UNDERSTANDING POST-TRAUMATIC STRESS DISORDER

Defining PTSD

First, let’s define Post Traumatic Stress Disorder. In 2013, the American Psychiatric Association revised the PTSD diagnostic criteria in the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders (*DSM-5). The criteria below are specific to adults, adolescents, and children older than six years.

A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:

C. Persistent avoidance of stimuli associated with the traumatic event(s): (one required)

D. Negative alterations in thoughts and mood associated with the traumatic event(s) that began or worsened after the traumatic event: (two required).

E. Trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event: (two required)

F. Persistence of symptoms (in Criteria B, C, D, and E) for more than one month.

G. Significant symptom-related distress or functional impairment (e.g., social, occupational).

H. Disturbance is not due to medication, substance use, or other illness.

The onset of symptoms can be years or decades after the traumatic event. Trauma may be a one-time event such as a car accident or more long term such as growing up in a household with repeated instances of domestic violence or a soldier in a war zone or a soldier with multiple deployments to war zones.

Defining “trauma”

We separate trauma into two groups for treatment purposes. Big T traumas are traumas that we know that everyone going through this type of trauma will have some degree of Posttraumatic Stress Symptoms. These are traumas like being a soldier in combat, being kidnapped or a prisoner of war, sexual assault, major natural disasters like Hurricane Katrina or the Indonesia tsunami, mass shootings, the Oklahoma bombing and 9-11.

Small t traumas or “difficult life events” are things like a divorce or break-up, losing a job, sudden death, a car wreck, a health scare or serious medical diagnosis, being bullied and even things like public speaking. Some people going through these types of life events will develop Post Traumatic Stress symptoms and others will not. The same person can go through the same type of event several times and not develop Post Traumatic Stress symptoms and then the next time develop some symptoms. Some of these difficult life events will not meet the criteria for a clinical diagnosis of PTSD (see criterion A above).

Natural Healing Properties

Our bodies are designed with natural healing properties. If you get a cut, your body has a process in place to clot the blood and then for the skin to knit back together. If you break a bone, your body has a process for the bone to knit back together. If you sprain your ankle, your body has a process in place to heal that injury. Sometimes if an injury is severe enough medical intervention is needed to help the body heal. So if I have a paper cut I don’t need medical intervention and my body will heal that cut. However, if I broke my arm, I would need to go to the doctor to have my arm set and a cast put on and then the natural healing processes of the body would take over.

The brain is responsible for healing mental, emotional, and spiritual hurts. Just like the rest of the body’s healing processes if it is a minor hurt (a store clerk was rude to me) my body will heal that hurt just like it healed the paper cut. But if it is a bigger injury such as being a soldier in combat or being sexually assaulted, I will need medical help in the healing process just like my broken arm needed medical help to fully heal. So let’s first talk about how the brain is supposed to work under normal circumstances.

How the brain works under normal circumstances

The brain is designed to work similar to the digestive system. When we eat food the food travels through the digestive system and the digestive system does a sifting process and pulls out the nutrients we need to keep such as protein, amino acids, electrolytes, vitamins and minerals and sends it out to the body to be used and eliminates what we don’t need to hold onto. The brain works in a similar way. The brain takes in information from your five senses (sight, smell, taste, hearing, touch), sifts it, pulls out what we need to hold onto and eliminates the rest. So for instance, many years ago my kids talked me into riding the Texas Giant at Six Flags. This is a huge, old, wooden roller coaster. The only information my brain needs to hold onto is that it was scary, shakes you like crazy which makes you really sore, and was not fun! I don’t need to hold onto the actual body sensation of fear in the pit of my stomach. When my brain processed or “digested” this event it dumped or eliminated the body sensation. I also don’t need to hold onto the emotion of fear. The actual feeling of fear also got dumped or eliminated. So the next time I’m at Six Flags and someone suggests riding the Texas Giant I remember being afraid but I don’t actually feel the emotion of fear or feel the body sensation of fear. It takes too much energy to hold onto body sensations and emotions, whether good or bad. So, when our brain processes or “digests” information that’s what it dumps or eliminates. When I think of my wedding day I remember feeling anxious and nervous and happy and stressed and excited, etc. but now 32 years later I don’t actually feel those emotions and body sensations when I think of my wedding day. My brain has eliminated or dumped that information (the emotions and body sensations).

The next step in the brain is to decide what to do with the information it has pulled out. The brain has to decide if the information is only needed for the short term or does the information need to be stored long term. So for instance with a weather forecast, I don’t need to know six weeks from now that it was hot and dry today. My brain will dump this information unless there is some special significance to it. For instance I will probably always remember what the weather was like for my daughter’s outdoor wedding. Or that it was rainy and cold the day my granddaughter was born. But that it was hot and dry on a June day in Dallas, nothing special about that!

So what does the brain do with information that it needs to store for a longer period of time? That information goes into what I call the “archives” of the brain. Think of the “archives” of the brain like a giant room with filing cabinet after filing cabinet after filing cabinet filled with information. So now your brain has to decide which filing cabinet, which drawer, which folder to put that piece of information into. Your brain will choose a folder that has information in it that would “link” with the new information in some way. Information may be “linked” together by a sound, a smell, a taste, the way it looks, the way it feels on our body, the emotion it evokes, or the thoughts that go with it (i.e., I’m not safe, I failed, I did something wrong, etc.)

Here are a few examples of how things can “link” together in the brain (i.e. the brain puts those events in the same folder):

Next let’s define what a “trigger” is. In the first example about hearing a song on the radio, the song is the trigger. Hearing the song opens the file folder and pulls out the memory (or memories) that are stored with the song. So for example, remember that old song “Wipe Out”? Every time I hear that song a memory comes up of being in the 5th grade and the teacher stepping out of the classroom and Terry Lowe sneaking back to the back of the room and playing that record on the record player. It was the first time I had ever heard rock and roll as my parents were into big band music. I never think of that memory unless I hear that song (or am explaining what a trigger is).

Now that we understand how the body works normally let’s look at what happens in the body when we experience a traumatic event.

What happens in the body when a trauma occurs

When your body senses danger your body goes into what used to be called the “fight or flight” response. We now know that there are 4 responses that all mammals can go into when they sense danger. They are fight, flight, freeze and posturing. Fight is just that, I am going to fight. In the flight response I am going to run away. Freezing is done by a lot of animals that can camouflage. So if I am a deer in the forest I may freeze and hope that I blend in with my surroundings and the hunter doesn’t see me. If my presence is detected then my body will go into the flight response and I will bound away. Posturing is trying to intimidate the opponent to get them to back down so I don’t have to fight. So if I am a gorilla I might charge, roar, and beat my chest to scare you. If I am a grizzly bear I might stand up to my full height, roar, and show my big teeth and claws. If I am a teenage boy I might insult, verbally threaten, trash talk, get up in your face, or shoulder bump you to intimidate you. The body chooses the response that it feels gives you the best chance of surviving the danger, not necessarily avoiding it. For women and children the body almost always chooses the freeze response since the most common predator of women and children is an adult male. A woman or child is not likely to outrun, out fight, or intimidate an adult male. It is important to understand that whichever of the four responses our body goes into it is an automatic response in the body, not something that we can consciously choose.

(EXCEPTION: there is an exception to this rule and that is with military and first responders. They go through extensive training to have a more conscious choice over which response is used.)

Regardless of which response the body chooses several important things happen in the body when the body goes into the stress/danger response.

One of the first things that happens in the body is a significant increase in adrenaline as well as other stress hormones and brain chemicals. Secondly, the body becomes very energy efficient. Resources are diverted to the areas of the body most needed during the stress response such as the heart, lungs and muscles. Other systems of the body receive minimal resources. So if you are Mr. Caveman running through the forest and Mr. T-Rex is about to have you for lunch your body doesn’t care about your stomach digesting that turkey leg you just ate. That’s why people who have gone through a major trauma or who have chronic trauma often complain of stomach problems or “nothing tastes right” or “nothing sits right on my stomach” etc. Other systems that get limited resources are your immune system. Again, if Mr. T-Rex is about to have you for lunch your body doesn’t care about catching the flu. That’s why people who have gone through a trauma often will have lots of health issues following the trauma. They seem to catch everything that goes around and develop health problems such as acid reflux, ulcers, irritable bowel syndrome, and fibromyalgia. Your reproductive system also receives limited resources. If you are about to serve as an appetizer for Mr. T-Rex your body doesn’t care about having periods, going into puberty or menopause, or having an erection. I typically see that once the body has come out of the trauma/danger response that it can take up to 18 months to 2 years for the body to “reset” all of the systems and build itself back up. So following trauma treatment I encourage patients to get a lot of rest, eat healthy nutritious meals, and take a good multivitamin to help the body rebuild.

Parts of the brain also receive limited resources. The brain stem will receive more resources since it controls the major life functions. Other parts of the brain will receive limited resources. Let’s look more at what happens in the brain when a trauma occurs.

What happens in the brain when a trauma occurs

As the body goes on red alert for danger, the heart rate increases, blood pressure rises, and stress hormones like cortisol and adrenaline flood the body.

During a traumatic experience, the body goes through even more profound changes. These changes have become clearer in recent years because of breakthroughs in brain scans like functional magnetic resonance imaging (fMRI), which enables scientists to look at how the brain functions in real time, rather than just taking a still photograph. This technology has given us a much greater understanding of how trauma impacts the body. A key finding from these brain scans is that during traumatic stress, the speech center shuts down—one reason why many people cannot completely put what happened to them in words. This is why traditional talk therapy is limited in helping someone recover from or heal from overwhelming stress or a traumatic event and therapies that work with the brain, such as EMDR are more successful. (For more on EMDR go to www.emdria.org)

The Survivors Club (www.thesurvivorslub.org) describes some other things that happen in the brain during a trauma:

The experience of trauma can actually cause neurological changes in the structure of your brain. For weeks or even years you may have been thinking you’re crazy, but there are scientific reasons for much of your behavior, including increased, diminished and killed brain regions, functions and neurons.

Understanding that there are actual physical changes in the body that result in the symptoms of PTSD helps survivors and their loved ones understand why you can't 'just get over it.' Recognizing that trauma’s effects have been concretely documented by evidence-based data should let you know that PTSD is not a condition completely within your control. Like any other major injury to the body you will need help from medical professionals to heal.

For me I see PTSD as a physical injury as well as a mental injury. One of the first things that I tell clients with PTSD is that they have PTSD not because they are weak but because they cared. If they didn’t care they would not have developed PTSD. A person who lacks the ability to love or establish meaningful personal relationships or to feel appropriate guilt is called a psychopath or sociopath. So it is a good thing to care even if that means developing PTSD.

So to wrap all of this up let’s go back to our example of the brain working like the digestive system. If you eat some bad food (remember that sweet and sour chicken I ate at Kings Island?) the food does not process through your digestive system normally and you keep re-experiencing it in some way such as belching, burping, heartburn, acid reflux, gas, diarrhea, stomach pains, and/or vomiting. When you experience a trauma – and all of those automatic body responses happen – the information gets “stuck” in the brain. The event does not get “digested” or processed. The emotions and body sensations do not get dumped or eliminated but instead stay active. The memory does not get moved to the “archives” but instead stays in the forefront of our memory. And many things constantly trigger the traumatic memory. And just like the bad food, you keep re-experiencing the event. This is the flashbacks, nightmares, anxiety, depression, irritability, hypervigilance, intrusive thoughts, feeling numb, etc. If it is a mild case of food poisoning I will be sick for a couple of days and then my body’s natural healing process will take over and I will feel better. (But I may never eat sweet and sour chicken again). If it is a mild trauma (a scary encounter with loose dogs in the neighborhood) I may be anxious for the next few days on my walk but when nothing else happens my brain processes the information and my anxiety goes away. If it is a severe case of food poisoning I will need medical intervention and may end up in the hospital on IV’s. If it is a severe trauma (a soldier in combat / being sexually assaulted / childhood abuse / witnessing a sudden death, etc.) I will also need medical intervention in order to heal. So when we experience a trauma and the body goes into the stress/trauma response our brain does not process or “digest” the information correctly – it does not dump the emotions and body sensations – and the memory gets stuck and we keep re-experiencing it including actually feeling the emotions and body sensations. So we have nightmares and flashbacks, feel anxious and are hypervigilant.

Have you ever felt sick to your stomach and tried not to vomit? It is incredibly difficult if not impossible to stop that bodily process. The same is true of PTSD symptoms. When that anxiety, irritability, and hypervigilance come out I call it “vomiting the symptoms”. And like physical vomit, PTSD vomit tends to land mostly on those we are closest to.

So here is the good news in all of this. We now understand PTSD so much better than we used to and we have very effective means of treating it and reducing or eliminating the symptoms. Remember, you did not develop PTSD because you are weak – you developed PTSD because you cared about what happened and your brain and body went into the stress/trauma response and got stuck there. PTSD is a normal response to an abnormal event. To find a therapist who can help you “reset” your brain go to www.emdria.org.

1. Directly experiencing the traumatic event(s)
   
2. Witnessing, in person, the event(s) as it occurs to others
3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse).

Note: This does not include indirect non-professional exposure through electronic media, television, movies, or pictures.

1. Recurrent, involuntary, and intrusive distressing memories.
2. Recurrent distressing dreams.
3. Dissociative reactions (e.g., flashbacks).
4. Intense or prolonged distress after exposure to traumatic reminders.
5. Marked physiologic reactivity after exposure to trauma-related stimuli.

1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
   
2. Avoidance of or efforts to avoid external reminders (e.g., people, places, conversations, activities, objects, or situations) that arouse distressing memories, thoughts, or feelings about or are closely associated with the traumatic event(s).

1. Inability to remember an important aspect of the traumatic event(s) (not due to head injury, alcohol, or drugs).
   
2. Persistent and distorted negative beliefs and expectations about oneself, others, or the world (e.g., "I am bad," "The world is completely dangerous").
3. Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences.
4. Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or shame).
5. Markedly diminished interest or participation in (pre-traumatic) significant activities.
6. Feelings of detachment or estrangement from others.
7. Persistent inability to experience positive emotions.

1. Irritable or aggressive behavior
   
2. Self-destructive or reckless behavior
3. Hypervigilance
4. Exaggerated startle response
5. Problems in concentration
6. Sleep disturbance
   

• Ever hear a song on the radio and have a memory pop up that you haven’t thought about in years, maybe decades?
• What comes up for you when you smell a pine tree? Do you immediately think of Christmas? Or maybe you think of the camping trip you took to the mountains.
• Just hearing the words sweet and sour immediately makes me think of the time when I contracted a severe case of food poisoning from eating sweet and sour chicken at Kings Island Theme Park in Ohio when I was a teenager (which was a very long time ago!). I can even picture the little Hawaiian hut where we bought the food and the picnic tables around it.
• The information that it was cold and rainy on the day my granddaughter was born is in a file with information that it was cold and rainy the day I graduated from high school. Those two pieces of information are “linked” together by cold and rainy and that they were important days in my life.
  

• Can’t find the words to express your thoughts? That’s because the prefrontal lobe (responsible for language) can be adversely affected by trauma, which gets in the way of linguistic function.
• Can’t regulate your emotions? How could you when the amygdala (responsible for emotional regulation) is in such overdrive that in some PTSD survivors it actually enlarges.
• Having problems with short-term memory loss? Of course you are: studies show that in some PTSD survivors the hippocampus (responsible for memory and experience assimilation) actually shrinks in volume.
• Always feeling frightened no matter what you do? Understandable when your medial prefrontal cortex (responsible for regulating emotion and fear responses) doesn't regulate itself or function properly after trauma.