PTSD - A Psychiatrist's View
The following article is a description of PTSD and its effects written by Professor Dr. Gordon Turnbull, an ex-RAF consultant psychiatrist and expert on the subject of trauma.
Psychological trauma
If you experience something that represents a threat to life or limb, the standard way to react is to develop a cluster of changes in the way you feel and behave. This is a survival reaction and it represents a normal reaction to an abnormal event which overwhelmed all attempts to cope, was extremely frightening, and went so completely out of control that it left you feeling utterly helpless. Such an event is known as a trauma.
If you have been involved in a rail crash then it is likely that you are already familiar with how a survival reaction feels. To begin with, in what is known as the acute phase (which lasts for the first month or so), you will know that it can involve:
- Vivid memories, flashbacks or nightmares about the event
- Avoiding reminders of the event
- Feeling emotionally numb
- Feeling irritable and constantly on edge
- A change of appetite or drinking or smoking habits
- Mood swings
- Finding it more difficult to get on with other people
Potential for a positive outcome
Many people get over experiences like this if they are able to process the event - that is to make sense or meaning of the trauma and to accept the lessons about life that it has taught, however roughly and cruelly. For example, involvement in a traumatic event, such as a rail crash, can teach that life is never completely predictable or safe and that there is a lot to be said for living in the present rather than dwelling too much in the past or making too many plans for the future. Such a personal audit can freshen up attitudes to personal direction, relationships etc.
However, if the experience is denied or for some other reason the opportunity is not taken to process the trauma, the acute reaction phase is converted into a chronic (long-term) reaction after about a month that can last for many months or years. This is called Post-Traumatic Stress Disorder, or PTSD for short, and it represents either the inability or the lack of opportunity to process the trauma.
There are two main reasons for inability to process the trauma and, at first sight, they may appear confusing because they seem to be opposites. If you have a very strong personality then the temptation is often to deny the impact of the trauma on yourself and other people. That is why it is often a good idea for such people (who tend to be attracted into roles in life such as being in the emergency services, the police, the military, doctors and nurses, or who just simply believe that 'the stiff upper lip' is the best way to deal with things) to receive some psychological first-aid. If you have had good personal resources in the past but they have been used up dealing with something else that is still going on, such as an ongoing worry causing anxiety or depression, then it makes sense that you will not be able to make your best shot at processing the new challenge that the trauma has thrown down in your path.
The lack of opportunity to process the trauma is usually because you need to concentrate on dealing with secondary spin-off products of the trauma. Some of these secondary events, such as being seriously physically injured, need to be tackled as a priority and there is no way of getting round that fact. Some are unnecessary, such as the attitude of family or employers who refuse to believe that trauma has a psychological impact and think that it should be ignored.
Traumatic events
PTSD can start after any traumatic event. A traumatic event is one where we can see that we are in danger, our life is threatened, or where we see other people dying or being injured. Examples are rail crashes and other man-made disasters, natural disasters (such as the tsunami), serious road accidents, military combat, violent personal assault (sexual assault, physical attack, abuse, robbery, mugging), being taken hostage, terrorist attack, being a prisoner-of-war and being diagnosed with a life-threatening illness.
Even hearing about the unexpected injury or violent death of a family member or close friend can start PTSD. Therefore, it is possible that if you have been involved in a rail crash, a close friend, family member or partner may develop the typical reaction known as Post-Traumatic Stress Disorder.
The features of PTSD
You might feel grief-stricken, depressed, anxious, guilty and angry after a traumatic experience but, in addition to these perfectly understandable emotional reactions, there are three main types of symptoms triggered by such an experience:
Flashbacks and nightmares
You find yourself reliving the event again and again. This can happen both as a 'flashback' by day or at night in the form of nightmares. These can be so realistic that it feels as though you are living through the experience all over again. You see it and hear it in your mind, like a video, but may also feel the emotions and physical sensations of what happened - fear, helplessness, horror, smells, physical pain etc. It is important to realise that the memory material that is the very stuff of flashbacks or nightmares has not yet been processed and has not yet been 'date-stamped'. When re-experienced, these memories get confused with what is happening in the present and this can be very frightening in itself.
Avoidance of reminders
It is upsetting to relive a trauma over and over again and so it is natural to try to avoid doing so. This can be achieved:
- psychologically: by distraction, by diverting mental energy into other things such as work
- behaviourally: by avoiding places and people that would remind you of the trauma, and by avoiding conversations about it
- chemically: by numbing with alcohol or other substances that will blur memories
Hyperarousal
Until there is a sense that safety has been restored, mental and physical emergency systems will remain 'switched on'. Although this makes sense in terms of keeping you 'on guard' it is often also very uncomfortable, and can lead to anxiety, overcaution, sleeping problems, jumpiness, increased irritability, headaches, palpitations, excessive sweating, gastro-intestinal symptoms and an uneasy feeling of vulnerability and the need to be vigilant, even to the extent of being suspicious and paranoid.
Not only do these symptoms of increased adrenaline activity make you uncomfortable, it also makes you uncomfortable to be with for others.
PTSD represents 'blocked processing' of a trauma, and the ongoing symptoms are strategies that the mind uses to try to find a way to overcome the obstruction.
When you are frightened, you will notice that you remember things very clearly. Dangerous events are important. You need to learn important survival skills from them. That is why military training, for example, can sometimes be so close to the mark. Although it can be distressing to remember these things, it helps you to understand what happened in detail, and, in the long run, makes you a better survivor.
The flashbacks, or replays, force us to think about what has happened. After a while, we learn to think about it without becoming upset.
- It is tiring and distressing to remember a trauma. Avoidance and numbing keep the number of replays down to a manageable level.
- Being 'on guard' means that you can react quickly if another crisis happens. It also gives you energy to do the reparative work after an accident or crisis.
When you can think about the trauma without becoming distressed, no longer feel constantly under threat, and no longer think about the trauma at inappropriate times, then you know that you have successfully processed the experience.