t have a diagnosis of PTSD. They will be best equipped to see your symptoms in context and may think to ask you questions and address other symptoms that a non-trauma informed therapist may not think about, e.g. the impact of traumatic events on the body and nervous system, the experience of dissociation (e.g., feeling like you are not fully here, spaced out, as if the world is not real, or as if you are disconnected from yourself or your body). For more on dissociation and its connection to trauma, you can visit the International Society for the Study of Trauma and Dissociation.

That being said, PTSD is one possible outcome of experiencing a traumatic event. We prefer to think of it as a reaction to trauma which fails to normalize over time, even if the traumatic event is no longer happening. Namely, most people who experience a traumatic event will have a response to it. This response may involve hypervigilance, nightmares, anxiety, low mood, hyper alertness, negative thoughts and self-doubts, intense emotional reactions and even bodily symptoms such as tenseness, tightness, heart racing, etc. All of these constitute a normal response in abnormal circumstances! We all will have some or all of them (and more) if we are exposed to a traumatic event. This is why we do not diagnose PTSD immediately after trauma, because you are expected to experience the above. It is the body’s natural reaction to something so out of the ordinary, something so scary or upsetting, that it sends us into a survival mode-type reaction.

You can think of PTSD as a combination of experiences, that can add up to feeling significant distress, which we then try to avoid at all cost. And, indeed, in many occasions, the cost is high. The general symptoms fall within several clusters. Please have in mind that you may not experience all of the symptoms in any given cluster. Only a few, usually one or two per cluster, are enough for a diagnosis.

Intrusive Symptoms Cluster

We call these symptoms of re-experiencing. They are internal experiences that feel as if they are keeping the memory of the trauma alive and our bodies and minds can lose track of time…as if the traumatic event is not in the past but in the present.

  • Intrusive memories that are unwanted—these can be throughs, images, sensations that are brought up by some stimuli in the environment, or even sometimes seemingly out of nowhere. You find yourself thinking about what happened, even though you do not want to be. They are different from flashbacks in that you don’t lose awareness of where you are, and yet cannot easily redirect your attention to other thoughts.
  • Flashbacks—you may feel like the traumatic event is happening to you over again. This may be a fleeting moment, when you see, hear, smell, or feel something and you are transported back to when the trauma occurred. Or it may be a longer episode in which you become disoriented and lose track of where you are, time becomes distorted, and you have to reorient yourself to your surroundings.
  • Nightmares—whether they are a repetitive nightmare, in which the trauma plays out over and over again, or more general bad dreams that leave you feeling anxious, angry, panicky, or generally off kilter
  • Emotional distress when reminders of the event are present—e.g. you become easily upset and have difficulty composing yourself again when any of the above happen, or when something in your environment reminds you of your trauma. For instance, if you experienced medical trauma, being in a hospital, or even watching a TV show that shows one can be upsetting.
  • Physical reactivity—when thinking about the event or perceiving triggers in the environment, you may feel your heart rate and blood pressure increase, experience heart palpitations, feel suddenly hot or cold, feel your palms get sweaty, have difficulty breathing or breathing shallowly, feel your head suddenly get foggy or heavy, or even feel physical tension and pain in certain areas. For instance, many survivors of sexual assault experience significant pain and discomfort in the pelvic area, which may fluctuate in intensity.

Changes in arousal and reactivity

Think of these symptoms as your nervous system’s reaction to trauma. During a traumatic event, your body will most likely experience a physiological stress response. When we have PTSD, it is as if our bodies never fully returned to normal functioning and are constantly living in a state of increased stress, as felt in:

  • Hypervigilance—constantly watching our back, scanning the environment for threats or cues that we may get hurt (both physically and emotionally)
  • Increased startle response—for instance, having a startle reaction to sudden movements or loud sounds, that would be more intense than or last longer usual
  • Engaging in risky behaviors—such as increased alcohol or drug use, reckless driving, increased spending, risky sexual behaviors, aggression and destructiveness
  • Difficulty concentrating—mind may be preoccupied with worries or overwhelmed, feeling scattered
  • Difficulty sleeping—either due to not being able to relax your mind and body enough, feeling unsafe to be in such a vulnerable state, or worrying about having nightmares
  • Irritability or aggression—finding yourself more on edge, engaging in more verbal or even physical arguments, feeling more easily overwhelmed by people’s demands on you and wanting to crawl out of your skin

Changes in cognition and mood

This cluster of symptoms can be thought of as the negative changes in our thoughts and emotions that develop as a result of trauma.

  • Global and general negative thoughts about yourself, others, or the world—for example thoughts that nobody can ever be trusted, that the world is all bad and hopeless, that you are not worthy of love or care. These are dangerous because they may subjectively feel true. For instance, if you experienced assault or abandonment, it may feel like nobody can ever be trusted. If you survived a natural disaster or witnessed atrocities of war, it may feel like the whole world and people in it are bad. But thinking in such absolute terms is a symptom of being traumatized and of having survived something very difficult, not an objective truth.
  • Excessively blaming yourself or others for the trauma—this is especially prominent when the trauma is losing someone you care about. Our brains tend to look for rhyme or reason, for explanations and responsibility. It is easier to accept a world where we are in control, albeit blaming ourselves, than a world in which sometimes tragedies happen. We are also often raised to believe in a fair world, one in which good things happen to good people and bad things to bad people. While we may know from experience this is not always the case, in the aftermath of trauma, it is hard to reconcile this belief with something bad happening to us. As with the above point, excessive self-blame (or other blame) is a symptom of our whole being experiencing a conflict between what we have been taught and something highly abnormal and traumatic happening to us.
  • Negative affect—frequently one or more of the following feelings: fear, horror, anger, guilt, shame having difficulty pulling yourself out from those emotional states
  • Anhedonia—loss or a decrease in positive affect. For instance, catching yourself in situations where you might think “this good thing happened, I should probably be feeling happy or joyful, or excited” but not being able to feel it
  • Losing interest in activities you previously liked—similarly as above, not being able to get enjoyment out of things that you used to enjoy or difficulty finding the motivation to even try
  • Forgetting some key parts of the traumatic event—feeling like you should be able to remember them, or maybe that if you really tried hard you could, but it is as if your brain is refusing to go there, or the time/scene is just lost in your memory
  • Feelings of isolation—becoming increasingly withdrawn, feeling like you can’t be close to anyone, or to very few people, but even then keeping them at a distance

Avoidance cluster

And finally, you can think of these symptoms as your attempts to cope with all of the above.

  • Avoiding trauma-related thoughts or feelings—while it may seem a little unclear what we mean by this, think of all the ways we try to avoid painful emotions: drinking and drugs, mechanically overeating, excessive exercise, aggression towards others because if we scare them the will stay away, leaving in the middle of arguments, numbing ourselves out through excessive TV watching…
  • Avoiding external trauma reminders—people, places, or things that in some way bring your mind back to what happen. Maybe you never drive over bridges, or never go out in the dark. Maybe you have not seen your doctor in years because of a fear of hospitals. Or maybe you have not even driven a car after the accident. Maybe you avoid talking to certain family members because they ask questions about your military service, or maybe you have not been to a family party in years because of the noise and chaos.

The distress caused by the symptoms described above can often feel overwhelming. We spend so much time and efforts to try to manage our anxiety and arousal, our bodily reactions of tenseness and pain, the constant emotional up and down roller-coaster, the intrusive memories, and unwanted thoughts. We pick up all the cues in the environment that remind us of what happened, songs, colors, places, people, TV programs, areas in our town, public transportation and crowded places, garbage pales on the side of the road, driving in traffic…

So eventually, we learn that if we avoid them, maybe we can manage ourselves a little better, feel a little less activated and always on edge. The avoidance comes naturally, sometimes to a point where we don’t realize we are mapping alternative routes, even if they take twice as long, that we are skipping medical appointments, that we haven’t seen friends in months. Avoidance cluster symptoms are ways of managing, but they also make our world very small.

A note on dissociation

Dissociation is a mental process, which can become very exaggerated during and after experiencing trauma. When diagnosing PTSD, clinicians will also pay attention to possible symptoms of dissociation, and the two types that serve as qualifiers for the PTSD diagnosis, if present: depersonalization and derealization. We will have a whole article on the dissociation and trauma in the future, but in the meantime, if interested, you can start by visiting the page of the International Society for the Study of Trauma and Dissociation

As scientists and clinicians, we are still learning about human resiliency and what factors contribute to why some people develop PTSD after a traumatic event and others do not. In fact, it is more accurate to say that most, if not all, people will have some type of trauma response to a traumatic event, but that a number of them will spontaneously recover after it, without long-lasting symptoms. About a third will not, and will go on to develop PTSD. (For an interesting review article on the matter, please click here)

What we do know is that there are a number of factors that may contribute to the development of PTSD after trauma:

  • chronic vs one-time trauma
  • preexisting mental illness or family history of mental illness
  • who the perpetrator is (someone known and trusted vs. a stranger)
  • social support
  • availability of resources such as medical and psychological care after the trauma
  • general level of stress and coping skills
  • type of trauma (e.g. sexual trauma vs natural disaster)

Overall, it appears that the higher the chronicity and intensity of the trauma, the more personal it is (e.g. natural disaster vs interpersonal violence), the more stressors and fewer support systems/resources the person has, the more likely they are to develop PTSD. Early trauma or adversity are also likely contributing factors, and so is family history of mental illness or already present mental illness in the trauma survivor. At the end of the day, it is especially important to remember that PTSD, or any other mental health issue following trauma, is not weakness, lack of desire to “just get better,” or “not trying hard enough.”

If you are interested in learning more about the impact of early childhood trauma and adversity, we recommend reading about the Adverse Childhood Experiences (ACEs) study.

Traumatic memories feel fresh in our minds, often times as if they are happening all over again. There is no easy answer to this question, because at the end of the day, it is this stuckness that is causing you significant distress. One way to understand the re-experiencing cluster of symptoms (see Question 2) is through the lens of what function they serve. During a traumatic event, your whole body is mobilized for survival (see fight/flight/freeze response).

Reexperiencing has a purpose

In that sense, reexperiencing, which triggers all of the other symptom clusters, ensures that you remain vigilant even in the present moment. It ensures that you cannot fall asleep and thus be in a vulnerable position, that you stay irritable or angry (or in a constant state of anxiety/panic) so that you can fight or flee, should a danger present itself. In a way, your mind and brain are trying to stay constantly on stand-by. The problem is that this constant stand-by, constant state of activation, is no longer applicable, because you are no longer in the traumatizing situation that caused this in the first place. But you keep reacting to the world as if you are.

Traumatic events have a way of “getting stuck” in our bodies and minds. But they can also be released. Therapy addresses some of this through teaching relaxation strategies and coping skills, but also through allowing you to address the ways in which trauma has impacted you in a safe environment. Trauma-informed therapists are also knowledgeable in how to help you with the physiological components of how trauma is lodged in your body and its emotional core.


Children are incredibly resilient! Often times, they are able to cope with difficult and challenging events better than we anticipated. We are often in awe of how they use their creativity, imagination, and inner strength to combat sadness, anxiety, and anger.

However, at times difficulties can overwhelm their inner resources. There are a number of behaviors and signs that your child may be experiencing a traumatic reaction to an event or events. Sometimes, you may know that something happened (e.g. bullying, a natural disaster) and be vigilant about how child is coping. Other times, you may not know that your child has been exposed to a traumatic event, but a change in their behavior, sleep and play patterns, concentration, and mood may be a good indication that your child is hurting:

  • Changes in sleep or appetite
  • Persistent nightmares or difficulties falling and/or staying asleep
  • Anger or rage
  • Difficulty being soothed
  • Unreasonable fear
  • Regressing to a previous developmental stage (e.g. wetting bed after that had stopped)
  • Unusually strong startle response
  • Sudden difficulties at school, grades decreasing
  • Lethargy
  • Withdrawal from previously trusted adults
  • Clinginess or intense anxiety when separated from parent
  • Frequent stomach aches and/or headaches
  • Unusual shyness or acting out in social situations

Regression

Of the above, several are particularly telling of when a child is coping with a traumatic event. One of those is regression, i.e. returning to a previous stage of development. This can be emotionally, when a child who had achieved a level of independence is suddenly much more clingy and starts asking of their parents to perform tasks/chores/responsibilities that the child had mastered. Or it could be through regressing in bodily control, such as sudden enuresis (bed wetting) or encopresis (bed soiling alternatively, some children may signal distress through withholding their bowel movements), suddenly forgetting how to talk, or regressing in other already achieved milestones.

Loss of imaginative play

Most children, unless they are experiencing neuro-developmental delays, show signs of imaginative play early in childhood. As they progress through the developmental stages, their play becomes more and more complex, with whole stories and characters existing only in their rich imaginations.

Because traumatic events overwhelm our emotional resources, directing all efforts and attention towards coping with their aftermath, children in particular can struggle to remain playful and imaginative after trauma. If you are noticing that your child’s play is repetitive, unimaginative, and even has a perseverative quality to it, or if your child is enacting a traumatic event over and over in their play, this may be a sign that they are struggling to process the event and recover from it. A skilled child therapist will be able to help them utilize their play to “digest” the difficult event and heal from it.

Most of us are by now familiar with the fight/flight response to danger. They are evolution’s gift to us, to ensure our physical survival. A neighbor cave man tries to steal our meat, we beat them up with a stick. The truth is, in a traumatic situation (read: one that we perceive as physically or emotionally dangerous), we cannot say for sure which one will kick in.

In therapy, we hear many people express self-blame for a third type of reaction – freezing. They report becoming paralyzed and then experiencing crushing shame that “I didn’t run away, or scream, or push the attacker away,” “I did not report what happened,” “I couldn’t move and save these people.” However, freezing, just like fight or flight, is an evolution-determined response of the nervous system. It is not more or less likely than its two counterparts, nor is it a choice that you make during the experience of trauma. Just like fighting or fleeing, in certain dangerous situations, it may ensure your survival, and even if you are not “playing dead” in front of a bear, your body may still freeze in the face of other traumas. We believe this video may be interesting to you, if you wish to learn more about the freeze response:

Protective factors – The power of connection

As we discussed earlier, you are expected to feel some distress after experiencing a traumatic event. Not much is yet known about what factors are at that critical time most effective in protecting from PTSD. Further, each person will move through those first days and weeks at their own pace, having their own unique emotional experienced and coping strategies.

What we do know, however, is that traumatic events can feel very isolating. As a result, we tend to withdraw and often distance ourselves from others. In contrast, it seems that people who, in the aftermath of a traumatic event, are able to reach for and accept help, support, and care from others fare off better. There is very little empirical support for any psychological or crisis first aid interventions being especially effective in the immediate aftermath of traumatic events. This may be because, in general, for therapy to work, a good, trusting, and collaborative relationship between patient and therapist is essential. In the immediate days after a traumatic event, we may be too activated, in shock, or in crisis, to be establishing new connections. Therefore, leaning on those who are already there, such as friends, family, social circle, appears to be immensely helpful. It seems that feeling connected with others produces hormones that make our immune systems stronger to withstand adversity.

For an excellent book on this subject, we recommend Sebastian Junger’s book “Tribe: On Homecoming and Belonging”

In contrast, avoidance seems to be correlated with a higher likelihood of developing PTSD. The more you try to tell yourself to ignore it, the more you risk having longer-term symptoms, as trauma becomes lodged in the body, which has no way of releasing it. Disclosing the trauma to loved ones, on the other hand, appears to be beneficial.

Treating PTSD

Each person will progress through treatment of trauma-related symptoms and/or PTSD at their own pace. One of the most important factors in therapy, it is worth repeating, is a sense of comfort and feelings of trust and safety with your therapist. From there on, your therapist will work with you on creating a treatment plan that is best fit for you, based on type and severity of symptoms, current stressors, and other factors.

There are a variety of treatment approaches to trauma. APA’s guidelines for the treatment of Post-Traumatic Stress Disorder (click here) recommend Cognitive Therapy (CT) or Cognitive Behavioral Therapy (CBT) as effective modalities, as well as several varieties of CBT, such as Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE). These therapies are highly structured and promise results within a limited number of sessions (usually 12 to 18). However, they may not be suitable for some people. For instance, recent brain imaging research (click here) suggests that only certain patients may benefit from Prolonged Exposure, for instance.

The APA guidelines also suggest that several other types of therapy, e.g. ones combining CBT and psychodynamic interventions, as well as Eye Movement Desensitization and Reprocessing (EMDR) and Narrative Exposure Therapy may work with good effect as well.

Treating the whole body

It is also important to remember that other methods of treatment can be effective, either on their own or in combination with the above modalities. They have not been included in these guidelines not due to their ineffectiveness, but often because conducting clinical research trials is an expensive and time consuming, not to mention difficult, undertaking and there is simply not enough well-regulated studies out there to support their inclusion in guidelines.

As clinicians, we know that there is also a bodily component to trauma (see Question 4, for example). Therefore, it is essential to include a component of relaxation, somatic work, art work, perhaps even meditation and trauma-sensitive yoga practices, as adjunct to treatment. Therapies like Somatic Experiencing and Sensorimotor Psychotherapy have shown great results in treating complex traumatic reactions.

In children, Trauma-Focused CBT has a wide foundation of empirical support. It combines elements of traditional CBT therapist with a narrative component, as well as a module in teaching children how to relax their bodies and manage heightened emotional states.

Ideally, your therapist will have background in at least a few (or many) of the above and be able to combine interventions from them to best fit your needs.

The very short answer is NO, it is not too late. Just like with any other chronic affliction, when untreated, PTSD can last a lifetime. Studies (like this one) with Vietnam-era veterans have found that untreated symptoms persisted 40 years after the service members’ return from war.

If you have been suffering from PTSD symptoms for a long time, by now you probably realize the many ways in which they have affected your life, from relationship difficulties, to troubles sleeping, to becoming emotionally upset at the sight/smell/sound of certain triggers, to panic and anxiety (for a full list, see Question 2).

However long you have been experiencing these symptoms, treatment with a caring, understanding, and trauma-competent clinician can help tremendously improve your symptoms and quality of life. You may wonder how this could happen if therapy can’t take the memories away. But there is a difference between curing (eliminating all signs of an illness) and healing (becoming whole again). While we cannot cure PTSD in the sense that we cannot eliminate all traces of the trauma (e.g. the memories), we can help you heal and feel whole again through lessening the power that those memories have over you, your emotions, and your body.

As we discussed above (in Question 8), the impact of trauma can last for many years, even decades, if untreated. Also, avoidance is one of the primary symptoms of PTSD. We simply do not want to talk about and relive the traumatic event. Most of the time, we already spend so much effort and mental resources to manage our internal struggle, that it seems unbearable to talk about what is causing us to feel this way in the first place. And then there can also be feelings of shame, which can develop as a result of the trauma. They make it even more difficult to talk about it, for fears of being judged, seen as damaged or broken, or being blamed for what happened.

However, we know that the more we avoid talking about the trauma or doing anything about our symptoms, the longer they are likely to persist. Avoidance has a way of “encapsulating” the trauma in our minds and bodies. We may think that not addressing what happened or our symptoms will make them lessen or go away overtime, but in reality, avoidance makes our world much smaller, albeit seemingly more predictable. The truth it, triggers in the environment are unpredictable. If we don’t learn how to better manage our symptoms, memories, and emotional reactions, we are constantly at the mercy of our environment and the triggers in it.

That being said, there are many ways to approach the treatment of symptoms following stressful and traumatic events. Some treatment modalities will require talking at length about what happened, and others do not. A good therapist, trained in working through a trauma-informed lens, will work with you at your own pace and selecting treatment approaches that work for you. It is important that you express your needs and worries, and that you feel comfortable with your therapist, so that you can begin this journey towards healing armed with the knowledge that they have your back!

PTSD has only existed as a diagnosis in the DSM since 1980, and only in the last version of the DSM did it become separated from the Anxiety Disorders cluster of diagnoses. This change finally granted it a recognition it did not before have, acknowledging that PTSD is not just another variation of an anxiety dysregulation and that its symptoms are rather unique. While this is a significant change, PTSD and trauma treatment in general, are still in the beginning stages of empirical study. There is little in the scientific literature that empirically traces what PTSD recovery looks like.

The National Center for PTSD, recognizes four stages of PTSD recovery: Impact, Immediate, Intermediate, and Long-term.

Impact Phase

These are the very first hours, days, and weeks after a traumatic event. During those, everyone is expected to experience some kind of trauma response (shock, feelings of helplessness, fear, powerlessness, guilt, panic, dissociation). Additional stressors, like separation from loved ones, medical trauma, loss of a loved one, and many others may further contribute to these feelings.

However, many of us have experienced multiple traumatic events. When trauma is chronic, we learn to adapt to it in ways that may keep us alive, but have a high psychological cost. If the dangerous or hurtful event is ongoing, or if we continue to be exposed to hardship, our minds and bodies will summon all resources to ensure physical (and psychological) survival, but the recovery stages will look different, as will the steps that need to be made to ensure safety. Recovery from what is frequently called Complex PTSD, then, will not necessarily follow these stages exactly.

Immediate (Rescue) Phase

This is described as the phase in which “there is reckoning with what has happened.” We now know that during this phase, people may exhibit significant resilience in coping, as they attempt to get their life back together and deal with the aftermath, support other loved ones, and work on achieving stability again.

However, many may experience delayed emotional reactions. They will often report that keeping busy in the first months after a traumatic event (e.g. after returning from deployment, or after surviving a natural disaster) has kept the feelings at bay, but as life starts to settle in, waves of emotional and somatic/physical reactions may begin to appear including: denial or shock, sadness, anger, fear, numbness, feeling overwhelmed, complex grief responses, flashbacks and nightmares, feelings of despair and hopelessness, loss of purpose or meaning.

Intermediate (Recovery) Phase

During this phase is when we start to adjust to the new normal and begin to try to achieve equilibrium. This may be the phase when we start seeking treatment, or begin acknowledging that perhaps there are psychological needs that need to be addressed. Recovery can be complicated by additional stressors, of course, but the core of the problem begins to be more recognizable. For instance, this is when nightmares or intrusive memories, which we thought would go away, continue to persist. Or we find ourselves withdrawing more from the loved ones around us. We realize that we have new anxieties or anger that were not there before, or certain things that did not matter before bother us more. We can become disillusioned or begin experiencing also more physical symptoms and illness. Stress we are experiencing can begin to impact our relationships and work.

In this recovery stage, it is important that we address the impact of trauma on our nervous system, bodily reactions, and reexperiencing symptoms, as well as learn to regulate our emotional reactivity and intensity. Recovery will begin by starting to establish safety, recognizing the triggers in the environment that now remind us of the trauma and cause us to feel unsafe, anxious, or angry. We learn coping skills for our anxiety, and we learn to relax our bodies enough so that they can progress to the next phase, Restructuring or Long-term Recovery, which would be difficult if we become panicky, shut down, or hyperactivated every time that the trauma is mentioned or when our emotions are easily dysregulated.

Long-term (Reconstruction) Phase

This is the meaning-making phase of recovery. Once you are able to address the traumatic event and its impact, you can become examining the deeper-held beliefs that it may have left in its aftermath. Beliefs related to the world, others, or yourself. Beliefs that tell you that nobody can be trusted, or that it is your fault for taking too long to recover and heal, or that you cannot ever trust your mind or your body to protect you, or that since help was unavailable at the time, nobody would ever be there for you to help.

Those are only a small sample of the insidious negative thoughts that result from those first moments of feeling powerless, helpless, and terrified during a traumatic experience, or the longer-term distrust in the world and others or oneself that chronic trauma can cause.

One of the most challenging but rewarding tasks of this stage is making meaning of what happened and integrating it into your story of who you are, where you came from, and who you want to become. This also helps in reestablishing a sense of control over your life goals and course, and finding a sense of purpose again, and learning to trust your judgment and abilities to overcome adversity. Some do this through acts of altruism, while others work on rebuilding a sense of a stronger self as a survivor.


Can PTSD be mild? Do the traumas have to be of a certain kind? - Psychology

National Association of Adult Survivors of Child Abuse

Recovery from child abuse is available, if we work for it

There are many paths to recovering from child abuse, and some of them cost almost no money. Then, too, there are benefits from getting assistance from the professional community trained to assist us.

Trauma specialists believe that "what is most tragic about child abuse and neglect is the exploitation of the child's attachment to the parent." To be sure, it is far easier to abuse one's own children, precisely because their love and loyalty to the parent render them much more compliant than they would be to a stranger. It is exactly this attachment exploitation that teaches children they are not safe in a relationship to other human beings.

Children are born into the world absolutely dependent and helpless. They depend on others for food, warmth, cleanliness and protection from threat. Children's natural and healthy helplessness is transformed into terror and dispair when those needs are ignored, or when a parent plays "let's make a deal" with those needs.

Childhood should be a time of no-risk dependency. Many children, in desperation, learn to care prematurely for themselves. at the expense of trust in others, emotional growth and self-acceptance. Unfortunately, try as they might, such children can never absolutely ensure their survival, simply because it is never absolutely within their control.

Try as they might, parents cannot always protect their children from trauma. A relative dies. The house burns down. The child witnesses a fatal car accident. The child is molested by someone outside the family and terrorized into keeping the secret. Yet, children can survive intact emotionally if adults provide them with a sense of safety and well-being in the aftermath of traumatic events.

Realistic, protective and compassionate treatment by adults can become more meaningful than the trauma itself, thus lessening its after-effects. However, when the source of the trouble is within the family, realism, protection and comapssion are usually in short supply. It is often not so much what actually happened that causes the "persistant negative effects" of trauma, as it is the absence of healing responses. what didn't happen afterward.

Suppose that in the midst of a tornado a child sought comfort and protection from his parents and was told, "What tornado? It's a beautiful day. Go outside and play." That's how crazy and unsafe the world seems to some children. Some survivors have tried to tell the truth about the abuse and were called liars or accused of being responsible for the abuser's behavior.

When a victim or survivor is disbelieved, shamed, threatened into silence, or when the disclosure is minimized or becomes cause for punishment, the trauma inflicted by willful ignorance compounds the original trauma. Children can withstand a lot with the help of other people conversely, the denial or rejection of children's normal thoughts and feelings about trauma can cause as much pain as the original trauma.

To minimize the damage of trauma, children also need protection from further harm. But in troubled families it is not in the abuser's best interest to teach the child how to prevent further abuse. The nonprotective parent who denies or minimizes the abuse is usually passive. The child is usually left on his own to figure out the best way to protect himself.

Survivors rarely, if ever, benefitted from the compassionate and reasonable reactions that would have lessened the effects of their troubled childhoods. Given the enormity of what didn't happen after their traumas, it isn't surprising that they entered adulthood numb and anxious, or both. Protective numbing and reactive anxiety are, after all, normal reactions to abnormal situations.

Clearly, people were not meant to be physically or sexually abused. Human beings are not equipped to understand abuse as it happens, not to feel the full force of their physiological response at the time. And they cannot, at that moment, find meaning in the experience of the abuse. Each of these important elements of accomodation can only happen later, in distinct stages.

Survivors commonly speak of how they endured trauma by pretending that their mind and spirit had gone to a safer place, leaving the body behind to endure the abuse.

Abused children abandon reality, dissociating mind from body so they won't be overwhelmed and their ability to cope won't be shattered. Even a relatively minor trauma can provoke dissociation until a person is later able to integrate the experience. "Later", in the case of chronic abuse, particularly where the child has no support, may mean years later.

In the short run, dissociation is a very effective defense, walling off what cannot be accomodated. Sometimes the actual memory of the abuse goes into deep freeze. An incident in the present may trigger strong feelings that really belong to an incident in the past. The survivor may become enraged by what merely annoys others, devastated when others are momentarily sad, panicked when others are just worried. Present events tap into a deep well of feelings whose source remains alusive.

When asked what the worst memory from their childhood is, many survivors reply, "My worst memory has yet to surface."

Sometimes only the feelings go into deep freeze. Some suvivors have perfect, excruciating detailed recall of the abuse itself, but are numb to their feelings. Their hearts are in deep freeze. They do fine when they are not provoked to feel too much. They may avoid friendships and romance, or enter into them only on their own terms. They believe their feelings are as troublesome and overwhelming today as their parents once told them they were. They are numb to feelings as a way to keep control.

Many survivors ask, "If I don't remember the trauma, or if I don't have strong feelings about it, isn't that better?" Dissociation eventually takes far more effort than it is worth. The more we try not to, the more feelings and thoughts assert themselves, unconsciously demanding our attention. It takes an enormous toll to keep perfectly legitimate memories and feelings about childhood trauma in deep freeze. In the long run, one is better letting the thaw happen, and with the support of others, participating in some manner of "cure" that will allow life to go on.

Some survivors don't know they have a highly recognizable and treatable anxiety disorder called Post Traumatic Stress Disorder (PTSD), which has been associated with survivors of the Vietnam War, the Holocaust, mass murders, natural disasters, rape, kidnapping, accidents, torture, and other extraordinary events.

People with PTSD often re-experience the trauma in their minds. When the memory brings on a physiological response or feeling this is called an abreaction. (The release of emotional tension through the recalling of a repressed traumatic event.) Often the situation that brings on the abreaction is reminiscent of the original trauma.

An abreaction could be triggered by something someone says, circumstances such as the press of a crowd, being left totally alone, a darkened room. or even a particular time of the year, smells, touch, tastes. or other things associated with the trauma. Suddenly, the survivor is transported as if in a time machine to the event of the original trauma and reacts with the emotional intensity that would have been appropriate then, though not now. During an abreaction it is difficult to distinguish "what was" from "what is".

Herein lies the Achilles Heels for survivors. They function well in many aspects of life until they encounter the events or circumstances that are likely to trigger abreactions: emotional vulnerability, physical illness or evasive medical procedures, struggles with authority figures, cultural oppression or abandonment, to name a few.

A person with PTSD lives with a persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness. Survivors with PTSD may avoid any intimate connection, often resulting in feelings of detachment or estrangement from others. Survivors often have highly developed social skills and may seem to be extremely extroverted, but their dealings with others may preclude vulnerability. They can talk about movies or work or the weather, but they have difficulty expressing their feelings. Or, they may have constricted feelings. They may be unable to identify and express a wide range of emotions, particularly the anger, fear and sadness so closely associated with the original traumatic events.

Certain circumstances can make the disorder longer lasting and more severe. If a trauma is repeated, for instance, as in chronic physical or sexual abuse, then the disorder might persist more than it would after only one incident. Repitition does not make one immune to the consequences of trauma. Rather, it has a cumulative effect, as unresolved trauma is layered upon unresolved trauma.

Traumatic events that are human in origin seem to have more severe after-effects than natural disasters. Hurtful and frightening as it is to be raped by a stranger, or to be in the path of a natural disaster, the creation of a personal disaster by a loved one is vastly more bewildering and overwhelming.

Another circumstance that contributes to the persistance of PTSD is the victim's age. The younger the victim, the more vulnerable he is. The more developmental skills and life experiences uncontaminated by trauma a child has, the more he has to draw on in the face of trauma. When life goes well, and children are loved and protected, each day is like a deposit in a savings account. Neglect, repeated physical abuse or sexual assault. or other life-threatening events, make huge withdrawals on the account. The more a child has in the bank when the trauma occurs, the better the prognosis for a quick recovery. Small children who are repeatedly traumatized usually have few deposits and easily become emotionally bankrupt.

When the survivor is ready to deal with it, memories and feelings begin to reconnect. He or she remembers, with the mind and feelings, instead of dismembering through dissociation.

The beginning of reconnection is usually attibuted to the fortuitous occurence of a trigger - an event or circumstance obviously associated with or reminiscent of the original trauma. There must also always be the simultaneous occurence of a positive trigger before the reconnection can begin. For instance, the survivor may have found someone trustworthy to talk to (therapist, friend, partner, support group) and may finally feel safe and sane enough to explore and accept her feelings.

The pain and disorientation can be balanced by focusing on the positive trigger. During this process, survivors should ask themselves, "Why now? Why didn't I remember this two years ago? Five years ago?" The answer lies in the conjunction of this trigger, along with the negative one, which tells the survivor "you can afford to reconnect now. you have the power, judgement, insight and support that you truly did not have as a child. It is safe enough."

Walling off parts of the trauma was once the solution to an unbearable situation. Eventually, it causes problems in the mind, heart and spirit, in one's relationships with the child within and others, and in one's work. Trauma, if left unresolved, is destined to be re-enacted in one of those vital aspects of the self.

To recognize that a mother is exploiting you for her own ends, or that a father is unjust and tyrannical, or that neither parent ever wanted you, is intensely painful. Moreover, it is frightening. Given any loophole, most children will seek to see their parent's behavior in some more favorable light. This natural bias of children is easy to exploit.

It is not just the child's body that is abused or neglected. Troubled families mess with a child's mind. Virtually all survivors believe that their ability to think, to intellectually master the challenges in their lives, was of of their greatest strengths as children. Like other coping mechanisms, their over-reliance on rationality fell into obsolesence and became one of their greater weaknesses.

Children struggle to make some sense of a loved one's abusive and neglectful treatment. If the child understood what abuse really was, a random and violent imposition of another's will onto a relatively helpless person, he would despair at such hopelessness and betrayal. Therefore, he uses every mental effort to make himself seem in greater control while transforming the abusive parent into the safe and loving caretaker he so desperately needs. Such lies of the mind require mental gymnastics.

Children don't do this thinking in a vacuum. In some situations they are told what to think. In most cases they are influenced by the abuser's faulty thinking and by the rationalization of the adults who passively enable the abuse to go on. Children hear what those powerful adults say and what they don't say.

On top of the abuse and neglect, denial heaps more hurt upon the child by requiring the child to alienate herself from reality and her own experience. In troubled families, abuse and neglect are permitted it's the talking about them that is forbidden.

Minimization is a thinking error designed to protect the injured self, making one seem a little less injured. The need for it can lessen as the survivor can afford to embrace the full reality of the past. (Refraining from denial is an act of courage for survivors. They have to choose quite literally between being alienated from themselves and reality. or being alienated from family members who still deny abuse.)

In troubled families, the thinking around who is responsible is convoluted at best. Abusive parents externalize, blaming other people, places and things for their behavior. They compensate by controlling everyone around them. But. in their heart of hearts. they feel out of control. They must blame others because it is too painful to take responsibility for their unhappiness. Children are easy targets because they cannot challenge their parent's thinking errors. Few children can argue when facing an enraged mother. Hearing accusations often enough, children come to believe that they are responsible for their parent's troubled behavior.

Unfortunately, children receive an internal psychological payoff when they believe the abuse is their fault. a false sense of power. The child can let the unfairness and danger of the violence shatter him, or he can tell himself, "I'm not frightened or angry or sad or helpless or innocent. There is nothing wrong with this situation. This is happening to me for a good reason. This is happening to me because I deserve it, because I provoked it, because I was put here on Earth to endure such things. There is really nothing out of the ordinary about this."

The child is doing the best he or she can do to make sense out of the abuse or neglect, by feeling guilty and responsible, thereby holding on to the illusion that he or she is in control of what is truly out of control. This illusion of power seems better than acknowledging that one has no power at all. Such pseudologic quells feelings of hurt, rage, terror, confusion or sadness. rationalizing them into a deep freeze.

The child's sense of guilt and responsibility is useful to the abusive parent, who believes he isn't abusive..that it is the child who forces him into being abusive. The nonprotective adults want the child to bear the guilt so they won't have to face the harm their neglect is causing. So. the dance of the violent family begins: Children are responsible for adult's behavior. adults are responsible for nothing.

Faced with random, senseless abuse, a child begins to think herself as inherently unlovable.

Believing oneself to be guilty, responsible, or in control of others' hurtful behavior can be a tenacious habit. Many survivors deal with any overwhelming experience - physical illness, abandoment by a friend or spouse, academic or job demands - by "comforting" themselves with the illusion that they are in fact in control and to blame. An enormous amount of energy is sapped by this irrational guilt.

Rarely do survivors see themselves as so powerful over the good in their own lives. Here, their parent's constant projection has left it's mark. Many survivors, convinced of their inherent worthlessness and inadequacy, look to other people, places and things for salvation. Only when they have the "perfect intimate partner, their dream house, or public recognition for their work" will they be redeemed. Of course, anything so powerful to save their lives might also destroy their lives, which brings the survivor back full circle to his original feeling of powerlessness. Reasponsible for all the pain in the world. he is inept at enjoying his own happiness.

Fantasy, as a coping mechanism can also be a weakness. Too often fantasies become more real than relationships. Survivors may fantasize a lot about what other people think or feel about them.

Trauma influences our ways of organizing in our minds what goes on out in the world. Survivors who have not fared well in life tend to think in sweeping generalities. people are either good or bad, with no gray area in between. Everything is "always" or "never", with no room for "doesn't matter much." In contrast, some survivors have thinking that is highly compartmentalized.

Children simply do not have the cognitive development or life experience for clear thinking in the face of trauma. Their thinking errors reflect their best attempt to comprehend the incomprehensible. when the truth wasn't offered or allowed. A first step to recovery, then, is to examine, challenge, and change these old ways of thinking about trauma.

The goal of sorting through the lies of the mind is to learn to take the abuse less personally, and thereby to feel safer. By looking back, the powerful adult mind can more objectively measure the powerlessness of the traumatized child.

Thinkly clearly may not be the entire answer, but it is an excellent and necessary beginning. Emerson wrote: "It is the oyster who mends its shell with pearls." But, unlike oysters, we are not solitary creatures. We mend one another as well as ourselves. Pearls of wisdom help us to take the next step. to heal in the company of other people, feeling the effects of the trauma while we hold onto our life rafts.

Feelings begin in the body, not in the mind. Many survivors say, "I know what happened wasn't my fault, but I still feel somewhat unlovable and damaged. My self-worth is measured by how other people see me. My head knows that is wrong, but my heart feels differently. Thinking comes much more easily to me. it's still a big risk to feel. If I ever started to cry, I'd cry a river. If I ever felt the terror of it all, I'd disintegrate into nothingness."

Children don't innately know how to repress their spontaneous responses. They have to be taught, and troubled parents are perhaps the best teachers of all. There are three iron-clad rules in the abusive home: Don't talk. Don't trust. Don't feel. To break any of them means risking rejection or punishment.

One of the few predictable aspects of a violent family is the unpredictablity of the parent's responses. Every time the child cries, he gets a different response. Soon he realizes that it is unsafe to cry. After a while, he keeps his feelings to himself and perhaps loathes spontaneity because it causes so much trouble.

Young children offer their feelings to adults as gifts, as their currency of exchange in intimacy. All they can do to be close to adults is to offer their feelings. When their feelings are ignored or rejected as wrong, bad, troublesome, sick, crazy or stupid. they feel rejected. The young mind reasons "since my feelings are unacceptable, I must be unacceptable, too."

Beyond teaching children to recognize and articulate their feelings, parents help children to contain and express feelings constructively. When children do not learn how to do this they may become overwhelmed by them, experiencing them as floods. They may come to fear or loathe their feelings.

Adults from abusive homes can also become pain-avoidant. Survivors attempt to control the people and events around them so that they will never feel pain again.

What is most tragic about pain-avoidant behavior is that it is a defense against something that has already happened and cannot be undone. A survivor cannot live fully in the present until he or she has the past in perspective. Sometimes being preoccupied and defensive about the pain waiting in the future is just a distraction from addressing the real pain in the past.

To be intimate is to risk pain. There are no guanantees. To miss years of loving to avoid the pain of loss is too high a price to pay.

Survivors attempt to flee from feelings about having been abused, from normal reactions to an abnormal situation. Because that situation was life-threatening in the past, some survivors mistakenly believe that to experience those feelings today would also be life-threatening, would bring on an emotional breakdown, a falling apart akin to death. They do not understand that the breakdown has already happened, when their feelings were preempted by shame.

A survivor can afford to look that "death" squarely in the face when he has people who will stand by him, as well as the insight and power he did not have as a child. When it is finally safe enough, the survivor will remember the memories and feel the feelings about the trauma. Such a "thawing out" is a second chance, an emotional reincarnation. Still. the first sensations that have been repressed or avoided all of one's life can feel like a tidal wave.

When he is ready, the thoughts and feelings return. In response to what has been uncovered, he often feels great anger at the betrayal itself and the injustice and randomness of the violence.

Underneath that anger is a terror and helplessness that is more difficult to experience than the anger. ("Maybe it wasn't as bad as I remember. Maybe I'm just exaggerating.") This can go on for a long time, but with the help of others, the survivor will eventually accept that the trauma was as bad as he knows it was.

Profound sadness follows. This compassionate acceptance of "poor me" and the mourning of the losses that the trauma created eventually lead to resolution.

When the losses engendered by trauma are fully mourned, the trauma loses its power over the survivor. Instead of the emotional breakdown they feared. survivors experience an emotional breakthrough! Completing the grieving process means divorcing the trauma from one's sense of identity and self-worth.

This was written by me around 1990-1991. I had been in a psychiatric hospital for the first time for a couple weeks, and part of my therapy after being discharged was to keep a journal.

This came from that journal.

If I ever let out the scream inside me, it will be heard for miles. It will echo across acres of land and tens of years. It will be a scream of rage and hurt and violation and of things wrongfully taken. It will put fear into the hearts of wild beasts, topple mountains and shatter the calm. It will ripple and grow and turn in upon itself as it simultaneously devours everything in its path.

If I ever let out the scream inside me, it will come from the very depths of my soul. It will start at my toes, explode through my heart, spring out through my tears. It will freeze my face in an expression of terror and pain. It will rip through the essence of my being. It would convulse my body into spasms of anguish and sorrow.

I would know, at that instant, how murders happen, how suicides are excused or explained. how vulnerable each of us really are.

I would scream the rage for myself and every other child throughout time that has been hurt, abused, neglected, afraid, abandoned or forgotten. I would scream the rage for myself and every other child throughout time that has sought comfort and been turned away or ignored, that looked for answers without knowing the questions.

If I ever let out the scream inside me it would be an emotional vomiting of things rotten and diseased, of things soured and spoiled. contaminated things that sit and churn and cannot be purged by any other means than an immense, sudden and explosive release. For the feelings behind the scream are volatile. and pressurized.

If I ever let out the scream inside me, I will have to do it alone, for I was alone when it was forced upon me in the first place. The scream is mine and mine alone. It is one of the few things I was allowed to keep. Most everything else was taken.

But now the scream wants to be set free. it doesn't want to be mine anymore. It demands release. How can I expect anyone to hold me near? I don't even want to be here. Hide, hide! Go to sleep! Maybe it will fade away. Maybe it will stay. I don't think so. I think it wants out.

It hurts! It swells and presses outward. but I can't let it go. I am paralyzed by it. It's got ME captive instead of the other way around.


Understanding OCD

While many people have repetitive behaviors or driven thoughts, the thoughts and behaviors of a person with OCD are persistent and disruptive to daily functioning.

Obsessions

Obsessions are recurring and persistent thoughts, impulses, and/or images that are viewed as intrusive and inappropriate. The experience of obsessions causes considerable distress and anxiety for a person.

It's important to understand that the obsessions in OCD are not just worries about real-life problems.

People will try (often unsuccessfully) to ignore or "push away" these recurrent thoughts, impulses, or images, usually knowing that they are unreasonable and from their own mind. Yet people with OCD cannot suppress or ignore their obsessions.

Compulsions

Compulsions are repetitive behaviors (for example, excessive hand washing, checking, hoarding, or constantly trying to put things around you in order) or mental rituals (for example, frequently praying, counting in your head, or repeating phrases constantly in your mind) that someone feels like they have to do in response to the experience of obsessive thoughts.

Compulsions are focused on trying to reduce or eliminate anxiety or prevent the likelihood of some kind of dreaded event or situation. Like obsessions, a person with OCD knows that these compulsions are illogical, which causes further distress.

Diagnosing OCD

To be diagnosed with OCD, a person must experience more than one hour per day of intrusive and uncontrollable obsessions and/or compulsions. In addition, these obsessions and/or compulsions must cause considerable distress and impair functioning such as at work, school, or spending time with friends.


1. Only soldiers are affected.

Photo by British Library on Unsplash

While the biggest concern surrounding combat is the development of PTSD, soldiers are not the only group susceptible to it. Anyone who has experienced a traumatic event, first or secondhand, such as death, violence, abuse, etc. and does not receive proper support or care to process it, can experience long-lasting post-traumatic stress. Both children and adults are susceptible to it.


Links Between Trauma, PTSD, and Dissociative Disorders

Carly Snyder, MD is a reproductive and perinatal psychiatrist who combines traditional psychiatry with integrative medicine-based treatments.

There is a very strong link between trauma (especially childhood abuse and/or neglect) and dissociative disorders, and the relationship is important in both directions.   It's thought that long-term trauma is a root cause of dissociative disorders, with dissociation occurring as a coping strategy that allows people to distance themselves from a trauma that may otherwise be unbearable.

When dissociation continues when real danger no longer exists, however, it can prolong or even prevent recovery from abuse and neglect. There is also a connection between dissociation and post-traumatic stress disorder (PTSD).   Changes in brain function may further explain the connections among these causes and conditions.


Do I Have It?

To figure out if you have it, your doctor will talk to you about the trauma and see if your reactions fit into the American Psychiatric Association’s criteria for PTSD. You must meet all eight of them in order to be diagnosed with PTSD. Here are the criteria:

Criterion A: You must have been exposed to or threatened with death. Or, you must have had an actual or serious injury, or actual or threatened sexual violence. You must have experienced at least one of these things in the following ways:

  • First-hand experience
  • Witnessing the event
  • Learning that a close friend or relative experienced it or was threatened
  • You’re regularly exposed to other people’s trauma, maybe for your job

Continued

Criterion B: You experience the trauma over and over through at least one of the following:

  • Flashbacks
  • Thoughts you can’t control
  • Emotional distress
  • Physical symptoms when thinking about the event

Criterion C: You avoid things that remind you of the trauma. To meet this criterion, you must do one of these things:

  • Avoid thoughts or feelings related to the trauma. For example, you might refuse to talk about war if war was the cause of your symptoms.
  • Avoid things that remind you of the trauma. You might not watch war movies for fear of triggering painful feelings, for instance.

Criterion D: You have negative thoughts or feelings that started or got worse after the trauma. To meet this criterion, at least two of these must be true for you:

  • You remember little about the event
  • You’re overly negative about yourself or the world
  • You blame yourself or others for the trauma, even if it’s not true
  • You lack interest in activities you used to enjoy
  • You feel lonely and isolated
  • You find it hard to be positive or experience joy

Continued

Criterion E: Your symptoms started or got worse after the traumatic event. At least two of these things must be part of your experience:

  • You’re often irritable or angry
  • You constantly feel on guard, or you’re easily startled
  • You engage in risky or dangerous behavior
  • You have trouble sleeping
  • You have trouble staying focused

Criterion F: You meet this criterion if any of your symptoms have lasted for more than a month.

Criterion G: Your symptoms make it hard to work or keep up with daily life.

Criterion H: Your symptoms aren’t caused by medicines, illegal drugs, or another illness.

If you meet all of these standards, your doctor will diagnose you with PTSD. Next step: treatment.


Clinical trials are research studies that look at new ways to prevent, detect, or treat diseases and conditions. Although individuals may benefit from being part of a clinical trial, participants should be aware that the primary purpose of a clinical trial is to gain new scientific knowledge so that others may be better helped in the future.

Researchers at NIMH and around the country conduct many studies with patients and healthy volunteers. Talk to your health care provider about clinical trials, their benefits and risks, and whether one is right for you. For more information, visit NIMH's clinical trials webpage.