PTSD and trauma
Introduction
I see a lot of clients with Post Traumatic Stress Disorder (PTSD), and wanted to write a little about what it is, what we understand about how the brain works when it is traumatised and treatment options.
People often associate PTSD with military personnel, which is being identified and, thankfully, treated much more frequently. However, PTSD is not a condition purely limited to people who have been in war zones and conflict areas. Indeed, it possible to develop PTSD after being in any situation which has involved a fear of serious injury or death, either of the individual involved, or someone close to them. This includes road traffic collisions, domestic violence incidents, abuse or sexual assault. Research suggests that 1 in 4 people who have been in such a situation will develop features of PTSD.
More recently, work by Shapiro (1995) suggests that the brain can be traumatised by incidents that are stressful, and not necessarily perceived to be life threatening, such as childhood bullying, parental conflict, redundancy and relationship breakdowns. This list however is not exclusive, and ultimately, as in CBT overall, I focus on how my client has been affected by what they have endured; indeed, trauma for me as a therapist is defined by the effect it has rather than the incident that caused it.
Types of trauma – 1 and 2
Broadly speaking, there are two types of trauma; ‘Type 1 Trauma’, which is caused by a single incident and ‘Type 2 Trauma’, which results from a number of incidents over an extended period of time. Type 2 trauma can occur when people have been subjected to an extended period of stress, such as prolonged childhood abuse, on-going domestic violence or extremely stressful work or study environments.
PTSD is the clinical term used for a collection of symptoms, and is generically used to describe both Type 1 and Type 2 trauma. Increasingly, especially within EMDR (see my page on EMDR), these symptoms do not have to be completely present for someone to benefit from trauma focused therapy and clients I have worked with often wouldn’t identify with every aspect of PTSD, but have benefited greatly from EMDR.
Symptoms
Symptoms of the classically defined PTSD include flashbacks to what happened, either during waking hours or in the form of nightmares. These may be unclear, for example, someone involved in a traffic collision may keep seeing bright lights in their dreams, and notice physical symptoms of anxiety, however may not identify these with the headlights that came towards them during the collision. People suffering PTSD will often have some symptoms of re-experiencing, even if it is just of the emotions they had during the trauma (often referred to as hyper arousal). It could be, for example, that someone who was sexually assaulted immediately feels anxious if they see someone who looks similar to their perpetrator; someone who was shouted at by a parent may feel extreme anxiety when anyone raises their voice, or someone who was attacked by an individual wearing a blue jumper may become inexplicably anxious when they see the colour blue. People with PTSD often struggle not to think about the trauma, although they often try very hard to 'block' it from their mind.
As a result of these symptoms, it is usual for people with symptoms of PTSD to avoid certain situations that make them feel uncomfortable. Again, this may be subtle, and the sufferer may not realise why they are avoiding things, for example, someone who has PTSD from a domestically abusive incident may avoid conflict of any kind as it causes them so much distress.
Type 2 trauma may also come with the same symptoms as above, but generally has more of an impact on an individual’s overall personality. For example, if someone was abused as a child, they may find themselves being excessively avoidant of relationships or other people throughout life. Someone who has been in a war zone may find they become more hostile than before being in this situation, or someone who has been bullied in a work environment might become extremely emotional in any work situation.
I often find that the ‘Trauma types’ are not completely clear cut, and again, my emphasis in therapy is to identify, with my clients, what is causing their distress, and how it can be treated. Recently, I have found an increasing number of clients present with disorders such as OCD, panic or health anxiety, which transpire to be a symptom of past trauma. Someone with OCD for example, might want to control his or her environment to ensure their safety, or the safety of loved ones. However, when explored in therapy, we have realised this is rooted in childhood trauma, or bereavement, during which the person felt extremely out of control. In this case, processing the trauma could help my client to move forward from the OCD.
What happens to a traumatised brain?
Brain chemistry is key in understanding what happens when people develop PTSD, and brain scans have shown us that a traumatised brain looks different from a non-traumatised brain.
When, as humans, we enter into a situation that feels threatening to us, a part of our brain called the amygdala reacts and makes our body respond with adrenalin, which is intended to help us to survive a dangerous situation. Following such an incident, or trauma, our brain is then designed to ‘process’ emotions linked to the event, by thinking about what happened. Chemically, this is actioned by the memory of the event travelling through a part of the brain called the hippocampus, and ultimately becoming stored in the ‘cortex’ of the brain (which we consider to be the brain’s ‘filing cabinets’). When something has been particularly horrific, people often don’t want to think about it, or aren’t given any time to consider what happened, resulting in the ‘memory’ getting ‘stuck’. In this instance, anything that reminds us of our trauma causes our amygdala to react in the same way it did when the event happened – with an immediate and intense release of adrenalin. This is what we refer to as PTSD, and our job in therapy is to help ‘un-stick’ the traumatic memories and allow them to move healthily to the cortex of the brain.
We sometimes consider this in a metaphorical term, and imagine that the memory is like a huge duvet that we’ve tried to squeeze into a small airing cupboard, without folding it up. Whilst it isn’t folded, it keeps popping out and we have to keep one hand on the airing cupboard door to make sure it stays closed. Treatment, however, allows us to open the door and let the duvet out on the floor before neatly folding it back up and storing it away safely. To do this is normally painful and challenging, but a huge relief when treatment is finished!
Treatment options
Currently, the most evidence-based treatments for trauma are CBT and EMDR. Broadly speaking, the treatments aim to move the memory from the Amygdala into the cortex of the brain, which involves thinking about what happened and processing the related emotions. In my practice, I tend to use CBT for single incident traumas, and EMDR for multiple incident traumas, however I am flexible in considering what will work best for the client I am working with and the treatment they prefer.
I am constantly amazed at the radical effects trauma treatment can have on my clients. We will often have conversations beginning with phrases such as; 'you know what, I just realised I got into the car yesterday and felt totally OK; that would never have happened before'. It often feels like a sudden surprise or realisation that things are changing in a very organic and natural way. And in fact, this is exactly what happens in trauma treatment, a natural and organic change in the way memories are stored in the brain.
Treatment Results
In my experience, treatment of trauma is very effective. Through my work, I have seen people who have had nightmares every night for as long as they can remember, suddenly sleep through peacefully. I’ve seen people who couldn’t leave the house, start employment or regular social activity, and I’ve seen people who are terrified of social situations give presentations to large groups of people. I’ve often found that treating the traumatic incidents below the presenting difficulty can make a huge difference, especially in people who have already tried addressing the daily difficulties using a therapy like CBT.
Conclusion
In conclusion, trauma can occur in anyone, at any time. The examples I have given above are absolutely not exclusive, and if you think you may be affected by trauma, get in touch so we can arrange a 20 minute free telephone consultation.
