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A Guide to Understanding Post-Traumatic Stress Disorder

PTSD is a complex interplay of symptoms affecting millions of Americans. Here are the facts.
Helen Massy
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Helen Massy

Invisible wounds are often the most profound, causing lifelong struggles unnoticed by the outside observer. Among these silent battles is post-traumatic stress disorder (PTSD). The disorder is characterized by a complex interplay of psychological, emotional and physiological symptoms, and it affects millions of individuals worldwide.

The National Center for PTSD reports about 5 percent of adults in the United States have PTSD in any given year, and that about 6 percent of the U.S. population will experience PTSD at some point in their lives. To put that into context, about 13 million Americans suffered from PTSD in 2023.

Statistics indicate women are more than twice as likely to develop PTSD than men. In part, this is because women are more susceptible to physical and sexual assault.

Despite PTSD being more common in veterans, it can affect anyone who has experienced or witnessed a traumatic event, such as a natural disaster, physical or sexual assault, serious accidents or the loss of a loved one. The disorder transcends boundaries of age, gender, ethnicity and socioeconomic status.

What is PTSD?

"Essentially, PTSD is based in the human fight-or-flight response, which has remained partially active after a trauma event though the causal event is no longer present," said Terence Watts, a London-based psychotherapist, author and founder of The BWRT Institute.

"Even after the event has passed, the memory of it remains vividly lifelike and can trigger strong emotional responses, mainly fear and/or anger," Watts said.

The UK National Health Service defines PTSD as an anxiety disorder caused by very stressful, frightening or distressing events, according to Simon Davies, a walking therapist at Living Well UK, providing free mental health services in Birmingham and Solihull, U.K. While the symptoms can vary between individuals, they are generally characterized by:

  • Avoidance of situations and experiences linked to the traumatic event
  • Feeling extremely anxious and on edge nearly all of the time and/or feeling emotionally numb or detached
  • Re-experiencing the traumatic event(s) in flashbacks, nightmares or physical sensations

"The exact mechanisms that lead to some people developing PTSD are not fully understood, but there are theories that are helpful in understanding the condition," Davies said.

When going through an extremely distressing or frightening experience, he noted, our brains and bodies engage in a survival mechanism known as the fight-or-flight response.

This floods the brain and body with natural stress hormones such as adrenaline to deal with a perceived threat, increasing our heart rate, moving blood to our muscles, and temporarily reducing activity in areas of the brain associated with memory and emotional processing.

"While all of these changes can help us deal with a threatening situation in the short term, for some people, these changes remain after the event and are seen in the symptoms described above," Davies said.

Theories suggest this may either be the brain and body's way of protecting us from similar events happening again or because we weren't supported enough to fully process what happened in the first place.

Symptoms and diagnosis

Davies explained that PTSD is diagnosed by a medical professional, following criteria described in the two main manuals of mental health conditions: the International Classification of Diseases, 10th Edition (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).

PTSD manifests through a range of symptoms categorized into four main types:

  1. Avoidance symptoms that involve efforts to avoid reminders or triggers associated with the traumatic event. People with PTSD may go to great lengths to avoid places, people, conversations or activities that remind them of the traumatic experience.
  2. Negative alterations in cognition and mood symptoms that involve changes in an individual's thoughts, emotions and beliefs. People with PTSD may develop negative beliefs about themselves, others or the world around them. They may experience persistent feelings of guilt, shame or anger. They may also have difficulty experiencing positive emotions and feel detached from loved ones or lose interest in previously enjoyed activities.
  3. Hypervigilance, or being constantly on guard for potential threats. They may have difficulty concentrating or sleeping and experience irritability, anger outbursts or reckless behavior. They may also have an exaggerated startle response and may feel a sense of being constantly on edge.
  4. Re-experiencing symptoms, which involves intrusive thoughts, memories or flashbacks related to the traumatic event. Individuals with PTSD may experience recurring distressing memories or nightmares about the event.

For a doctor or a psychiatrist to diagnose PTSD, Watts noted the individual must present the following symptoms:

  • Be aware of three or more situations that they will avoid at all costs.
  • Frequently replay at least one element of the trauma event or situation.
  • Have two or more episodes of "hyperarousal"—anger outbursts, panic, etc.
  • Have two or more permanent changes to their mood and behavior.

These symptoms must persist for at least 28 days and significantly impair daily functioning to meet the criteria for a diagnosis of PTSD.

When should you seek professional support?

It is normal to have experiences such as the symptoms above after any severely distressing experience, Davies noted. However, not all people will develop clinical PTSD. According to the National Centre for Clinical Excellence (NICE), for two out of three people, on average, these experiences will subside within a month after an incident.

"However, 1 in 3 people will experience symptoms for more than a month after an incident, with a small minority experiencing delayed symptoms months or years after the event," he said.

Watts said people should look out for negative changes in their mood or personality that persist more than a month after a traumatic situation.

"It doesn't matter if they believe the event 'didn't touch them' because that is sometimes one of the brain's defense mechanisms," he said.

In particular, sudden anger/violence outbursts that are "out of character" and "over the top" should be investigated as soon as possible to ensure there is not a physical cause that needs attention.

Talking your symptoms through with your healthcare provider is the best first step for getting the right support.

Misconceptions about PTSD

Davies noted that PTSD is not to be confused with the more common usage of the word "traumatic," which is often used to describe any experience that has a lasting negative effect on us.

"While these experiences can be extremely unpleasant and often warrant psychological support, PTSD is a specific set of symptoms diagnosed by a medical professional and treatable through a combination of psychological therapies and drug treatments," he explained.

This misconception was echoed by Watts, who emphasized PTSD is not inevitable following trauma. Some people will go through the most harrowing of experiences and be perfectly well a week or two later.

"It's not solely the ferocity of the event that causes the problem since the personality and previous life experience of the individual experiencing the event is highly contributory," Watts said.

Being bullied at work or school, for example, is not enough on its own to elicit a PTSD response. However, being bullied and believing your very existence is under threat may be. For PTSD to occur, there must be genuine heart-racing distress and fear during the event, not outraged indignance that it's happening.

"There must be a conviction of impending disaster, not just a belief that it's totally unfair and/or not justified," Watts said. "In other words, the focus will be on the event, not on yourself."

5 facts everyone should know about PTSD

Davies and Watts focused on the five fundamental facts that we should all know about post-traumatic stress disorder:

  1. Nearly all people will experience symptoms like these within a month after a distressing experience. For many, these will subside within about a month. If these persist beyond a month, a medical professional may then consider a diagnosis of PTSD.
  2. The symptoms of PTSD—in particular, flashbacks and emotional numbing or detachment—can be distressing to the point of fearing you might be "going crazy." However, PTSD is an extremely unpleasant but ultimately natural result of the brain and body doing their best to survive a severely frightening or stressful experience.
  3. Suffering PTSD after a traumatizing situation is not a sign of weakness, deficiency, character flaw or any other frailty of the "human condition." It's the result of the way the brain and body have evolved in order to keep us safe. The fight-or-flight response is millions of years old and has survived because it is so effective. So in some ways, PTSD could be said to be a "natural response" to trauma.
  4. If you're experiencing these symptoms or are concerned you may have PTSD, the best first step is to discuss this with a medical professional such as your healthcare provider.
  5. PTSD is treatable through a combination of psychological therapies and drug treatments.

"If we encounter a dangerous situation with which we cannot cope or have no resources to deal with, it means nothing more than that we have not yet learned how to deal with that situation," Watts said. "We don't fear that which we can control, but we can't not fear that which we cannot control."