What Is Post-Traumatic Stress Disorder?
Post-Traumatic Stress Disorder (PTSD) is a psychological reaction that occurs after an extremely stressful event, such as physical violence or military combat. Those suffering from PTSD have recurring memories of the stressful event and are anxious or scared even in the absence of danger. Flashbacks and nightmares are common symptoms as well.
Much of what I write about relates to the concept of posttraumatic stress disorder (PTSD), the primary psychiatric disorder that follows from traumatic life experiences. Because PTSD is so central to much of what we talk about in relation to stress and trauma, I believe that this post is needed to provide some clarification for those who have not yet memorized the 20 diagnostic symptoms, and to lay a foundation for future posts.
PTSD, which first appeared in the formal Diagnostic and Statistical Manual (DSM) classification system in 1980, is both highly adopted and under attack at the same time. On the one hand, PTSD has been so well accepted into the lexicon of our culture that books and movies revolve around central characters with PTSD as part of the driving narrative (e.g., American Sniper), or activists try to link their causes to PTSD to gain instant authenticity (see my last blog Stress Is Not Trauma). On the other hand, critics constantly attack alleged flaws of PTSD in order to promote other agendas. So, what exactly is PTSD and how good is it?
The diagnostic criteria for PTSD in the fifth and latest edition of the DSM (DSM-5) consist of 20 possible symptoms that are divided amongst 4 clusters.
5 symptoms in the re-experiencing cluster:
· Intrusive recollections
· Psychological distress at reminders
· Physiological distress at reminders
2 symptoms in the avoidance cluster:
· Avoidance of internal reminders
· Avoidance of external reminders
7 symptoms in the altered cognitions and moods cluster:
· Dissociative amnesia
· Negative beliefs about oneself and the world
· Distorted blaming of oneself
· Negative persistent emotional states
· Loss of interests
· Detachment from loved ones
· Restricted range of affect
6 symptoms in the increased arousal cluster:
· Exaggerated startle response
· Concentration difficulty
· Sleep difficulty
· Irritability or outbursts of anger
· Self-destructive or reckless behavior
To qualify for the diagnosis of PTSD, an individual must have at least 1 of the five re-experiencing, 1 of the two avoidance, 2 of the seven altered cognition, and 2 of the six increased arousal symptoms. The algorithm ensures that a variety of different types of symptoms are represented. The algorithm creates a fairly high bar so that minimally symptomatic individuals do not get over-diagnosed. Thus, an individual with the diagnosis can have as few as 6 or as many as 20 of the possible symptoms.
This Is Your Brain on Trauma
An inside look at the traumatized brain, and how you can start to heal.
Approximately 50 percent of the population will experience a traumatic event at some point in their lives. While reactions to trauma can vary widely, and not everyone will develop Post-Traumatic Stress Disorder (PTSD), trauma can change the brain in some predictable ways that everyone should be aware of, especially if you or someone close to you is struggling to cope after trauma. With increased awareness, you can seek treatment to address your symptoms and learn skills that could actually rewire your brain for recovery. Additionally, knowing what’s going on can be immensely helpful because it may help you realize that you’re not crazy, irreversibly damaged, or a bad person. Instead, you can think of a traumatized brain as one that functions differently as a result of traumatic events. And just as your brain changed in response to your past experiences with the world, it can also change in response to your future experiences. In other words, the brain is “plastic,” and you can change it.
The formal diagnosis is based on an algorithm that requires symptoms from all four clusters. Trauma can alter brain functioning in many ways, but three of the most important changes appear to occur in the following areas:
1. The prefrontal cortex (PFC), known as the “Thinking Center”
2. The anterior cingulate cortex (ACC), known as the “Emotion Regulation Center”
3. The amygdala, known as the “Fear Center”
The PFC, or thinking center, is located near the top of your head, behind your forehead. It's responsible for abilities including rational thought, problem-solving, personality, planning, empathy, and awareness of ourselves and others. When this area of the brain is strong, we are able to think clearly, make good decisions, and be aware of ourselves and others.
The ACC, or emotion regulation center, is located next to the prefrontal cortex, but is deeper inside the brain. This area is responsible (in part) for regulating emotion, and (ideally) has a close working relationship with the thinking center. When this region is strong, we are able to manage difficult thoughts and emotions without being totally overwhelmed by them. While we might want to send a snarky email to a coworker, the emotion regulation center reminds us that this is not a good idea, and helps us manage our emotions so that we don’t do things we regret.
Finally, the amygdala, a tiny structure deep inside our brain, serves as its fear center. This subcortical area is outside of our conscious awareness or control, and its primary job is to receive all incoming information – everything you see, hear, touch, smell, and taste – and answer one question: “Is this a threat?” If it detects that a dangerous threat is present, it produces fear in us. When this area is activated, we feel afraid, reactive, and vigilant.
What’s Going on in a Traumatized Brain
Traumatized brains look different from non-traumatized brains in three predictable ways:
1. The Thinking Center is underactivated,
2. The Emotion Regulation Center is underactivated
3. The Fear Center is overactivated.
What these activation indicate is that, often, a traumatized brain is "bottom-heavy," meaning that activation's of lower, more primitive areas, including the fear center, are high, while higher areas of the brain (also known as cortical areas) are under activated. In other words, if you are traumatized, you may experience chronic stress, vigilance, fear, and irritation. You may also have a hard time feeling safe, calming down, or sleeping. These symptoms are all the result of a hyperactive amygdala.
At the same time, individuals who are traumatized may notice difficulties with concentration and attention, and often report they can’t think clearly. This, not surprisingly, is due to the thinking center being underactivated.
Finally, survivors of trauma will sometimes complain that they feel incapable of managing their emotions. For example, if someone spooks them, they may experience a rapid heart rate long after the joke is up, or may have a hard time “just letting go” of minor annoyances. Even when they want to calm down and feel better, they just can’t. This is in large part due to a weakened emotion regulation center.
What You Can Do Now
Changing the brain takes effort, repetition, and time. The best gift you can give yourself toward this goal is psychotherapy. If you’re ready to start that journey, look for a psychologist who specializes in trauma and PTSD, and who uses evidence-based methods that change the brain by working with both the body and the mind.
Also, consider adding a body-based or mindfulness-based technique to your daily routine, to help begin deactivating the fear center. This is a vital first step to healing, as when we are able to quiet the fear center, we are better able to work on strengthening and activating the thinking center and emotion regulation center. Two such exercises include diaphragmatic breathing and autogenic training. (Access free, guided practices of these techniques HERE.) The recommendation is to practice these techniques, or similar ones, for short periods of time multiple times per day. Remember, practice makes progress.
You may feel helpless, but there are many things you can do. Nobody expects you to have all the answers. If you feel there is a crisis for you or your loved one, use one of these toll-free, confidential hotlines:
- The National Suicide Prevention Lifeline is a 24-hour hotline for anyone in emotional distress: 1-800-273-TALK (8255). There is also an online Lifeline Chat available from 5 pm to 1 am EST, weekdays.
- The Veterans Crisis Line connects Veterans in crisis and their families and friends with VA responders through a 24/7 hotline: 1-800-273-TALK (8255), PRESS 1. There is also a 24/7 online Confidential Veterans Chat or text message support at 838255.
- The National Domestic Violence Hotline offers 24/7 anonymous access to shelters and domestic violence programs as well as legal advocacy, public education, and training: 1-800-799-SAFE (7233) or 1-800-787-3224 (TTY).
- The National Sexual Assault Hotline operated by RAINN (Rape, Abuse & Incest National Network) is a 24/7 resource to link victims to counseling and legal advice: 1-800-656-HOPE (4673). There is also a National Sexual Assault Online Hotline for messaging.
- The National Child Abuse Hotline is a 24/7 resource you can contact if you suspect a child is being abused, if you fear you might hurt your child, or if you have been abused: 1-800-4-A-CHILD (422-4453).
General resources for family and loved ones
Family members and close friends sometimes neglect their own needs when they commit themselves to caring for someone with PTSD. It is important for you to find support for yourself when you are helping someone deal with PTSD.
- Most US States have a National 211 referral line that connects people with important community services (employment, food pantries, housing, support groups, etc.). Dial 2-1-1.
- The SIDRAN Institute is a nonprofit organization that helps people understand, recover from, and treat traumatic stress and offers a referral list of therapists for PTSD. You can contact the Help Desk via email or by leaving a confidential voicemail: 1-410-825-8888.
- The National Alliance on Mental Illness (NAMI) offers a Family-to-Family Education Program for caregivers of people with severe mental illness. You can also email or call the Information Helpline: 1-800-950-NAMI (6264).
- You can find more resources on our Web Links: Families page.
Resources for loved ones of Veterans and Service Members
Some of the resources listed above are specific to Veterans and Service Members. Additional resources are listed below:
- The VA Caregiver Support program provides services to support family members who are taking care of a Veteran: 1-855-260-3274
- VA's Coaching Into Care program helps family and friends of returning Veterans find the right words to help their loved one get into care. For free, confidential coaching email or call: 1-888-823-7458
- The Vet Center Combat Call Center is a 24/7 call center for combat Veterans and their families to talk about their military experience or issues about readjustment to civilian life: 1-877-WAR-VETS
- The Defense Centers of Excellence (DCoE) 24/7 Outreach Center offers information and consultation in mental health and traumatic brain injury: 1-866-966-1020. DCoE also offers email and online chat support.
- The National Resource Directory links to over 10,000 services and resources that support recovery, rehabilitation, and reintegration for wounded, ill, and injured Service Members, Veterans, their families, and those who support them.
- Give an Hour is a nonprofit organization offering free mental health services to US military personnel and their families affected by Iraq and Afghanistan.
- You can find more resources on our Web Links page for Families, Military Resources, and Veterans Service Organizations.
Resources for children with a parent who has PTSD
Children respond to their parents' PTSD symptoms. A child may behave like the parent to try to connect with him or her. Some children take on an adult role to fill in for the parent with PTSD. If children do not get help with their feelings, it can lead to problems at school, in relationships, or with emotions (like worry, fear, or sadness).
- MilitaryKidsConnect (MKC) is an online community for military children (age 6-17) with resources for children to give support before, during, and after a parent's or caregiver's deployment.
- Sesame Street offers a Talk, Listen, Connect parent toolkit to help military families coping with deployment.
- It is important children know that a parent's PTSD symptoms are not their fault. An interactive workbook for teens may help: "Finding My Way: A Teen's Guide to Living with a Parent Who has Experienced Trauma"
- You can find more resources on our Web Links: Children and Teens page.