PTSD and Trauma
Trauma: (Greek 17c), literally meaning ‘wound’
What is Trauma?
Confusingly the word ‘trauma’ is often used to describe a traumatic life event (ie an event that is out of the ordinary, and threatens the survival of ourselves or those we care about), and also the subsequent distress that occurs as a reaction to the traumatic event. Therefore, for clarity, in this article, the event or series of events will be described as “traumatic event”, and the subsequent traumatic reaction as “traumatic stress”.
What is a traumatic event?
Psychiatric diagnostic manuals list potentially traumatic events as: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence
However, what is considered traumatic by one person, may not be by another; therefore rather than list the type of events that could be labelled as ‘traumatic’, it may be easier to define a traumatic event by considering it as extremely upsetting, distressing, out of your control, and causing you to feel that your resources are overwhelmed, and that you cannot cope with what is happening/what has happened on an ongoing basis. The traumatic event may have occurred recently, or long ago. It may be a one off event, or experienced on an ongoing basis (such as in childhood abuse, neglect or domestic abuse).
Signs of Traumatic Stress
Feeling highly anxious, avoiding situations that remind you of the traumatic events, and intrusive images or memories are common symptoms of traumatic stress. A further symptom called dissociation is also common. Dissociation causes a feeling of being emotionally numb, feeling unconnected to your surroundings, not feeling as if you are real, not feeling as if your surroundings are real, and can cause memory loss in some cases. These symptoms may sound frightening and unpleasant, and many people I help who have experienced trauma feel like they are losing their mind, thus creating further anxiety. If you are experiencing symptoms of traumatic stress, it is important to remember that no matter how frightening they are, these are to be expected following a traumatic event. You are not losing your mind, or going ‘mad’, you are simply biologically and psychologically adapting to the impact of the traumatic event(s).
When does traumatic stress become Post Traumatic Stress Disorder?
In the aftermath of a traumatic event, it would be highly usual to experience the symptoms discussed above. However, if symptoms persist beyond one month following the event, it is possible that PTSD may be occurring.
The trouble with the symptoms of post traumatic stress is that they can cause us to behave differently; we start to avoid doing things we would usually do to avoid stimulating a flashback or unwanted memory; we become alert to the threat that we view as being all around; we may do things to avoid having memories/feelings such as drinking excessively, taking drugs, etc. The routine every day things that we used to take for granted become so unmanageable that we stop doing them, eg working, socialising, taking care of the home, taking care of ourselves. Sleep can be disturbed due to nightmares, and excessive anxiety. All of these knock on effects can lead to secondary conditions such as depression, anxiety, panic disorder, substance dependency, physical health problems, self harm & sometimes suicidal acts. These in turn can lead to job loss, financial hardship, and relationship breakdown to name but a few.
People who dissociate may feel physically disconnected from themselves and the world around them. Dissociation is a way the mind copes with too much stress. Periods of dissociation can last for a relatively short time (hours or days) or for much longer (weeks or months).
The effects of dissociation can also be highly disturbing; whilst dissociating is considered adaptive during the traumatic event(s), continued dissociation can seriously impair your ability to live your life.
Severe dissociation has been described as a “phobia of memories in the form of excessive or inappropriate physical responses to thoughts or memories of old traumas” (Janet, 1920). Continued dissociation in this way can lead to PTSD developing, as dissociation can impact the processing of traumatic memories, thus creating more flashbacks and intrusive images, leading to further avoidance and heightening of anxiety.
The impact of a traumatic event, or series of events also alter our views about the world, of others, and particularly about ourselves. Suddenly the secure world as we knew it no longer feels safe, and danger can lurk beyond every corner. People may no longer feel trustworthy. In the event of a significant death, it can feel as if previously cherished religious beliefs are no longer believed in. The familiarity of our own privately held beliefs are no longer there, and are replaced by fear inducing thoughts and expectations.
Furthermore, it is not uncommon to develop negative beliefs about ourselves as a result of the traumatic event “I should have stopped it”, “I am weak”, “I am worthless” etc, leading to heightened feelings of shame, guilt and anger. We can become a stranger in our own lives.
How the body and brain respond to trauma
Why am I having these symptoms?
You may be experiencing some, or all of the symptoms discussed to varying degrees (and maybe some additional ones). To try to explain why you may be experiencing symptoms of traumatic stress it is necessary for me to briefly discuss the inner workings of your brain and nervous system. You do not have to be a brain expert in order to follow me (I’m not!), but sometimes it can help to have a little bit of knowledge of theories about what might be happening at a biological level (Rothschild, 2000; Ogden, 2006; Porges, 2003).
The middle part of your brain is called the limbic system, and is responsible for survival responses. When we experience a traumatic event we are thrown into survival response mode. The limbic system is a ‘non-thinking’, reactive area of the brain.
There is a little almond shaped area called the amygdala. The amygdala takes in sensory information from the outside world through the five senses, and also from our internal world through our unconscious perception of movement and spatial awareness (arising from stimuli within the body itself) and the defibrillator sense. At all times the amygdala is working away and evaluating sensory information and giving instructions on how the body should respond. As an experiment notice the internal sensations you have as you visualise a past love, or a current crush….the amygdala is responsible for those sensations!
The sensory nervous system is the part of the nervous system that takes in information and records information about the body. There are external sensors ‘exteroceptors’; the sensory nerve end receptors that respond to external stimuli located in the skin, oral cavity, eyes, ears, and nose. Internal sensors form the ‘interoceptive’ part of the sensory nervous system where proprioception, and the vestibular senses are. The vestibular is our sense of balance and proprioception is how we are able to locate our body in space including position and movement, and also our internal sense, for instance being able to feel your heartbeat or butterflies in your stomach.
So the sensory nervous system records all those things. For example, if I were attacked as I walked down the street the exteroceptors will respond. There’s visual and auditory sensing as well as touch: I see the attacker, I hear their voice, and I feel my skin as I am being grabbed. Then on the inside via the ‘interoceptors’ I feel my heart rate go up, my stomach goes in knots, and I can’t catch my breath. If I were to experience pain during the attack, that is also registered in the sensory nervous system. I am also registering my inability to be able to get away from the attacker, and that’s partly due to the internal proprioceptive sense.
It is the sensory nervous system that records what is happening during a traumatic event and stores a record. I will come back to why this is important a little later on.
So, as you experience a traumatic event the amygdala first receives the sensory information through sight, sound, hearing, etc. and tells the body how to respond. It evaluates that information and instructs the body either to go into “fight or flight” mode, or whether to initiate a “freeze” response. The system known as the “sympathetic” nervous system is responsible for the “fight or flight” response, and is associated with maintaining arousal and attention, and the consolidation of memories. Typically, under conditions of threat, the brain releases stress releasing hormones (such as adrenaline) to initiate running or fighting. When the stress is removed, the system returns to its usual baseline state. However, if you are experiencing the symptoms of traumatic stress, it is more difficult for the system to return to baseline, and I will explain why.
There’s another part of the brain called the hippocampus, and normally when stress levels are low the function of the hippocampus is to help the mind or ‘cortex’ to understand time and space content. For example, when remembering an incident the hippocampus gives a time-stamp of beginning, middle, and end. So, if you remember a meeting that you had in work last week, your hippocampus is responsible for giving you the information that the meeting started at 1pm on Wednesday, and finished at 4pm.
During a traumatic event, however, the hippocampus can get shut down by the stress hormones being produced by the amygdala and not function properly (this can be a bit like ‘blowing a fuse’ when all your lights go off at home, and you have to re-set the fuse box). Therefore, it’s not able to give that traumatic event the time-stamp of beginning, middle and end—which is possibly why people who experience traumatic stress or PTSD, continue to respond in their nervous systems as if the traumatic event is continual, and has not ended. This explains the high levels of anxiety and arousal associated with traumatic stress, even if no obvious threat is present.
This may seem really inconvenient, however, this is an evolutionary strategy (which is possibly working TOO well) to ensure that we are permanently physiologically primed to respond to threat, and therefore continue to survive. When there’s a threat we want to be able to respond automatically without having to think about it. Nature has designed this stress system so that when there’s a life threat, the hippocampus actually gets suppressed so the amygdala can do its safety sequence and protect the body as quickly as possible.
For those who are experiencing trauma symptoms the amygdala continues to suppress the hippocampus, therefore the alarm system is permanently switched ‘on’. It is this process that is responsible for the symptoms of heightened fear/arousal, re-experiencing images/memories, dissociation, and avoidance of things which remind you of the original traumatic event.
As mentioned earlier, the hippocampus is responsible for allocating biographical information to our memories, i.e., I wore a red dress to the black tie ball I attended with my best friend at The Grosvenor Hotel last Saturday evening. When the hippocampus becomes suppressed during a threat response, it is not able to allocate time, and store the memory in the same way. Therefore, most of the memory is stored by the sensory nervous system.
Remember I said earlier that the sensory nervous system keeps the record, and this is important? What this means is that not only does the memory have no time allocation, and appear to continue to be happening in ‘real time’ (in terms of the fight or flight alarm remaining ‘on’), but the memory is not able to be stored and retrieved in the same way as everyday memories. If we return to my memory of the red dress at the black tie ball, I can recall details of what I was wearing, where I went, and who I was with. I can store and recall this memory at will, because it has been processed by the hippocampus.
However, if we return to the memory of being attacked whilst walking down the street, that memory remains in my sensory nervous system (SNS), as the amygdala will have ‘fused’ the hippocampus during the intensive release of stress hormones, thus disabling biographical memory storage. My SNS does not want the memory to remain there, it wants the memory to be ‘processed’ and ‘date stamped’ by the hippocampus. Therefore, to kick start this processing, when I encounter a similar smell, internal sensation, or sound that is associated with that traumatic event, I will experience a flashback (i.e the sensation of being back in the traumatic situation, and re-experiencing it all over again, flashbacks disorientate time and space) or an intrusive image of the traumatic event. This is the brain trying very hard to get the memory processed.
I will experience this as happening completely ‘out of the blue’ which will further compound my anxiety. Furthermore, because this is such a distressing experience I am likely to try to prevent this remembering by whatever means necessary (avoidance, blocking, alcohol, self harming), and if I can’t stop it, I am likely to become even more anxious. This continues to leave the memory unprocessed, and me at further risk of flashbacks and intrusions. And so the symptoms of post traumatic stress persist.
When memories have been ‘date stamped’ by the hippocampus, they are able to be stored and retrieved at will (like my red dress memory). It is possible for your traumatic memories to be stored so that you can gain some control over them, and reduce flashbacks and intrusions.
The ‘freeze’ response
A word about the “freeze” response and childhood sexual abuse
So far, much has been said about the amygdala releasing stress producing hormones that stimulate the sympathetic nervous system, to mobilise the “fight or flight” response. However, in some circumstances, particularly if the threat seems inescapable, such as in times of sustained sexual or physical assault, whether in childhood or adulthood, or during sustained combat, a third response can occur.
This is an immobilising response that is activated by the parasympathetic nervous system, and is called the “freeze” response. Remember I talked about fight or flight being a cunning evolutionary strategy to keep us alive? The freeze response mimics death; that is, in evolutionary terms to fool the hunter into thinking that you are dead, and therefore you do not make good prey. Animals use this response a lot: if you have ever seen a cat when it unexpectedly comes across a dog you will see the freeze response in action, the cat almost looks like stone. When the freeze response is activated, blood pressure actually decreases, rather than increases, the muscles become floppy and fainting can be induced (this response also happens with needle and blood phobias, and in shock). This response is also your brain’s clever way of taking you away from inescapable psychological and physical pain by blocking your consciousness of it. If the freeze response has been activated during the traumatic event(s) it is likely that dissociation has occurred, and may continue to occur as a safety strategy to prevent you from further psychic pain.
Individuals that I have worked with who have experienced childhood sexual abuse often cannot recall details, and may even dissociate when trying to remember. This can be very frightening, yet is a natural reaction to the traumatic memories, and being able to understand why this is occurring can be helpful.
A note on ‘complex or chronic PTSD’
Sometimes, those who have experienced neglect or abuse during childhood (including sexual abuse), can learn to ‘dissociate’ from these terrifying experiences, by withdrawing their senses and attention from the source of fear. As mentioned above, this ‘freeze response’ is a highly adaptive response at that time, but unfortunately, can lead in later life to problems in connecting with others, and connecting with the world around you. This can develop into what is known as ‘complex’ or ‘chronic’ PTSD’. Those who have sought help often feel like having ‘complex/chronic PTSD’ means that they can’t treated, and have no hope. This isn’t the case, but it does mean that therapy can take a little longer, and that a sensitive, compassionate therapist can help you to build a trusting relationship, learn grounding techniques, and then move on to trying to ‘process’ the original traumatic events. Often, these are not one-off events but a series of painful and traumatic experiences. Embarking upon this path requires courage, determination, and the ability to develop self-compassion.
If you think you would benefit from trauma focused therapy with Nicola at Nine Wellbeing, you can make an enquiry or book a consultation on the contact page.
When someone we love dies, the emotional and physical reaction that follows is called grief. Grief is a natural process that usually evolves over time (see grief pages for more information). Sometimes, however, the grief reaction can become problematic.
Complicated or traumatic grief can arise when the circumstances of the death have been sudden, gruesome, or particularly traumatic. Complicated or traumatic grief responses can also occur following a long illness due to the prolonged effect of watching helplessly as your loved one suffered. However, there are no rules as to what constitutes a traumatic bereavement. What tends to make the grief reaction more problematic is avoidance of the painful processing of grief, which can lead to the grief becoming ‘stuck’, resulting in symptoms of trauma similar to those already discussed: flashbacks, severe anxiety, reduction in functioning, dissociation.
A special word goes to grief during the Covid-19 crisis
During the global coronavirus pandemic we are facing a tragic loss of life, often under unimaginable circumstances.
If you have lost someone you love during Covid-19, you may have experienced any or more of the following extraordinarily painful experiences:
• The person you love dying alone, due to infection control measures; with you and others close to you not being allowed to say goodbye.
• The illness progressing suddenly with sudden deterioration. This would be tremendously shocking and if you are not able to view your loved one’s body, you may not be able to accept the finality and process the reality of their death.
• Not being able to grieve with family and friends collectively & to physically offer each other comfort and support.
• Being unable to arrange a funeral that can be attended by all loved ones, to acknowledge the finality of your loved one’s death and to offer comfort, love and commemoration to one another.
• The constant sense of threat from the virus itself - no safe shelter “Who will be next”.
• Constant reminders and intrusion arising from constant media coverage.
It would make sense that grief during the Covid-19 crisis could be considered traumatic grief. Therefore, the grieving process may not follow the ‘usual’ path. If this is the case, this does not mean that there is something wrong with you, so please be compassionate with yourself and others around you who may also be suffering in this way. What it does mean is that your grief may need to be processed in different ways, and may unfortunately take longer.
If you think that you may be experiencing a complicated or traumatic grief reaction then you may benefit from trauma focused bereavement therapy, to help you to work through your reaction to the bereavement.
How can therapy help with symptoms of traumatic stress and/or PTSD?
If you recognise any of the above symptoms and you have experienced a traumatic event (even if it was many years ago), I would encourage you to discuss this first and foremost with your GP who can discuss your options with you. Medications can help, and specially adapted trauma focused therapies. Some of these recommended therapies are called EMDR, and Trauma Focused CBT.
If you are having therapy for symptoms of traumatic stress or PTSD, this therapy has to be adapted to accommodate the memory processing (from storage in the sensory nervous system to be ‘date stamped’ by the hippocampus). This is likely to involve your therapist teaching you some grounding and relaxation techniques – this is a very important part of the therapy process and it can take some time to find the techniques that work for you. Your therapist will also educate you about the biological, psychological, and social impact of trauma, so that you can understand more clearly why you are experiencing the difficulties that you are, and hopefully reduce your anxiety further. It is likely you will then move on to organising a ‘hierarchy’ of your traumatic memories, and staring with the least difficult memory, you will be encouraged and supported by your therapist to expose yourself to the memories, whilst simultaneously utilising your grounding techniques to help processing to occur.
Trauma focused therapy is an intensive therapy, and it is important you find a therapist that you feel comfortable with, and who also has experience of working with trauma. Whomever you choose, the therapy should go at your pace, and you will only be encouraged to process the memories that you want to. Different therapists work in different ways, just as individual clients respond to different therapeutic interventions. Some therapists may encourage you to use creative ways to expose yourself to your memories, by art or crafts, with music, poetry, writing stories, or by focusing on sensations in your body, and body movements. All of these methods can help to process your response to the traumatic event.
Whatever path you choose to help you to process your trauma, my hope is that this article has helped you to understand what may be happening to you, and I offer you my encouragement to find the courage, determination and resilience to recover your life.
If you think you would benefit from trauma focused bereavement therapy for your loss, you can make an enquiry at the contact page.
The final word goes to ‘hope’
When something traumatic happens, it can feel as if there is a mountain to climb in order to reclaim and rebuild your life. Just reading through this article is exhausting when you see all that is to be faced, biologically, psychologically and socially. When tragedy strikes, rebuilding the foundations of our assumptive world, and all that we have believed in seems insurmountable. However, my personal experiences of trauma, therapeutic experience of helping those who are traumatised, & a wider body of academic trauma research has shown that the long term legacy of traumatic pain involves suffering, but can, surprisingly, also facilitate growth.
“the powerful negative consequences of trauma – pain and suffering, the recognition of increased vulnerability and the related acknowledgement of meaninglessness and arbitrary loss serve as catalysts for post traumatic growth. Strength through suffering, psychological preparedness, and existential re-evaluations involve confrontation with agonizing challenges and painful realizations. The positive and negative are inextricably linked”
Finally, if you are reading this article, and you have experienced a traumatic event, I urge you to remember one thing – you have survived it. This means that no matter what your sensory nervous system is doing to protect you by tricking you into feeling constantly under threat, you have to recognise that it is over. You have survived. Take your first step towards recovery with that in mind.
List of References
Ogden, P., Minton, K., & Pain, C. (2006). Trauma and the Body: A Sensorimotor Approach to Psychotherapy. USA: Norton.
Porges, S. (2003). Social Engagement and Attachment: A Phylogenetic Perspective.
Annals of the New York Academy of Sciences, 1008, 31-47.
Rothschild, B. (2000). The Body Remembers: The Psychophysiology of Trauma and Trauma Treatment. USA: Author.
Nicola Forshaw holds a Masters Degree in Counselling (with distinction), a diploma in Cognitive Behavioural Therapy, and a certificate in Dialectical Behaviour Therapy. Nicola is a highly experienced trauma/PTSD therapist, with a special interest in traumatic grief and is fully qualified in EMDR (Eye Movement Desensitisation and Reprocessing). She is accredited by BACP (British Association of Counselling & Psychotherapy), and is also a registered member.