the symptoms listed in the DSM-5, but also other common effects of PTSD such as suicidality, physical health effects, and problems in daily living.
PRACTICAL EXERCISE — RECOGNIZE YOUR SYMPTOMS
You may have spent a lot of time and energy trying to avoid your symptoms of PTSD, but the more you resist, avoid, and try to suppress these symptoms, the more persistent they will get. Start by writing in your workbook or journal about the symptoms you’re experiencing. To do this, just put your pen to paper and let whatever comes out, come out.
REFLECTIVE QUESTIONS
• Of the symptoms listed above, which can you relate to most? Which can you relate to least?
• Are there symptoms you are experiencing that are not listed? If so, what are they?
• Of the symptoms you are experiencing, which are most distressing to you?
DEVELOPMENT AND DURATION
PTSD starts with an acute stress reaction following a traumatic event. Symptoms may start immediately, or there may be a delay, usually not more than six months. Sometimes it is not until many years later when another traumatic event or a reminder of the original trauma triggers PTSD. In fact, I have met several people who experienced trauma early in life and then functioned relatively well for many years before developing PTSD. For some, it developed after exposure to further trauma, while for others, it was triggered by an accumulation of what would be considered typical life stressors. Although PTSD is not caused by “normal” stressors, there are times when situations of high stress, including what would be considered “normal” stress, can trigger PTSD in those who have a history of trauma. This can be very confusing to the person as they struggle to understand why they were able to function well for so long and then suddenly develop PTSD so many years after the precipitating trauma. Here is an example:
I experienced a lot of childhood trauma, but I was doing well in life. I went to college, was married, had two healthy kids, and was working full-time as a respiratory therapist. Then I had a string of bad luck. I broke my arm and needed surgery. I couldn’t work for a time when we were already having money problems. This caused problems in my marriage. By the time I went back to work after recovering from surgery, I was very stressed and anxious. On my third day back, I had to withdraw a dying patient’s ventilator while her husband and ten-year-old son stood at the bedside. Seeing the look on her son’s face broke me. I had a complete mental and emotional breakdown. As time went on, I continued to get progressively worse. A year later, I was diagnosed with PTSD.
Here is an example of delayed onset caused by a reminder of the original trauma:
I was a teacher, functioning well in life. I was successful by all standards — married, kids, financially stable, healthy — I had everything. Then one day I came face-to-face with a man who had been there the night I was raped. He wasn’t involved in any of the things that happened. He is a really good guy, but he was at that party all those years ago, and I hadn’t seen him since. Memories came flooding back. The nightmares started. I felt anxious and scared. I didn’t know what was going on with me. My principal noticed the change in my stress level and suggested I take time off work, but I was stubborn. I thought I could work through it, but a few months later I completely broke down. I was diagnosed with PTSD soon after.
PTSD can also develop as a result of extreme repeated trauma that is not recognized as trauma. Here is an example of this:
I’d been working in the prison system for eighteen years. I’ve seen lots of things. Things you can’t unsee. But the thing is, I had no reaction to it, except maybe in the first few weeks of starting the job. I was very quickly desensitized. I really didn’t think it was having an impact on me. I slept like a baby. Never had nightmares or fears. I had good, respectful relationships with my colleagues and the inmates. I was calm and levelheaded, no matter what chaos was happening in the jail. I was a high-energy person, motivated, athletic, with relatively healthy habits. Then last summer I started feeling unwell. I had no energy, couldn’t sleep, and was moody. My normally optimistic outlook turned negative. Everywhere I looked, it was shit. My tolerance level for anything and anyone crashed down. I was angry and pissed off for no reason. Things that normally wouldn’t have phased me were bothering me a lot. Then one day at work, inmates were arguing (an everyday occurrence), and I just blanked out for a second and then walked right out. Nothing major happened. I just couldn’t do it anymore. It was like Pandora’s box opened, and I’ve been having flashbacks and nightmares ever since. I wake up drenched, in a panic, and can’t lie back down for hours. I haven’t slept decently in over six months. I’ve been diagnosed with PTSD and haven’t been able to work or be productive since. I’ve been off work for three months and already had four medication changes. After talking with other people who’ve gone through this, they said it can take years to find the right combination of medications. I seriously don’t think I can handle years like this. It’s so frustrating. I just want to get better and get back to my old self.
The severity and duration of PTSD symptoms cannot be summed up into a logical formula. We cannot say that all people who experience a certain type of trauma will have X symptoms for Y amount of time. It is similar to when someone is diagnosed with a certain type of cancer. Doctors can only give an educated guess as to the progression of the disease and the prognosis, but there is no certainty with respect to how each individual will respond to the illness or to the treatment. The factors at play are just too complex and too vast. The reality is there are no set timeframes, and unfortunately no one can accurately predict how intense your symptoms will be or how long your trauma reaction will last.
PRACTICAL EXERCISE — GIVE YOURSELF PERMISSION
There is no right way to react to a traumatic event, so give yourself full permission to process your trauma. Avoid telling yourself things like: “I should be over this by now,” “I should be stronger,” “I can’t live like this,” etc. Putting pressure on yourself will not help. Comparing, judging, and criticizing yourself will hinder your healing. Be as patient and gentle with yourself as possible. Give yourself permission to take the time to heal. At least twice a day (morning and night), stand in front of a mirror and say, It’s okay to not be okay. Maintain eye contact with yourself for at least thirty full seconds afterward. Be aware of your thoughts and see if you can turn any negative thoughts into positive ones, the way you would if you were talking to a close friend or family member.
REFLECTIVE QUESTIONS
• What are you afraid might happen if you give yourself full permission to process your trauma in your own unique way? What good might come of it?
• In what ways might you be keeping yourself stuck in your trauma reaction by fighting it?
• How would your life be different if you were more patient with yourself and talked to yourself the way you would talk to your best friend?
THE NEUROBIOLOGY OF PTSD
Although there is still much to learn, we know that there are several key differences in the brain structures, neuronal activity, synaptic connections, and neurochemistry of those who have PTSD when compared with those who don’t. Commonly identified differences include (but are not limited to):
• Reduced hippocampal volume
• Less connection between hippocampus and prefrontal cortex
• Less activity in the prefrontal cortex
• Overactivity in the amygdala and a larger right amygdala
• Altered function of the HPA axis
• Atypical hormone and neurotransmitter levels, including:
• Low cortisol at time of trauma
• Elevated epinephrine and norepinephrine levels
• Low GABA levels
• Alterations in glutamate levels
These brain structures and neurotransmitters will