Overview

Post-traumatic stress disorder (PTSD) is an anxiety disorder caused by very stressful, frightening or distressing events.

Someone with PTSD often relives the traumatic event through nightmares and flashbacks, and may experience feelings of isolation, irritability and guilt.

They may also have problems sleeping, such as insomnia, and find concentrating difficult.

These symptoms are often severe and persistent enough to have a significant impact on the person's day to day life.

Causes of PTSD

Any situation that a person finds traumatic can cause PTSD

These can include:

• serious road accidents
• violent personal assaults, such as sexual assault, mugging or robbery
• serious health problems
• childbirth experiences

PTSD can develop immediately after someone experiences a disturbing event or it can occur weeks, months or even years later.

PTSD is estimated to affect about 1 in every 3 people who have a traumatic experience, but it's not clear exactly why some people develop the condition and others don't.

Complex PTSD

People who repeatedly experience traumatic situations, such as severe neglect, abuse or violence, may be diagnosed with complex PTSD.

Complex PTSD can cause similar symptoms to PTSD and may not develop until years after the event.

It's often more severe if the trauma was experienced early in life, as this can affect a child's development.

When to seek medical advice

It's normal to experience upsetting and confusing thoughts after a traumatic event, but most people improve naturally over a few weeks.

You should see a GP if you or your child are still having problems about 4 weeks after the traumatic experience, or if the symptoms are particularly troublesome.

If necessary, your GP can refer you to mental health specialists for further assessment and treatment.

How PTSD is treated

PTSD can be successfully treated, even when it develops many years after a traumatic event.

Treatment depends on the severity of symptoms and how soon they occur after the traumatic event.  Any of the following treatment options may be recommended:

• Watchful waiting - monitoring your symptoms to see whether they improve or get worse without treatment.
• Antidepressants - such as paroxetine or sertraline.
• Psychological therapies – such as trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR).

Symptoms

The symptoms of post-traumatic stress disorder (PTSD) can have a significant impact on your day-to-day life.

In most cases, the symptoms develop during the first month after a traumatic event.

But in a minority of cases, there may be a delay of months or even years before symptoms start to appear.

Some people with PTSD experience long periods when their symptoms are less noticeable, followed by periods where they get worse. Other people have constant severe symptoms.

The specific symptoms of PTSD can vary widely between individuals, but generally fall into the categories described below.

Re-experiencing

Re-experiencing is the most typical symptom of PTSD.

This is when a person involuntarily and vividly relives the traumatic event in the form of:

• flashbacks
• nightmares
• repetitive and distressing images or sensations
• physical sensations, such as pain, sweating, feeling sick or trembling

Some people have constant negative thoughts about their experience, repeatedly asking themselves questions that prevent them coming to terms with the event.

For example, they may wonder why the event happened to them and if they could have done anything to stop it, which can lead to feelings of guilt or shame.

Avoidance and emotional numbing

Trying to avoid being reminded of the traumatic event is another key symptom of PTSD.

This usually means avoiding certain people or places that remind you of the trauma, or avoiding talking to anyone about your experience.

Many people with PTSD try to push memories of the event out of their mind, often distracting themselves with work or hobbies.

Some people attempt to deal with their feelings by trying not to feel anything at all. This is known as emotional numbing.

This can lead to the person becoming isolated and withdrawn, and they may also give up pursuing activities they used to enjoy.

Hyperarousal (feeling 'on edge')

Someone with PTSD may be very anxious and find it difficult to relax. They may be constantly aware of threats and easily startled. 

This state of mind is known as hyperarousal.

Hyperarousal often leads to:

• irritability
• angry outbursts
• sleeping problems (insomnia)
• difficulty concentrating

Other problems

Many people with PTSD also have a number of other problems, including:

• other mental health problems – such as depression, anxiety or phobias
• self-harming or destructive behaviour – such as drug misuse or alcohol misuse
• other physical symptoms – such as headaches, dizziness, chest pains and stomach aches

PTSD sometimes leads to work-related problems and the breakdown of relationships.

PTSD in children

PTSD can affect children as well as adults. Children with PTSD can have similar symptoms to adults, such as having trouble sleeping and upsetting nightmares.

Like adults, children with PTSD may also lose interest in activities they used to enjoy and may have physical symptoms such as headaches and stomach aches.

However, there are some symptoms that are more specific to children with PTSD, such as:

• difficult behaviour
• avoiding things related to the traumatic event
• re-enacting the traumatic event again and again through their play

When to seek medical advice

It's normal to experience upsetting and confusing thoughts after a traumatic event, but in most people these improve naturally over a few weeks.

You should visit your GP if you or your child are still having problems about four weeks after the traumatic experience, or if the symptoms are particularly troublesome.

Your GP will want to discuss your symptoms with you in as much detail as possible.

They'll ask whether you've experienced a traumatic event in the recent or distant past and whether you've re-experienced the event through flashbacks or nightmares.

Your GP can refer you to mental health specialists if they feel you'd benefit from treatment.

Who can get it

Post-traumatic stress disorder (PTSD) can develop after a very stressful, frightening or distressing event, or after a prolonged traumatic experience.

Types of events that can lead to PTSD include:

• serious accidents
• physical or sexual assault
• abuse, including childhood or domestic abuse
• exposure to traumatic events at work, including remote exposure
• serious health problems, such as being admitted to intensive care
• childbirth experiences, such as losing a baby
• war and conflict
• torture

PTSD is not usually related to situations that are simply upsetting, such as divorce, job loss or failing exams.

PTSD develops in about 1 in 3 people who experience severe trauma.

It's not fully understood why some people develop the condition while others do not.

But certain factors appear to make some people more likely to develop PTSD.

Who's at risk

If you've had depression or anxiety in the past, or you don't receive much support from family or friends, you're more susceptible to developing PTSD after a traumatic event.

There may also be a genetic factor involved in PTSD. For example, having a parent with a mental health problem is thought to increase your chances of developing the condition.

Why does it develop?

Although it's not clear exactly why people develop PTSD, a number of possible reasons have been suggested.

Survival mechanism

One suggestion is that the symptoms of PTSD are the result of an instinctive mechanism intended to help you survive further traumatic experiences.

For example, the flashbacks many people with PTSD experience may force you to think about the event in detail so you're better prepared if it happens again.

The feeling of being "on edge" (hyperarousal) may develop to help you react quickly in another crisis.

But while these responses may be intended to help you survive, they're actually very unhelpful in reality because you cannot process and move on from the traumatic experience.

High adrenaline levels

Studies have shown that people with PTSD have abnormal levels of stress hormones.

Normally, when in danger, the body produces stress hormones like adrenaline to trigger a reaction in the body.

This reaction, often known as the "fight or flight" reaction, helps to deaden the senses and dull pain.

People with PTSD have been found to continue to produce high amounts of fight or flight hormones even when there's no danger.

It's thought this may be responsible for the numbed emotions and hyperarousal experienced by some people with PTSD.

Changes in the brain

In people with PTSD, parts of the brain involved in emotional processing appear different in brain scans.

One part of the brain responsible for memory and emotions is known as the hippocampus.

In people with PTSD, the hippocampus appears smaller in size.

It's thought that changes in this part of the brain may be related to fear and anxiety, memory problems and flashbacks.

The malfunctioning hippocampus may prevent flashbacks and nightmares being properly processed, so the anxiety they generate does not reduce over time.

Treatment of PTSD results in proper processing of the memories so, over time, the flashbacks and nightmares gradually disappear.

Treatment

The main treatments for post-traumatic stress disorder (PTSD) are psychotherapy and medication.

Traumatic events can be very difficult to come to terms with, but confronting your feelings and seeking professional help is often the only way of effectively treating PTSD.

It's possible for PTSD to be successfully treated many years after the traumatic event occurred, which means it's never too late to seek help.

Assessment

Before having treatment for PTSD, a detailed assessment of your symptoms will be carried out to ensure treatment is tailored to your individual needs.

Your GP will often carry out an initial assessment, but you'll be referred to a mental health specialist for further assessment and treatment if you've had symptoms of PTSD for more than four weeks or your symptoms are severe.

There are a number of mental health specialists you may see if you have PTSD, such as a psychologist, a community psychiatric nurse or a psychiatrist.

Watchful waiting

If you have mild symptoms of PTSD, or you have had symptoms for less than 4 weeks, an approach called watchful waiting may be recommended.

Watchful waiting involves carefully monitoring your symptoms to see whether they improve or get worse.

It's sometimes recommended because 2 in every 3 people who develop problems after a traumatic experience get better within a few weeks without treatment.

If watchful waiting is recommended, you should have a follow-up appointment within 1 month.

Psychotherapy

If you have PTSD that requires treatment, psychotherapy is usually recommended first. A combination of psychotherapy and medication may be recommended if you have severe or persistent PTSD.

Psychotherapy is a type of therapy often used to treat emotional problems and mental health conditions such as PTSD, depression, anxiety and obsessive compulsive disorder.

The treatment is carried out by trained mental health professionals who listen to you and help you come up with effective strategies to resolve your problems.

The main types of psychotherapy used to treat people with PTSD are described below.

Cognitive behavioural therapy (CBT)

Cognitive behavioural therapy (CBT) is a type of therapy that aims to help you manage your problems by changing how you think and act.

Trauma-focused CBT uses a range of psychological treatment techniques to help you come to terms with the traumatic event.

For example, your therapist may ask you to confront your traumatic memories by thinking about your experience in detail. During this process your therapist helps you cope with any distress you feel, while identifying any unhelpful thoughts or misrepresentations you have about the experience.

Your therapist can help you gain control of your fear and distress by changing the negative way you think about your experience. For example, feeling you're to blame for what happened or fear that it may happen again.

You may also be encouraged to gradually restart any activities you've avoided since your experience, such as driving a car if you had an accident.

You'll usually have 8-12 weekly sessions of trauma-focused CBT, although fewer may be needed. Sessions usually last for around 60-90 minutes.

Eye movement desensitisation and reprocessing (EMDR)

Eye movement desensitisation and reprocessing (EMDR) is a relatively new treatment that's been found to reduce the symptoms of PTSD.

It involves making side-to-side eye movements, usually by following the movement of your therapist's finger, while recalling the traumatic incident. 

Other methods may include the therapist tapping their finger or playing a tone.

It's not clear exactly how EMDR works, but it may help you change the negative way you think about a traumatic experience.

Group therapy

You may also be offered group therapy as some people find it helpful to speak about their experiences with other people who also have PTSD. Group therapy can be used to teach you ways to manage your symptoms and help you understand the condition.

There are also a number of charities which provide counselling and support groups for PTSD. For example:

• Combat Stress – a military charity specialising in helping ex-servicemen and women
• Rape Crisis – a UK charity providing a range of services for women and girls who have experienced abuse, domestic violence and sexual assault
• Victim Support – providing support and information to victims or witnesses of crime
• CRUSE – a UK charity providing support and information for people who have experienced bereavement

Medication

Antidepressants such as paroxetine, sertraline, mirtazapine, amitriptyline or phenelzine are sometimes used to treat PTSD in adults.

Of these medications, paroxetine and sertraline are the only ones licensed specifically for the treatment of PTSD. However, mirtazapine, amitriptyline and phenelzine have also been found to be effective and may be recommended as well.

However, these medications will only be used if:

• you choose not to have trauma-focused psychological treatment
• psychological treatment wouldn't be effective because there's an ongoing threat of further trauma (such as domestic violence)
• you've gained little or no benefit from a course of trauma-focused psychological treatment
• you have an underlying medical condition, such as severe depression, that significantly affects your ability to benefit from psychological treatment

Amitriptyline or phenelzine will usually only be used under the supervision of a mental health specialist.

Antidepressants can also be prescribed to reduce any associated symptoms of depression and anxiety and to help with sleeping problems. However, they're not usually prescribed for people younger than 18 unless recommended by a specialist.

If medication for PTSD is effective, it will usually be continued for a minimum of 12 months before being gradually withdrawn over the course of four weeks or longer. If a medication isn't effective at reducing your symptoms, your dosage may be increased.

Before prescribing a medication, your doctor should inform you about possible side effects you may have while taking it, along with any possible withdrawal symptoms when the medication is withdrawn.

For example, common side effects of paroxetine include feeling sick, blurred vision, constipation and diarrhoea.

Possible withdrawal symptoms associated with paroxetine include sleep disturbances, intense dreams, anxiety and irritability.

Withdrawal symptoms are less likely if the medication is reduced slowly.

Children and young people

For children and young people with PTSD, trauma-focused CBT is usually recommended.

This normally involves a course of 6-12 sessions that have been adapted to suit the child’s age, circumstances and level of development.

Where appropriate, treatment includes consulting with and involving the child's family.

Children who do not respond to trauma-focused CBT may be offered EMDR.

Complex PTSD

Complex PTSD - Post - traumatic stress disorder

You may have complex post-traumatic stress disorder (PTSD) if you have some of the symptoms of PTSD, and also have problems with managing your emotions and having relationships.

Symptoms of Complex PTSD

The symptoms of complex PTSD are similar to symptoms of PTSD, but may also include:

• feelings of worthlessness, shame and guilt
• problems controlling your emotions
• finding it hard to feel connected with other people
• relationship problems, like having trouble keeping friends and partners

Causes of complex PTSD

Complex PTSD may be caused by experiencing recurring or long-term trumatic events, for example:

• childhood abuse or neglect
• domestic violence
• sexual abuse
• torture, sex trafficking, or slavery
• war

You may also be more likely to develop complex PTSD if:

• you experienced trauma at a young age
• you were harmed by someone close to you who you trusted
• you were unable to escape the trauma

Treating complex PTSD

If you have complex PTSD, you may be offered therapies used to treat PTSD, such as trauma-focused cognitive behavioural therapy or eye movement desensitisation and reprocessing (EMDR).

You'll also be offered treatment for other problems you may have, such as depression or alcohol addiction.

You should be offered ongoing support after your treatment ends.

The mental health charity Mind has more information about complex PTSD.