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Symptoms of PTSD have been recognised since at least the sixth century BC, and has been given many names including shell shock, war neurosis, soldier’s heart, gross stress reaction, transient situation disturbance, tunnel disease, railway spine disorder, combat stress, combat fatigue, battle fatigue, stress breakdown, traumatic neurosis, and Buffalo Creek syndrome. Because of the devastating affects of this condition, it has also been described as ‘Horror Frozen in Memory’. The name PTSD first appeared in 1980 in DSM III, the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders 3rd Edition.
PTSD is actually a primitive, critical survival mechanism causing an extreme anxiety response; this affects the person’s perception of safety or makes them feel helpless. Patterns of symptoms involve anxiety reactions, tensions, nightmares and depression following a personal trauma.
It is the individual person’s subjective emotional experience, rather than the objective facts which determine the traumatic event. PTSD usually falls into three categories: Acute, Chronic and Delayed Onset. In the Acute category symptoms last less than three months, in the Chronic category symptoms last three months or longer. In the Delayed Onset category, symptoms first appear at least six months after the traumatic event.
Trauma which can lead to PTSD include war, natural disaster, car or plane crash, terrorist attack, rape, kidnapping, violent assault and sexual or physical abuse. The condition can also affect not only those who personally experience it, but those who witness it and those who subsequently pick up the pieces; including emergency workers and police officers. Symptoms may appear within hours or days of the event, or may take weeks, months or years to develop and can often get worse. They may also arise suddenly, gradually, or come and go over time.
The most disruptive symptoms involve flashbacks, nightmares and intrusive memories of the trauma. A person with this condition is at risk of developing other mental health disorders such as panic attacks, phobias, major depressive disorders, obsessive compulsive disorders and psychological issues. Substance abuse with alcohol or drugs is common, likewise self-mutilation or other types of self-harm. Most people who go through a traumatic or life-threatening event, experience some symptoms at first, such as anger, shock and anxiety; however not everybody goes on to develop PTSD. Whilst it is not possible to predict who will develop it, there are certain factors that appear to increase a person’s vulnerability.
The more extreme and prolonged the threat, the greater the risk. Traumatic events are more likely to cause PTSD when they involve a severe threat to a person’s life or personal safety. Intentional human-inflicted harm such as rape, assault and torture is far more traumatic than those considered to be ‘Acts of God’, or more impersonal accidents and disasters. Therefore a traumatic event is more likely to cause negative affects if it is inflicted by humans, repeated and ongoing, unexpected or unpredictable, sadistic or intentionally cruel, or experienced in childhood. Other risk factors for developing PTSD include previous traumatic experiences, especially in early life (cumulative trauma), a family history of depression, a history of physical or sexual abuse, substance abuse, depression, anxiety, high levels of stress in every-day life, lack of support after the trauma and lack of coping skills.
The dominant features of PTSD are emotional numbing, i.e. emotional non-responsiveness, irritability, hyper-arousal, i.e. on constant alert for danger, and re-experiencing of the trauma through flashbacks and intrusive emotions. The affected person will usually experience flashbacks and nightmares both day and night, so realistically that the experience is re-lived, emotions and physical sensations can actually be felt. They will make attempts at avoidance and numbing, by working hard to distract themselves, and by attempting to keep themselves busy with other things like hobbies. Avoidance of people and places which serve as a reminder is common. So too is avoidance of talking about the trauma, and generally communicating less with others, which makes it particularly difficult for those who have to live or work with that person.
Complex PTSD is the result of long-term trauma lasting months or even years. Examples of situations that can cause this include concentration camps, prisoner of war camps, long-term domestic violence, long-term severe physical abuse, and ongoing childhood sexual abuse. A diagnosis of Complex PTSD is possibly the best way to categorise the symptoms seen in people who have suffered prolonged trauma. The first requirement for this diagnosis is a long period of time, i.e. months to years of total control by another. The other criteria include symptoms that tend to result from chronic victimisation. During long-term traumas, the victim is generally held in a state of captivity, is under the control of the perpetrator and unable to escape, thereby generating a sense of helplessness.
Because doctors and researchers have found that the current PTSD diagnosis often does not capture the psychological harm that occurs with such prolonged, repeated trauma, Complex PTSD has been placed in a separate category. Symptoms include changes in the ability to control emotions, which may include symptoms such as persistent sadness, suicidal thoughts or explosive or inhibited anger. Changes occur in consciousness (dissociation), such as forgetting traumatic events, re-living traumatic events, or having episodes where they feel detached from their own body or mental processes. There may be changes in how the person views themself, which may include a sense of shame, helplessness, guilt, or of being completely different from others. Changes may also occur in how the person views the perpetrator, such as attributing total power to them or becoming preoccupied with their relationship to them, including desire for revenge. Relationships with others are affected by being viewed differently, including feelings of distrust and isolation. There may also be a change in the affected person’s system of meanings, which may include a loss of faith or a sense of hopelessness or despair.
Children experience PTSD differently from adults, and criteria now include age-specific features for some symptoms. Young children may present with very few symptoms, instead they may exhibit more generalised fears, e.g. stranger or separation anxiety, avoidance of situations that may or may not be related to the trauma, or a preoccupation with words or symbols that again may or may not be related to the trauma. Other symptoms may manifest themselves as losing previously acquired skills like potty training, sleep problems and nightmares without recognisable content, acting out the trauma through play, stories or drawings, new phobias and anxieties that seem unrelated to the trauma such as a fear of monsters, aches and pains with no apparent cause, irritability and aggression.
While adults who have been through overwhelming trauma can suffer a psychic numbing, blocking out the memory of a feeling about the catastrophe, children’s psyches often handle it differently. They less often become numb to the trauma because they use fantasy, daydream and play to recall and rethink their ordeal. Following an overwhelming trauma a child needs endless repetitions, replaying it over and over again in a grim, monotonous ritual.
All uncontrollable stress can have the same biological impact, it is the element of helplessness that makes a given event subjectively overwhelming. However, if the affected person can understand that their anxiety nightmares and panic are part of the symptoms of PTSD, then this can make the symptoms themselves less frightening.