The Complex Symptoms of Trauma

A brief look at common responses to trauma, addressing some of the complexity in these responses, and the relationship between associated disorders: 640 words.

The symptoms of Post Traumatic Stress Disorder (PTSD) are a common response to a traumatic event. They include vividly re-experiencing the event and associated anxious arousal, but also growing avoidance of anything related to the trauma, and an increasingly negative view of the world. For the majority of people such symptoms will subside over time, particularly if they are well supported in the period after the trauma. But for a significant minority the symptoms will persist.

Not all responses to trauma fit this picture however. The situation is often complicated when we are exposed to more than one traumatic event, when we experience trauma as a child, or when our trauma has an interpersonal element, as in abuse. Feedback loops that develop after trauma can set in motion processes associated with other disorders, such as anxiety and depression. And many people will become addicted to alcohol or other drugs in an unhelpful attempt to manage these complex and self-reinforcing symptoms, and addictions cause a whole set of problems by themselves.

It may be helpful to think of each person’s trauma response as a point floating somewhere in the Venn Diagram below, often falling within the PTSD oval, but just as often encompassing greater complexity. And so to make sense of these complexities it is useful to consider other diagnoses and their relationship with PTSD.

A person’s response to trauma may fall somewhere within this Venn diagram. PTSD symptoms are common, but so is a mixture of symptoms from related mental health disorders, as are addiction and relationship problems (not represented here).
Anxiety

Anxiety symptoms are often prominent after trauma. We commonly react to anxiety by avoiding the things that make us anxious, but avoidance undermines our confidence and leads to further anxiety and avoidance in a vicious cycle. The traumatised person may avoid doing things and going places that remind them of the trauma, and may avoid even talking or thinking about the trauma. As their cycle of avoidance widens, they may begin to experience difficulty just leaving the house, or carrying out everyday tasks. I’ve worked with highly trained and very competent members of the military who were reduced to staying at home all day, reluctantly going out only with their partner, or who found it difficult to answer the phone and check their emails in case it meant doing something they felt unable to handle. In this way anxiety becomes its own problem as it spreads and leads to conditions like agoraphobia (roughly defined as a fear of public places), social anxiety, severe worry and stress.

Depression

Negative thinking and mood states are now formally part of a PTSD diagnosis, and the effects of trauma are so debilitating that people may understandably respond with the feelings of hopelessness and helplessness closely associated with depression. When you feel nothing can be done to help, you may give up and withdraw from life, and if you think nobody understands you, or that you are a burden on others, you may isolate yourself socially. Severe and chronic depression works against people seeking help and engaging in treatment, so when depression is bad enough clinicians may opt to treat this before addressing trauma symptoms, even if they think the trauma symptoms came first.

Borderline Personality Disorder (BPD)

This diagnosis represents long standing problems with strong and chaotic negative emotions, interpersonal insecurity, confusion with one’s own identity, and frequent self-harming behaviours, including suicide attempts. There are many variations of symptoms that can earn this label, so BPD can be experienced quite differently by different people. It may well develop from early experiences of repeated abuse, including sexual abuse, hence the relationship with trauma. The methods used to treat PTSD can be quite different from those appropriate for someone with BPD symptoms, so differentiating between them is important.

Conclusion

Perhaps it is to now state the obvious that determining how someone has been impacted by trauma is critical for planning their recovery, so I recommend an assessment by a qualified clinician as a good first step.

Post Traumatic Stress is like an Injury

Post Traumatic Stress Disorder (PTSD) is like an injury, and evidenced based psychological treatments are like rehabilitation exercises for this injury: 429 words.

In my early thirties I decided to get involved with a local soccer team. On my first training run, confident in the knowledge of how fit I used to be, I had a cursory warm up and started kicking the ball around with my new team mates. Within 20 minutes I had torn my calf muscle. I played on for a while that day, numbed by the adrenalin, and not realizing the seriousness of the injury. Afterwards I could still walk slowly, but any sudden movements and running were out of the question. When I later consulted my physiotherapist she said my muscles may never be as strong again, but with the right rehabilitation I could get back on the field.

Post Traumatic Stress Disorder is the mental health condition most like an injury. It can result from single or multiple traumatic events, and places significant limits on normal functioning, although not always right away. Certain experiences will trigger the mental pain of anxiety and anger. Many will try to kill this pain by self-medicating with alcohol and drugs, but this does not repair the damage. The traumatized live in fear of re-injury, and avoid situations they associate with their trauma. But it’s never enough to feel safe, and their lives narrow. Depression may follow.

A debilitating mental injury is a bad break for anyone, but for highly trained members of the military, emergency services and other high-risk occupations, their being confined to the bench can be a shaming experience. We may feel only sympathy for an elite athlete who suffers a career-limiting injury, but those impacted by post-traumatic stress fear being stigmatized as weak and unworthy. Attitudes towards mental illness and injury remain negative compared to their physical counter-parts.

Rehabilitation for physical injury is a gradual process, slowly building the strength and flexibility of muscles, and psychological treatment for PTSD usually proceeds in a similar way. For trauma survivors this involves slowly building confidence – confidence that they can face the memory and reminders of their trauma without suffering harm. Jumping straight in at the deep end is often too much too soon, but to hide away at home will only result in atrophy. Gradually facing fears is necessary if they want to get back on their feet, and then one day take to the field again.

People routinely seek help from physiotherapists, doctors and other health professionals for physical injury. It is my hope that greater awareness of PTSD as a kind of mental injury will make accessing treatment for this debilitating but treatable condition just as routine.