Post-traumatic stress disorder (PTSD)

Introduction

Post-traumatic stress disorder (PTSD) is an anxiety disorder caused by very stressful, frightening or distressing events.

Someone with PTSD often relives the traumatic event through nightmares and flashbacks, and may experience feelings of isolation, irritability and guilt.

They may also have problems sleeping, such as insomnia, and find concentrating difficult.

These symptoms are often severe and persistent enough to have a significant impact on the person’s day-to-day life.

Read more about the symptoms of PTSD.

Causes of PTSD

The type of events that can cause PTSD include:

• serious road accidents
• violent personal assaults, such as sexual assault, mugging or robbery
• prolonged sexual abuse, violence or severe neglect
• witnessing violent deaths
• military combat
• being held hostage
• terrorist attacks
• natural disasters, such as severe floods, earthquakes or tsunamis

PTSD can develop immediately after someone experiences a disturbing event or it can occur weeks, months or even years later.

PTSD is estimated to affect about 1 in every 3 people who have a traumatic experience, but it’s not clear exactly why some people develop the condition and others don’t.

Read more about the causes of PTSD.

Complex PTSD

People who repeatedly experience traumatic situations such as severe neglect, abuse or violence may be diagnosed with complex PTSD.

Complex PTSD can cause similar symptoms to PTSD and may not develop until years after the event. It’s often more severe if the trauma was experienced early in life as this can affect a child’s development.

Read more about complex PTSD.

When to seek medical advice

It’s normal to experience upsetting and confusing thoughts after a traumatic event, but most people improve naturally over a few weeks.

You should visit your GP if you or your child are still having problems about four weeks after the traumatic experience, or if the symptoms are particularly troublesome.

If necessary, your GP can refer you to mental health specialists for further assessment and treatment.

How PTSD is treated

PTSD can be successfully treated, even when it develops many years after a traumatic event.

Any treatment depends on the severity of symptoms and how soon they occur after the traumatic event. Any of the following treatment options may be recommended:

• Watchful waiting – monitoring your symptoms to see whether they improve or get worse without treatment.
• Psychotherapy – such as trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR). 
• Antidepressants – such as paroxetine or mirtazapine.

Read more about treating PTSD.

Symptoms

The symptoms of post-traumatic stress disorder (PTSD) can have a significant impact on your day-to-day life.

In most cases, the symptoms develop during the first month after a traumatic event. However, in a minority of cases, there may be a delay of months or even years before symptoms start to appear.

Some people with PTSD experience long periods when their symptoms are less noticeable, followed by periods where they get worse. Other people have constant, severe symptoms.

The specific symptoms of PTSD can vary widely between individuals, but generally fall into the categories described below.

Re-experiencing

Re-experiencing is the most typical symptom of PTSD. This is when a person involuntarily and vividly re-lives the traumatic event in the form of:

• flashbacks
• nightmares
• repetitive and distressing images or sensations
• physical sensations – such as pain, sweating, nausea or trembling

Some people have constant negative thoughts about their experience, repeatedly asking themselves questions that prevent them from coming to terms with the event.

For example, they may wonder why the event happened to them and if they could have done anything to stop it, which can lead to feelings of guilt or shame.

Avoidance and emotional numbing

Trying to avoid being reminded of the traumatic event is another key symptom of PTSD. This usually means avoiding certain people or places that remind you of the trauma, or avoiding talking to anyone about your experience.

Many people with PTSD try to push memories of the event out of their mind, often distracting themselves with work or hobbies.

Some people attempt to deal with their feelings by trying not to feel anything at all. This is known as emotional numbing. This can lead to the person becoming isolated and withdrawn, and they may also give up pursuing activities they used to enjoy.

Hyperarousal (feeling ‘on edge’)

Someone with PTSD may be very anxious and find it difficult to relax. They may be constantly aware of threats and easily startled. This state of mind is known as hyperarousal.

Hyperarousal often leads to:

• irritability
• angry outbursts
• sleeping problems (insomnia)
• difficulty concentrating

Other problems

Many people with PTSD also have a number of other problems, including:

• other mental health problems – such as depression, anxiety or phobias
• self-harming or destructive behaviour – such as drug misuse or alcohol misuse
• other physical symptoms – such as headaches, dizziness, chest pains and stomach aches

PTSD sometimes leads to work-related problems and the breakdown of relationships.

PTSD in children

PTSD can affect children as well as adults. Children with PTSD can have similar symptoms to adults, such as having trouble sleeping and upsetting nightmares.

Like adults, children with PTSD may also lose interest in activities they used to enjoy and may have physical symptoms such as headaches and stomach aches.

However, there are some symptoms that are more specific to children with PTSD, such as:

• bedwetting
• being unusually anxious about being separated from a parent or other adult
• re-enacting the traumatic event(s) through their play

When to seek medical advice

It’s normal to experience upsetting and confusing thoughts after a traumatic event, but in most people these improve naturally over a few weeks.

You should visit your GP if you or your child are still having problems about four weeks after the traumatic experience, or if the symptoms are particularly troublesome.

Your GP will want to discuss your symptoms with you in as much detail as possible. They’ll ask whether you’ve experienced a traumatic event in the recent or distant past and whether you’ve re-experienced the event through flashbacks or nightmares.

Your GP can refer you to mental health specialists if they feel you’d benefit from treatment. See treating PTSD for more information.

Causes

Post-traumatic stress disorder (PTSD) can develop after a very stressful, frightening or distressing event, or after a prolonged traumatic experience.

Types of events that can lead to PTSD include:

• serious road accidents
• violent personal assaults, such as sexual assault, mugging or robbery
• prolonged sexual abuse, violence or severe neglect
• witnessing violent deaths
• military combat
• being held hostage
• terrorist attacks
• natural disasters, such as severe floods, earthquakes or tsunamis
• a diagnosis of a life-threatening condition
• an unexpected severe injury or death of a close family member or friend

PTSD isn’t usually related to situations that are simply upsetting, such as divorce, job loss or failing exams.

PTSD develops in about 1 in 3 people who experience severe trauma. It isn’t fully understood why some people develop the condition while others don’t. However, certain factors appear to make some people more likely to develop PTSD.

If you’ve had depression or anxiety in the past, or you don’t receive much support from family or friends, you’re more susceptible to developing PTSD after a traumatic event.

There may also be a genetic factor involved in PTSD. For example, having a parent with a mental health problem is thought to increase your chances of developing the condition.

Possible causes

Although it’s not clear exactly why people develop PTSD, a number of possible reasons have been suggested. These are described below.

Survival mechanism

One suggestion is that the symptoms of PTSD are the result of an instinctive mechanism intended to help you survive further traumatic experiences.

For example, the flashbacks many people with PTSD experience may force you to think about the event in detail so you’re better prepared if it happens again. The feeling of being “on edge” (hyperarousal) may develop to help you react quickly in another crisis.

However, while these responses may be intended to help you survive, they’re actually very unhelpful in reality because you can’t process and move on from the traumatic experience.

Adrenaline levels

Studies have shown that people with PTSD have abnormal levels of stress hormones.

Normally, when in danger, the body produces stress hormones such as adrenaline to trigger a reaction in the body. This reaction, often known as the “fight or flight” reaction, helps to deaden the senses and dull pain.

People with PTSD have been found to continue to produce high amounts of fight or flight hormones even when there’s no danger. It’s thought this may be responsible for the numbed emotions and hyperarousal experienced by some people with PTSD.

Changes in the brain

In people with PTSD, parts of the brain involved in emotional processing appear different in brain scans.

One part of the brain responsible for memory and emotions is known as the hippocampus. In people with PTSD, the hippocampus appears smaller in size. It’s thought that changes in this part of the brain may be related to fear and anxiety, memory problems and flashbacks.

The malfunctioning hippocampus may prevent flashbacks and nightmares from being properly processed, so the anxiety they generate doesn’t reduce over time.

Treatment of PTSD results in proper processing of the memories so, over time, the flashbacks and nightmares gradually disappear.

Treatment

The main treatments for post-traumatic stress disorder (PTSD) are psychotherapy and medication.

Traumatic events can be very difficult to come to terms with, but confronting your feelings and seeking professional help is often the only way of effectively treating PTSD.

It’s possible for PTSD to be successfully treated many years after the traumatic event occurred, which means it’s never too late to seek help.

Assessment

Before having treatment for PTSD, a detailed assessment of your symptoms will be carried out to ensure treatment is tailored to your individual needs.

Your GP will often carry out an initial assessment, but you’ll be referred to a mental health specialist for further assessment and treatment if you’ve had symptoms of PTSD for more than four weeks or your symptoms are severe.

There are a number of mental health specialists you may see if you have PTSD, such as:

• a psychologist – an expert in how the mind works
• a community psychiatric nurse – a nurse who specialises in mental healthcare
• a psychiatrist – a mental health specialist who diagnoses and treats mental health conditions

Watchful waiting

If you have mild symptoms of PTSD, or you’ve had symptoms for less than four weeks, an approach called watchful waiting may be recommended.

Watchful waiting involves carefully monitoring your symptoms to see whether they improve or get worse. It’s sometimes recommended because 2 in every 3 people who develop problems after a traumatic experience get better within a few weeks without treatment.

If watchful waiting is recommended, you should have a follow-up appointment within one month.

Psychotherapy

If you have PTSD that requires treatment, psychotherapy is usually recommended first. A combination of psychotherapy and medication may be recommended if you have severe or persistent PTSD.

Psychotherapy is a type of therapy often used to treat emotional problems and mental health conditions such as PTSD, depression, anxiety and obsessive compulsive disorder.

The treatment is carried out by trained mental health professionals who listen to you and help you come up with effective strategies to resolve your problems.

The main types of psychotherapy used to treat people with PTSD are described below.

Cognitive behavioural therapy (CBT)

Cognitive behavioural therapy (CBT) is a type of therapy that aims to help you manage your problems by changing how you think and act.

Trauma-focused CBT uses a range of psychological treatment techniques to help you come to terms with the traumatic event.

For example, your therapist may ask you to confront your traumatic memories by thinking about your experience in detail. During this process your therapist helps you cope with any distress you feel, while identifying any unhelpful thoughts or misrepresentations you have about the experience.

Your therapist can help you gain control of your fear and distress by changing the negative way you think about your experience. For example, feeling you’re to blame for what happened or fear that it may happen again.

You may also be encouraged to gradually restart any activities you’ve avoided since your experience, such as driving a car if you had an accident.

You’ll usually have 8-12 weekly sessions of trauma-focused CBT, although fewer may be needed. Sessions usually last for around 60-90 minutes.

Eye movement desensitisation and reprocessing (EMDR)

Eye movement desensitisation and reprocessing (EMDR) is a relatively new treatment which has been found to reduce the symptoms of PTSD.

It involves making side-to-side eye movements, usually by following the movement of your therapist’s finger, while recalling the traumatic incident. Other methods may include the therapist tapping their finger or playing a tone.

It’s not clear exactly how EMDR works but it may help you to change the negative way you think about a traumatic experience.

Group therapy

You may also be offered group therapy as some people find it helpful to speak about their experiences with other people who also have PTSD. Group therapy can be used to teach you ways to manage your symptoms and help you understand the condition.

There are also a number of charities which provide counselling and support groups for PTSD. For example:

• Combat Stress – a military charity specialising in helping ex-servicemen and women
• Rape Crisis – a charity providing a range of services for women and girls who have experienced abuse, domestic violence and sexual assault
• Victim Support – providing support and information to victims or witnesses of crime
• CRUSE – a UK charity providing support and information for people who have experienced bereavement

Medication

Antidepressants such as paroxetine, sertraline, mirtazapine, amitriptyline or phenelzine are sometimes used to treat PTSD in adults.

Of these medications, paroxetine and sertraline are the only ones licensed specifically for the treatment of PTSD. However, mirtazapine, amitriptyline and phenelzine have also been found to be effective and may be recommended as well.

However, these medications will only be used if:

• you choose not to have trauma-focused psychological treatment
• psychological treatment wouldn’t be effective because there’s an ongoing threat of further trauma (such as domestic violence)
• you’ve gained little or no benefit from a course of trauma-focused psychological treatment
• you have an underlying medical condition, such as severe depression, that significantly affects your ability to benefit from psychological treatment

Amitriptyline or phenelzine will usually only be used under the supervision of a mental health specialist.

Antidepressants can also be prescribed to reduce any associated symptoms of depression and anxiety and to help with sleeping problems. However, they’re not usually prescribed for people younger than 18 unless recommended by a specialist.

If medication for PTSD is effective, it’s usually be continued for a minimum of 12 months before being gradually withdrawn over the course of four weeks or longer. If a medication isn’t effective at reducing your symptoms, your dosage may be increased.

Before prescribing a medication, your doctor should inform you about possible side effects you may have while taking it, along with any possible withdrawal symptoms when the medication is withdrawn.

For example, common side effects of paroxetine include feeling sick, blurred vision, constipation and diarrhoea.

Possible withdrawal symptoms associated with paroxetine include sleep disturbances, intense dreams, anxiety and irritability. Withdrawal symptoms are less likely if the medication is reduced slowly.

Children and young people

For children and young people with PTSD, trauma-focused CBT is usually recommended.

This normally involves a course of 8-12 sessions that have been adapted to suit the child’s age, circumstances and level of development. Where appropriate, treatment includes consulting with and involving the child’s family.

Treatment with medication isn’t usually recommended for children and young people with PTSD.

Complex PTSD

Complex PTSD may be diagnosed in adults or children who have repeatedly experienced traumatic events, such as violence, neglect or abuse.

Complex PTSD is thought to be more severe if:

• the traumatic events happened early in life
• the trauma was caused by a parent or carer
• the person experienced the trauma for a long time
• the person was alone during the trauma
• there is still contact with the person responsible for the trauma

As it may take years for the symptoms of complex PTSD to be recognised, a child’s development, including their behaviour and self-confidence, can be altered as they get older.

Adults with complex PTSD may lose their trust in people and feel separated from others.

Symptoms of complex PTSD

The symptoms of complex PTSD are similar to symptoms of PTSD but may include:

• feelings of shame or guilt
• difficulty controlling your emotions
• periods of losing attention and concentration – this is known as dissociation
• physical symptoms – such as headaches, dizziness, chest pains and stomach aches
• cutting yourself off from friends and family
• relationship difficulties
• destructive or risky behaviour – such as self-harm, alcohol misuse or drug abuse
• suicidal thoughts

Treating complex PTSD

One of the key symptoms of complex PTSD is losing trust in people. If possible, people with complex PTSD are recommended to slowly start doing regular activities such as:

• finding friends
• getting a job
• regular exercise
• taking on hobbies

It’s important to try and develop some feelings of trust. It may take some time, but a trusting relationship with a therapist will help treat complex PTSD.

Treatment from a therapist may be given in three stages, described below.

Stabilisation

One of the first steps in treating complex PTSD may involve speaking with a therapist to learn how to control feelings of distrust and lose the feeling of being ‘disconnected’ from friends and family.

Certain techniques, known as ‘grounding’ techniques, may be able to help you separate an abusive or traumatic past from the present. The aim is to make the past seem less frightening and reduce the amount of flashbacks you experience.

With time, you can begin to experience less anxiety and learn to cope with daily life.

Trauma-focused therapy

Trauma-focused therapy may include:

• certain types of psychotherapy
• cognitive behavioural therapy (CBT)
• eye movement desensitisation and reprocessing (EMDR)

These treatments may help you to control any distressing thoughts but must be approached carefully to avoid making the situation worse.

Reintegration

The final stage is to begin to use these skills and techniques to develop better relationships with other people.

Medication, such as antidepressants, may still be recommended if psychotherapy isn’t possible or you feel unsafe.

You can read more information about complex PTSD on the Royal College of Psychiatrists website.

Self-help guide

If you think you’re experiencing post-traumatic stress disorder (PTSD) or complex post-traumatic stress disorder (CPTSD), it’s important for you to visit your GP and discuss your concerns. The PTSD and CPTSD self-help guide can help with managing symptoms while you wait for an assessment by your GP or a mental health professional.

This guide aims to help you:

• consider whether you’re experiencing symptoms of PTSD or CPTSD
• understand more about PTSD and CPTSD
• think about ways to manage or recover from PTSD or CPTSD

The PTSD and CPTSD self-help guide is based on Trauma-Focused Cognitive Therapy (TF-CT). TF-CT aims to help people who have been through trauma and adversity to make sense of what they’ve experienced, and become less distressed and affected by it.