Treatment for Post Traumatic Stress Disorder (PTSD) Symptoms
Most psychologists, psychiatrists and other stress practitioners agree that PTSD is the result of someone experiencing a particular stressful event such as:
- A motor vehicle accident (as a passenger or driver).
- Being mugged or otherwise assaulted – this could be physical or being threatened with violence.
- Terrorist outrage, e.g. witnessing or experiencing an explosion etc.
- Sexual assault including rape or abuse.
- Other terrifying or shocking’ experiences.
Traumatic events that lead to individuals experiencing PTSD are usually of such severe magnitude that they would distress most people. These incidents usually appear out of the blue, i.e. are totally unexpected. When these things happen we get a feeling that our lives or those of people around us are in very real danger. Such incidents and feelings have the effect of completely overwhelming our coping resources.
In addition to the one-off events that are considered traumatic, people can manifest the signs and symptoms associated with PTSD following a prolonged period of cumulative stress. A condition termed PDSD (Prolonged Duress Stress Disorder) may be used in such cases. There are, of course, those who also experience a series of multiple traumas such as the survivors of sexual abuse or torture.
It is often said that PTSD is a normal response to abnormal situations.
Personal experiences of treating clients with PTSD
The usual prescribed therapy for treating PTSD is CBT (more on this later) and the number of recommended sessions is usually 8–10. However, in severe cases the number of sessions may be increased substantially. To be effective, the sessions, if possible, should be scheduled on a weekly or fortnightly basis.
However, very often, due to litigation, legal processes and the wrangling between insurance companies, a lengthy period of time may have elapsed between the incident and referral for treatment. It is not unusual for cases to be delayed for several years before treatment is started. In some cases treatment has been deferred for between three and five years. These delays are not good for the patient and certainly not good for the treating therapist. While it is recognised that it is inappropriate to start treatment too soon after the event, it is generally accepted that a minimum period of a month should elapse before diagnosis and subsequent treatment is initiated.
The problem for the patient is that the delay in treatment means he or she has become used to living with a range of symptoms and a restricted social life. The person has developed a range of individual coping strategies, however inappropriate, to deal with the situations they face. The person may dread the mere thought of travelling by car, either as a passenger or driver, or if they have been attacked or been injured on a particular street they will avoid all people, places and items that remind them of the incident.
One salient feature that crops up time and time again is that when therapeutic progress is being made many clients ask ‘Why have I been left to suffer for all this time when help has been available?’ Therapists often feel quite strongly that these excessive delays need to be addressed by those who are directly involved such as the insurance companies and other medico-legal services.
PTSD – the therapist connection
Referrals are often made by way of direct contact from a specialist clinic, the solicitors involved in the case or by the client who has been given the therapist’s contact details. An initial assessment is likely to have been carried out by a clinical/consultant psychologist or psychiatrist who will have made the clinical diagnosis of PTSD. It is usual to be sent full details of the person including his or her medical history and any current medical conditions and details of any medication being taken. A report of the accident/ incident together with a quite lengthy psychological report of the incident is also provided and includes DSM-IV Diagnostic Criteria 309.81. This lists the criteria for the assessment of PTSD.
DSM-IV Diagnostic Criteria 309.81
Using the current DSM-IV diagnostic criteria, a person is deemed to be suffering from PTSD if their symptoms have lasted for more than one month and if those symptoms are causing significant distress or impairment in their social life, their work or in other areas of their life such as relationships with partners, family, friends or others.
The condition could be described as acute if it continues for one month and chronic if it continues for three months or more. At the time of writing, the ‘one-month diagnosis time frame’ is a matter of some debate, with a number of professionals urging that this be increased to six weeks. The main reason for this debate is that some professionals report that significant numbers of people manifesting classic symptoms at the one-month point are much improved, or even back to normal, at the six-week point.
Delayed onset of trauma symptoms is quite common. The symptoms are something akin to delayed shock. Any or all of the symptoms already described may surface up to six months or one year after the event occurred – even if the person coped at the time of the traumatic event.
PTSD and the adrenal system
For those with PTSD, research has shown that the adrenergic systems are much more active in both adults and children than is found in normal adults. The stress response is associated with increased levels of cortisol, but it is now known that PTSD sufferers may show cortisol levels that are lower than those without PTSD. It is thought that perhaps being involved in a life threatening experience is enough to shock the body’s system. There is also the possibility that people who develop PTSD may have weak or vulnerable systems and that being involved in a serious incident uncovers a biological irregularity that hinders their ability to deal with these sorts of event.
Responsibility to the patient starts from the initial contact, usually by phone, when there is a brief discussion to arrange the time and date of the first session. If the patient has been involved in a car accident and has problems driving, particularly when travelling away from their local area, it may not make sense to subject them to their most feared situation, i.e. driving on motorways or dual carriageways prior to or after the therapy sessions. Some therapists will visit the patient in their own home for the initial assessment and/or first few sessions.
Common reactions during the days following the accident or event
It is quite common for individuals to continue to react for some days, weeks or in some (severe) cases years, following the incident or accident.
A few of the most commonly reported reactions include:
- Anxiety or fear of being alone or other frightening situations with the fear that a similar event could happen again.
- Avoidance of situations or thoughts that remind the person of the traumatic event. This may involve travelling down a particular stretch of road or only travelling at off-peak times of day.
- Being easily startled by loud noises or sudden noises, e.g. a car door slamming or someone sounding their car horn nearby.
- Flashbacks where images of the traumatic event come suddenly into the mind of the person for no apparent reason.
- Physical symptoms such as tense muscles, trembling or shaking, diarrhoea or constipation, nausea, headaches, sweating and almost constant fatigue.
- Lack of interest in usual activities such as going to the gym, keeping in touch with friends and being less socially active. Loss of appetite or interest in food and a much reduced sex life are frequent symptoms.
- Sadness or feelings of loss or of being alone.
- Shock or disbelief at what has happened, feeling of numbness, unreality or feelings of isolation or detachment from other people.
- Sleep problems including getting to sleep, waking in the middle of the night, dreams or nightmares.
- Problems with thinking and concentrating, e.g. unable to read a newspaper, magazine or book for any length of time.
- Preoccupation with the trauma, i.e. the incident or accident is almost constantly on their mind.
- Guilt and self-doubt for not having acted in some way during the trauma, or for being better off than others, or feeling ‘responsible’ for another person’s death or injury.
- Anger or irritability at what has happened and the senselessness of it all. It is not unusual that people ask the question ‘Why me?’
Not everyone experiences all these reactions to the same extent, and there may also be other reactions added to the list. In most cases these symptoms will diminish over a period of time from a few hours to days or weeks. However, in some cases they may go on for months or years.
What is often forgotten or not considered is that the traumatic event not only affects the individual directly involved in the incident, but can also have a quite a damaging impact on significant others in that individual’s life.
Relationships and PTSD
People who have PTSD often experience difficulties with those they love and care about. This could be with their partners, close family, friends and neighbours or colleagues at work.
- PTSD sometimes interferes with the individual’s usual feelings and emotions such as feeling close and being able to communicate easily. Normal problem solving skills may also be much less effective.
- In some cases there may be a loss of physical affection, i.e. lovemaking or just hugging. There may also be a feeling of being distant from loved ones or a feeling of being emotionally numb.
- Partners, friends or family may to some extent feel a little hurt, alienated or discouraged and in turn may feel anger or distant towards the PTSD sufferer.
- It is fairly common for those with PTSD to feel irritated, hyper-alert or more easily startled, feeling unable to relax.
- Significant others may feel under pressure and sometimes feel as if they are being controlled as a result of the situation. This can manifest itself by the PTSD sufferer being hypercritical of others.
- Difficulty when falling asleep or staying asleep and severe nightmares may prevent both PTSD sufferer and partner from getting a good night’s sleep and makes sleeping together difficult. Often this leads to the PTSD sufferer sleeping alone, which can cause further problems.
- Memories of the traumatic event may surface from time to time in the form of flashbacks, and efforts to avoid memories or reminders can frequently make living with a PTSD sufferer feel like living in a potential disaster area.
- Reliving the traumatic event, the avoidance of memories and wrestling with fear and anger greatly interfere with the individual’s ability to listen attentively and make cooperative decisions.
Significant others may in some cases feel that dialogue and working together are not possible any more. In some cases this can lead to the breakdown of a relationship, separation, divorce, and in a work environment, leaving work.
John Clark trained at the Centre for stress Management in London and obtained his Diploma in late 2000. He has extensive experience of helping people recover from PTSD and other associated phobia. John has contributed numerous articles on stress-related issues to Stress News. He frequently speaks on stress matters on local radio in the northwest. He regularly contributes to articles in national newspapers and magazines on stress and health. John is author of ‘Stress: A Management Guide’. Email: email@example.com
Gladeana McMahon is a Fellow and Senior Registered Practitioner of the BACP and an Accredited Cognitive Behavioural Psychotherapist who is UKCP and UKRC registered. She has written or edited 20 books including an interactive training manual ‘Understanding Trauma’ (National Extension College, Cambridge), and self-help book ‘Coping with Life’s Traumas’ (New leaf, Gill and MacMillan). Email: firstname.lastname@example.org
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