Post-traumatic stress disorder (PTSD)

What is PTSD?

Post-traumatic stress disorder (PTSD) is the name given to a mental health condition that some people develop after they have experienced a major traumatic event.  

PTSD is a common mental health condition, with studies estimating that 7% of people will develop PTSD at some point in their lifetime; up to one third of people who have experienced a traumatic event go on to develop PTSD.

A traumatic event could be when a person experiences or witnesses a single incident that threatens or causes death, serious injury or sexual violence, or many incidents that have happened over weeks, months or years. 

Examples of traumatic events include: 

  • childhood abuse, including emotional neglect 
  • childbirth experiences 
  • civil war, unrest, or torture 
  • domestic violence 
  • first responder or military events 
  • life threatening illness or injury 
  • natural and man-made disasters 
  • physical assault 
  • road traffic accidents 
  • sexual assault 
  • terrorist attacks 
  • or any catastrophic situation 

Symptoms of PTSD

People with PTSD can suffer with different types of symptoms. These include: 

  • re-experiencing the trauma 
  • avoidance of thoughts 
  • memories and reminders of the trauma and a persistent feeling of ongoing threat 

People with PTSD often re-experience the traumatic event in the present, in the form of repeated and intrusive distressing memories of the trauma, even when they are trying not to think about it.  

There may be a feeling of reliving the traumatic event through flashbacks, where the person may lose track with the here-and-now and feel as though they are back in the traumatic event. This can be very disorientating and upsetting.  

People can also struggle with distressing nightmares of the traumatic event that can wake them up from sleep and be so distressing that they cannot get back to sleep.   

A person with PTSD may want to avoid thinking about or remembering a traumatic event, and try to push these thoughts and memories aside in their mind. 

There may be things that the person wants to avoid doing or being around in case that thing triggers a distressing memory; these are all examples of avoidance and often leads to a person’s life becoming restricted in terms of what they can still comfortably do. 

Avoidance is also one of the things that stops someone from being able to recover from a traumatic event.  

People with PTSD often feel a sense that even though the traumatic event is over, things continue to feel dangerous.  

We call this an ongoing sense of threat. As a result of this feeling, people with PTSD may feel constantly on-edge and unable to let their guard down.  

They might be very easily startled if there is a sudden noise, and constantly looking for potential danger in their surroundings; we call these sorts of behaviours hypervigilance.  

For people with PTSD, these features cause distress and significant problems in being able to function in their personal, family, social, educational or work life. 

People with PTSD often struggle with their sleep, finding it difficult to fall asleep and stay asleep for long enough. This might be because of a combination of not being able to relax and having nightmares waking them up from sleep.  

People with PTSD often have difficult emotions like feeling irritable and angry or numb and disconnected from other people. They may also blame themselves for what happened, and feel guilty, disgusted or ashamed, even if it wasn’t their fault. Sometimes these thoughts and feelings can have an impact upon their relationships. 

Some people with PTSD may not remember significant parts of the traumatic event, whilst others will think about the event all the time, which might stop them from coming to terms with it (they may, for example, ask themselves why the event happened to them or how it could have been avoided). 

Sometimes people with PTSD can feel so overwhelmed that they feel disconnected from their body or sense of themselves. This can include: 

  • going into a daze 
  • losing track of time 
  • feeling like surrounding are dream-like or changed 
  • not remembering what they were doing while this was going on  

We call this type of experience dissociation; it is a common feature in many mental health conditions, and it usually does not last for very long.

It is not uncommon for people with PTSD to also have other mental and physical health conditions such as: 

  • depression 
  • anxiety 
  • problems using drugs and alcohol 
  • heart disease 
  • gut health issues 
  • chronic pain conditions 

Features of CPTSD

People with complex post-traumatic stress disorder (CPTSD) have the symptoms of PTSD but also disturbances in self organisation that are described below. 

People with CPTSD can struggle to cope with distressing feelings, and their usual strategies to calm down and regulate their feelings don’t work as well.  

This means that relatively small triggers can lead to overwhelming feelings or feeling numb and detached. This often stems from a sense of being permanently unsafe, an associated state of hyper-vigilance and an inability to relax, and a belief one will soon experience catastrophic life-events. 

Traumatic events, particularly those associated with harm from others, can have a corrosive impact on a person’s self-worth and self-confidence. 

People with CPTSD often think about themselves in a persistently negative way, such as feeling worthless, hopeless, damaged or a failure wrapped up in a profound sense of personal shame. This can lead to avoidance and suppression strategies such as alcohol and substance abuse and a compulsion to prove oneself in career environments through overworking.  

Due to the harm they have suffered at the hands of others, people with CPTSD can understandably experience difficulties in trusting people and maintaining good relationships.  

This can have a big impact on their social functioning and ability to form supportive relationships that are so important when recovering from a traumatic event. 

CPTSD and borderline personality disorder (BPD) are separate conditions, but they have features that overlap with each other. 

People with BPD typically struggle with: 

  • feelings that can change rapidly over the course of the day 
  • not having a clear sense of how they feel about themselves 
  • acting impulsively 
  • getting into relationships but having a lot of fear that loved ones will abandon them 
  • repeated thoughts about or acts of self-harm or suicide 

In contrast, people with CPTSD tend to have a clear but negative sense of how they feel about themselves and tend to avoid close relationships. 

People can develop BPD after traumatic events, but some people develop BPD without any history of trauma. Some people with BPD might have features of PTSD or CPTSD at the same time. 

Establishing someone’s diagnosis can be very helpful to help people understand what they are experiencing and to guide what treatments may work best for them. 

It is, however, important to remember that people with PTSD and CPTSD present in different ways and the experience and appropriate management of symptoms should be personalised.  

Getting support

The first important step is to get in touch with your GP surgery and arrange an appointment to talk about your symptoms.

People who have been through a traumatic event are often anxious about having an assessment to talk about their trauma.

It is important to know that lots of details about the traumatic event are not necessary to go into at the first visit, or indeed until you are ready.

The assessment will focus more on symptoms and how the trauma is affecting a person’s life and relationships.

Remember that PTSD and CPTSD are treatable, and that you will be understood, supported and cared for by health professionals who will be able to discuss the best available treatments.

Please see our Helping to understand PTSD and CPTSD leaflet for more information on how to get help and what can be offered.

Treatment

PTSD and CPTSD are mental health conditions, and like any other mental health condition they can be very complex.

We need to be aware of and be able to treat all the factors in someone’s life that might be contributing to their condition in a positive or negative way.

We break these down into social, psychological and biological factors.

Social factors

Social factors are things like whether a person with PTSD or CPTSD has:

  • a safe place to live that is free from ongoing danger or risk of sudden change
  • access to financial support to make sure their basic needs are being met
  • a social network of support around them via friends, family or the wider community

These social factors are the most crucial things to address first, where necessary.

Psychological and biological factors

Once social factors are as good as they can be, there are several treatment approaches that are supported by research evidence as being effective in helping PTSD and CPTSD.

Psychological factors are things that can be treated with talking or psychological therapies, and biological factors are things that can be helped with medications.

Psychological therapies are the most effective treatments for PTSD and CPTSD. Some people choose not to access psychological therapies or are unable to access them.

They may also have tried psychological therapies and found that they have not helped them as much as hoped or they may be on a waiting list and wish to start medication before therapy.

Therefore, medications can be a helpful alternative, or addition, to psychological therapies.

Psychological therapies

There are some effective psychological therapies available for treating traumatic stress.

Psychological therapies are talking therapies which are usually delivered to a person with PTSD via a therapist over 60-90-minute weekly appointments over eight to sixteen weeks.  

Longer courses of therapy are often needed to help people with CPTSD because of the broader range of longer lasting and pervasive symptoms they experience.

The first few sessions are spent building up therapeutic goals and trust, understanding more about their condition and its symptoms and ensuring the person with PTSD or CPTSD has skills to help manage their symptoms before the trauma is focused on.

Homework is usually set at the end of each session for the person to complete before the next session.

EDMR and CBT-TF

Examples of effective psychological therapies for traumatic stress are eye movement desensitisation reprocessing (EMDR) and trauma-focused cognitive behavioural therapy (CBT-TF).

In EMDR, you bring to mind a traumatic event whilst using eye movements to stimulate the left and right parts of brain.

This can really help to reduce the emotional and physical distress associated with the memory and helps to change your most upsetting beliefs about yourselfves and the traumatic event.

Trauma-focussed CBT is another very effective approach, which helps change the meaning of the trauma memory and its impact.

Trauma-focused work

Common elements across trauma therapies are:

  • addressing trauma-related beliefs e.g. challenging the belief that the world or a situation will always be dangerous because of the traumatic event
  • engaging with and activating the traumatic memory e.g. actively turning towards the avoided trauma memory and exploring all aspects of it in a safe and controlled way
  • addressing avoidance e.g. learning how to overcome avoiding situations and reminders of the trauma in daily life)

Trauma-focussed work can be difficult, but most people who attend their sessions and complete their homework tasks will see an improvement in their symptoms.

Ongoing support

Unfortunately, waiting lists for psychological therapies can be long and people may need ongoing support from their GP or community mental health team whilst they are waiting.

People with PTSD and CPTSD may be offered treatments that do not focus on their traumatic event first but instead can help them develop emotional safety and stabilisation first.

Guided digital interventions

Guided digital interventions are relatively new and involve a therapist guiding a person with PTSD or CPTSD to use s web programmes based on cognitive behavioural therapy with a trauma focus.

There is a strong evidence-base for guided digital intervention for people who have mild to moderate PTSD following a single traumatic event and emerging evidence for the treatment of more complex presentations.

A therapist will meet with a person with PTSD to introduce them to the computer-based application and then guide them through the application as the person completes trauma-focused tasks in their own time.

Medication

The antidepressants paroxetine, sertraline, fluoxetine and venlafaxine, and the medication quetiapine can reduce the overall severity of PTSD symptoms.

A medication used for high blood pressure called prazosin can also help PTSD symptoms and can help with nightmares.

Medications are taken daily over the course of months and longer.

It can sometimes take six to eight weeks and medications, if tolerated, often need to be taken at higher does for the best effect.

If one medication or combination has not worked, others can be tried; the Cardiff Post-Traumatic Stress Disorder Prescribing Algorithm has been created to aid doctors and patients in deciding what medication choices are best for them.

Tips for people with PTSD

  • Give yourself time and space to acknowledge what you have been through, and the strong emotional reactions that you are having.
  • Avoid using alcohol and drugs to make you feel better. Although these may make you feel better in the short term, it can cause serious problems for you and your loved ones. They can also worsen symptoms and interfere with treatment.
  • You may be tempted to withdraw from social activities and your loved ones, but it’s important to stay involved with the people who care about you. Support from other people is vital to your recovery from traumatic stress.
  • Avoid being self-critical about the problems that you are having. Many people experience similar problems, and it is not a sign of weakness.
  • Try to be healthy. Do what you can to eat a balanced diet and get some regular exercise – even if it’s just going for a walk.
  • Stick to normal routines as much as possible. If you have problems with sleep, try to keep to a regular time when you wake and get up, and avoid caffeinated drinks after 4pm.
  • Set yourself small daily goals and challenges to confront the things that you avoid.
  • Remember the strengths that you have. It’s important to remind yourself that you have strengths and coping skills that can get you through tough times.
  • Don’t be afraid to seek help. Discuss your problems with someone that you can trust. Make an appointment to see your GP. There are a range of treatments that may be able to help you.

Tips for partners, families and carers

  • Try to be patient and understanding with the person who has been through a traumatic event.
  • Try not to take symptoms like emotional numbness, anger, and withdrawal personally. If the person who has been through a traumatic event seems distant, irritable, or closed off, remember that this may not have anything to do with you or your relationship.
  • If they are experiencing symptoms and haven’t done so, try to encourage them to seek professional help. A good place to start is discussing things with your GP.
  • Don’t put pressure on the person who has been through a traumatic event to talk about their experience but do allow them time and space to talk about it if they want to.
  • People who have been through traumatic events sometimes feel hopeless or ashamed of how they are coping. Try to help the person to recognise their strengths and positive qualities.
  • Try to encourage the person to establish normal routines; this helps to restore a sense of order and control in their life. Help them to start with small daily goals and to recognise each success.
  • If they haven’t done so, try to encourage them to seek professional help. A good place to start is discussing things with a GP.

Resources

Piece of Mind podcast: Recognising complex PTSD

Professor Jon Bisson and Michael Davitt discuss lived experience of complex post-traumatic stress disorder and the ongoing research looking into the diagnosis at the NCMH.

Piece of Mind podcast: Post-traumatic stress disorder (PTSD)

RAF veteran Darren and Dr Neil Kitchiner, director and clinical consultant lead at Veterans NHS Wales, discuss PTSD.

Websites