Signs of PTSD can range from flashbacks to nightmares, panic attacks to eating disorders and cognitive delays to lowered verbal memory capacity. Many trauma survivors also encounter substance abuse issues, as they attempt to self-medicate the negative effects of PTSD. The Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorder (DSM-IV) cites 17 major signs of post-traumatic stress disorder.
Just as not every trauma survivor will develop PTSD, not every individual with PTSD will develop the same signs – and rarely do all 17 exist in one individual.
Experts have created three categories (or “clusters”) of PTSD symptoms, falling into the categories of re-experiencing the traumatic event, avoidance of reminders of the traumatic event and responses of hyperarousal. PTSD symptoms will generally persist for at least a month and for many survivors, these signs represent their first struggles with anxiety.
Some of the most common symptoms of PTSD include the following:
- Intense feelings of distress when reminded of a tragic event
- Extreme physical reactions to reminders of trauma such as a nausea, sweating or a pounding heart
- Invasive, upsetting memories of a tragedy
- Flashbacks (feeling like the trauma is happening again)
- Nightmares of either frightening things or of the event
- Loss of interest in life and daily activities
- Feeling emotionally numb and detached from other people
- Sense of a not leading a normal life (not having a positive outlook of your future)
- Avoiding certain activities, feelings, thoughts or places that remind you of the tragedy
- Difficulty remembering important aspects of a tragic event
One or more symptoms are required from each of these clusters in order for a patient to receive a full diagnosis.
Those clusters include:
- Stressor – (one required) The person was exposed to injury or severe illness that was life-threatening, which includes actual or threatened injury or violence. This may include at least one of the following:
- Direct exposure to the trauma
- Witnessing a trauma
- Exposure to trauma by being a first responder, such as police, firefighter, medic, or crisis counselor
- Learning that someone close to you experienced the trauma
- Intrusion Symptoms (one required) – The person who was exposed to a trauma then re-experiences the trauma in one or more ways, including:
- Distressing and intense memories
- Distress or physical reactions after being exposed to reminders, known as “triggers”
- Unpleasant Changes to Mood or Thoughts (two required) –
- Blaming self or others for the trauma
- Decreased interest in things that were once enjoyable
- Negative feelings about self and the world
- Inability to remember the trauma clearly
- Difficulty feeling positive
- Feelings of isolation
- Negative affect, and difficulty feeling positive
- Avoidance (one required) – This occurs when a person tries to avoid all reminders of the trauma, including:
- Avoiding external reminders of what happened
- Avoiding trauma-related thoughts or emotions, sometimes through the use of drugs or alcohol
- Changes in Reactivity (two required) – This occurs when a person becomes more easily startled and reacts to frightful experiences more fully, including symptoms of:
- Aggression or irritability
- Hypervigilance and hyper-awareness
- Difficulty concentrating
- Difficulty sleeping
- Heightened startle response
- Engaging in destructive or risky behavior
- Difficulty sleeping or staying asleep
All of these symptoms must have persisted at least one month, and they must be causing distress or functional impairment of some kind. These symptoms must not be related to any substance use, illness, or medications.
How People Describe their PTSD
A person who describes his or her PTSD may say something similar to these sentences:
- “I don’t want to think (or talk) about it.”
- “I can’t get it out of my head.”
- “I feel like I’m losing my mind.”
- “I keep having panic attacks.”
- “I feel like it keeps happening over and over again.”
- “I don’t want to go out/see friends/visit loved ones/participate in activities.”
- “I just feel numb.”
- “My life is not normal anymore.”
- “I can’t remember what happened.”
- “I keep having nightmares.”
Flashbacks and Panic: Signs of Re-experiencing Trauma in PTSD
Everyday occurrences can “trigger” memories of the traumatic event. When the brain becomes reminded of the trauma, survivors of PTSD may re-experience the event itself, as if it were occurring in the present. Flashbacks cause the survivor to have a waking, conscious and often sensory experience of the traumatic episode, usually accompanied by visual or auditory immersions.
Intrusive thoughts can also represent the re-experiencing of trauma, as the survivor’s natural efforts to switch mental focus or block the experience fail. Another sign of re-experiencing trauma in PTSD is extreme psychological stress when triggers occur.
He or she may even experience physical sensations of re-experiencing, such as muscles freezing, profuse sweating, racing pulse or heartbeat, yelling, or running away when psychological or physical cues trigger the traumatic event.
Finally, persistent nightmares represent re-experiencing the trauma and in some cases, nightmares that cause the survivor to relive the event can be as traumatic as flashbacks.
Trauma Avoidance Signs of PTSD
Many survivors will avoid locations, people, or even topics of conversation that remind them of the traumatic event itself. Trauma avoidance signs of PTSD include an aversion to emotions, cognitions, or conversations about the traumatic experience, avoidance of places that cause reminders of the trauma and avoidance of hobbies or activities due to all of the fear surrounding the trauma.
Dissociative symptoms also can set in during the brain’s attempts at avoidance, including sensations of depersonalization (“out-of-body” experiences) and derealization (feeling detached from the world), as well as general emotional detachment and social alienation.
Many PTSD survivors also find themselves detached from positive feelings, as the brain attempts to build an emotional wall, leaving them with feelings of “emptiness” or “flat” demeanors. Many PTSD survivors will also begin to ascribe to the belief that they will not live a full life due to their near-death experiences, causing a host of lifestyle issues as they may avoid long-term planning around jobs, careers, relationships or families.
Hyperarousal Signs of PTSD
Some signs of post-traumatic stress disorder have to do with the brain and body’s hyperarousal in the wake of a traumatic threat. Because the brain interprets the traumatic event as a present danger, natural fight-or-flight reactions become engaged – and sometimes prolonged during re-experiencing of the event. In combination with general hypervigilance that so often accompanies PTSD, these signs of hyperarousal can amount to an exhausting and stressful experience for the survivor.
Insomnia is one PTSD symptom that is associated with hyperarousal. Many survivors with PTSD have significant difficulty falling asleep and staying in a deep sleep throughout the night. Due to persistent fears, some individuals with PTSD also sleep with the lights on, making it difficult to obtain a restful, REM-level of sleep.
Irritability is another symptom of hyperarousal, where survivors become prone to angry outbursts over slight issues. This may impact relationships and job performance. Many survivors also experience short-term memory difficulties, making focus, expression, and cognition a struggle.
Others experience constant hypervigilance, seeking to interpret virtually any slight physical or psychological cue and assess the possibilities of further danger. Finally, many survivors experience a strong “startle response,” which causes the person to suddenly panic and even run, shake, or scream when unexpected sensory input occurs, such as unwelcomed touch, loud noises, or unexpected visual events.
The Importance of PTSD Treatment
Many people are unaware that untreated post-traumatic stress disorder can have a devastating effect for both those who have the condition and their loved ones. It not only affects relationships with your family, friends and others, it can trigger serious emotional problems and even cause health problems over time.
PTSD affects people of all ages. It can even impact the health of unborn babies when the mother is under constant stress.
Common Medications Used in PTSD Treatment
After you experience a traumatic event, the chemicals in your brain can affect the way you feel. For instance, when a person experiences depression (no matter the cause), he or she may not have lowered amounts of “happy neurotransmitters” like serotonin or dopamine. Selective serotonin reuptake inhibitors (SSRIs) help increase the level of serotonin in a person’s brain. This type of antidepressant drug can help a person feel less worried and sad.
Here is a list of common SSRIs:
- Celexa (citalopram)
- Prozac (fluoxetine)
- Paxil (paroxetine)
- Zoloft (sertraline)
PTSD therapy helps change your relationship with the trauma. Therapy isn’t for erasing your memories. — Dr. Rebecca Liu, Clinical Psychologist
Prolonged Exposure Therapy (PE)
People with PTSD often try to avoid things that remind them of the trauma. This can help you feel better in the moment, but in the long term it can keep you from recovering from PTSD. In PE, you expose yourself to the thoughts, feelings, and situations that you’ve been avoiding. It sounds scary, but facing things you’re afraid of in a safe way can help you learn that you don’t need to avoid reminders of the trauma. What happens during PE? Your therapist will ask you to talk about your trauma over and over.
This will help you get more control of your thoughts and feelings about the trauma so you don’t need to be afraid of your memories. She will also help you work up to doing the things you’ve been avoiding. For example, let’s say you avoid driving because it reminds you of an accident. At first, you might just sit in the car and practice staying calm with breathing exercises. Gradually, you’ll work towards driving without being upset by memories of your trauma.
I learned with the Prolonged Exposure, by re-living some of the most scariest moments of my life when I was in Iraq, you learn that it’s there, but the intensity of the memory goes away. — Andrew Reeves, US Army (1999–2009)
Cognitive Processing Therapy (CPT)
After a trauma, it’s common to have negative thoughts — like thinking what happened is your fault or that the world is very dangerous. CPT helps you learn to identify and change these thoughts. Changing how you think about the trauma can help change how you feel. What happens during CPT? You’ll talk with your therapist and fill out worksheets about the negative thoughts and beliefs that are upsetting you. Then your therapist will help you challenge those thoughts and think about your trauma in a way that’s less upsetting.
Cognitive Behavioral Therapy
A mental health therapist can help a survivor process the trauma in a healthy, effective way. Therapy enables a person to replace negative thoughts with thoughts that are less distressing. If a person is experiencing guilt or anger, Cognitive Behavioral Therapy can help a person cope with their feelings. Other therapies, such as Dialectical Behavior Therapy, can help the individual cope with triggers and quickly resolve panics, communicate better about the trauma, and find new ways to combat flashbacks or physical sensations of trauma.
After a person experiences tragedy in their life, they may blame themselves for things they couldn’t have changed. Many people blame themselves for things that they could not have possibly controlled. These feelings can cause significant distress and are not necessarily rooted in logic, yet remain strongly rooted in thought patterns and beliefs, despite how distressing they are.
Cognitive Behavioral Therapy will help a person cope with their unnecessary feelings of guilt and help him or her realize that the outcome of a tragedy it is not their fault.
There are a number of treatments for PTSD, including newer treatments like EMDR (Eye Movement Desensitization and Reprocessing) and neurobiofeedback. You and your therapist can work together to decide which for of PTSD Treatment will work best for you to help get your life back on track.
Eye Movement Desensitization and Reprocessing (EMDR)
People with PTSD react negatively to the memory of their traumas. EMDR can help you process these upsetting memories, thoughts, and feelings. You’ll focus on specific sounds or movements while you talk about the trauma. This helps your brain work through the traumatic memories. Over time, you can change how you react to memories of your trauma. What happens during EMDR? Your therapist will ask you to choose a memory from the trauma and identify the negative thoughts, emotions, and feelings in your body that go with it. You’ll think about this memory while you pay attention to a sound (like a beeping tone) or a movement (like your therapist’s finger moving back and forth). Once the memory becomes less upsetting, you’ll work on adding a positive thought.
How can I decide which treatment is right for me?
The online PTSD Treatment Decision Aid (https://www.ptsd.va.gov/apps/decisionaid/) is a great way to learn about your options and consider which treatment is right for you. You can watch videos of providers explaining how treatments work, then build a personalized comparison chart of the treatments that appeal to you. You can share a printout of the chart with your provider as you decide together which treatment best meets your needs.
Where can I go to get help?
If you’re a Veteran, check with the VA about whether you can get treatment there. Visit http://www.va.gov/directory/guide/PTSD.asp to find a VA PTSD program near you.
If you’re looking for care outside the VA, ask your doctor for a referral to a mental health care provider who specializes in PTSD treatment, or visit https://findtreatment.samhsa. gov/ to search for providers in your area. When choosing a mental health care provider, here are some important things to consider:
Find a provider who uses PTSD treatments proven to work. It’s best if you can find someone who offers one of the treatments we’ve talked about in this booklet, since these treatments have strong evidence showing that they work. Many mental health centers in hospital or university systems offer these treatments.
What if I can’t find anyone who offers these treatments? Many doctors can treat PTSD with medication, but it may be hard to find therapists who use the other treatments we’ve talked about. If you can’t find a therapist who offers CPT, PE, or EMDR, ask about trauma-focused cognitive behavioral therapy. General cognitive behavioral therapy can also be a good alternative.
Find out what your insurance will cover. If you have health insurance, check to see what mental health services are covered.
Find someone who is a good fit for you. You and your therapist or doctor will work closely together, so it’s important that you feel comfortable asking questions and talking about problems in your life. It’s always okay to look for a different therapist or doctor if you’re not happy with the person you’re seeing.
I can carry on with my life and not feel so much guilt, so much anger and resentment. Besides my daughter and my wife, it’s the best thing that’s ever happened to me. — Joe Duarte, US Army (2002–2008)
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