Understanding and Coping with Post Traumatic Stress Disorder (PTSD)
Written in association with the Berkshire Traumatic Stress Clinic, United Kingdom
This document is for anyone who suffering from Post Traumatic Stress Disorder (PTSD). The first part helps you to understand what PTSD is, why PTSD develops, and why things may, at this time, not seem to be changing. The second part describes strategies to help manage some of the intense anxiety and distress PTSD can cause.
Alex was walking down the street one evening after having dinner with some friends when he was mugged by two men at knifepoint. Alex tried to run away but they caught up with him and took his wallet and his watch. During the attack, Alex believed that those men were going to stab him and that he would be killed.
After this event Alex started to feel more panicky whenever he was walking alone on the streets in the dark. He was also a lot jumpier than before. Memories of the attack haunted him almost every day, as if a film of the attack was playing in his head repeatedly. Alex started to avoid going out because he only really felt safe in his own house.
Whenever something reminded him of the attack, like seeing a knife or having someone approach him from behind, he felt in his body that the attack was happening all over again. He would feel shaky, sweaty, and short of breath and sometime believed that he was going to die. At night Alex would have nightmares about being mugged.
Alex lost confidence in managing day – to – day tasks and stopped socializing with friends unless they came to his flat. He found he would get easily distracted at work and could not concentrate on reading book, which used to be his hobby of his. This left him feeling low at time, and he would get frustrated with himself for feeling unable to do the thing he used to.
The effect of the attack on Alex is typed of people who experience PTSD. When we live our lives feeling scared or threatened, it is common to react in ways that we wouldn’t if we felt safe, calm, and relaxed.
Do you experience any of the same symptoms as Alex?
What is PTSD?
Post – Traumatic Stress Disorder, or PTSD, is the name given to a set of symptoms that many people experience after traumatic incidents. These traumatic events might be things that have happened to us directly or things that we might have witnessed. After a threatening experience, it is common and understandable to be distressed for some time.
For example, people often say that they find it difficult to get the thoughts and images of what happened out of their mind, and they may even experience nightmares about the events. It is also normal to feel more jittery and emotional after a traumatic experience – you may feel ‘on edge’, or the verge of tears. Because the event is upsetting, it is natural to want to avoid thinking about it, and we may avoid reminders of what happened.
Everybody has natural abilities to cope with life’s struggles. Over time, our natural resources help us cope with these difficult events and we may feel that we are able to put the horrible experience behind us. However, some people’s personal resource seems to be completely overwhelmed, and these difficulties don’t seem to get any easier. In fact, they may even start to feel worse. People develop PTSD if these initial difficulties persist over a longer period of time.
The symptoms of PTSD come in three main groups. Not everybody experiences all of these symptoms, but you will, more likely than not, experience at least one difficulty from each group. The following list does not cover everything and you might have some other experiences that are not listed here:
Symptoms of PTSD
Re – experience symptoms
- Upsetting memories come into your mind when you don’t want them to (images, feelings, sensations, sounds, tastes, or smells)
- Intense memories where it feels as though the trauma is happening to you again. You may lose touch with your surroundings)
- Nightmares of the traumatic event, or dreams with a threatening theme.
- Feeling physically and emotionally upset whenever you are reminded of the trauma
- Staying away from reminders of the event
- Trying not to think or talk about what happened
- Feeling disconnected or ‘numb’, like you have no feelings
Hyper – arousal
- Constantly looking out for danger and being more easily startled
- Problems sleeping
- Problems concentrating or problem with memory
- Feeling angry and frightened
Other common reactions to trauma
- Feeling depressed, anxious, or irritable
- Withdrawing from family and friends
- Feeling of guilt, self – blame, shame, or self – criticism
After a traumatic event, almost everyone will feel jumpy, and it is normal to have intrusive memories of what happened. Approximately two out of three of people will find that these symptoms fade over time. Other people may find that the symptoms of PTSD emerge sometime after the trauma occurred and almost seem to come “out of the blue”. This can seem very confusing, and they may ask themselves “why now?”
PTSD can be triggered if something acts as a reminder of the traumatic event. It could be that something similar to the original event happens again or that something happens in your life that reminds you of the traumatic event. Seeing someone go through a similar experience to your own can trigger traumatic reactions.
For example, someone who was in a car accident many years ago may have felt that they had ‘got over it’. However, years later they are involved in another minor accident and memories of the first accident can come flooding back. Our minds and bodies remember traumatic events in all of our different sense (sight, smell, touch, taste, sound, and feeling).
This mean that any sensations that are similar to ones present during the trauma might trigger PTSD later. Bodily or emotional feelings that we experience during the trauma can also trigger PTSD. For example, if we felt helpless during the trauma, then symptoms of PTSD may be triggered during other situations that make us feel helpless.
The threat system
What is the threat system?
The most important task for all living thing is survival. Over millions of years, all species have evolved ways of quickly detecting and responding to threats, increasing their chance of survival. Human brains have also evolved to detect threat and we have a built – in threat detection system.
The amygdala is the brain’s ‘alarm system’. It works to keep us safe by constantly being on the lookout for threat. A body – wide alarm system is set off if a threat is identified. The amygdala is very sensitive and lives by the rule ‘better safe than sorry’, so as soon as sign of danger are sensed it immediately kicks into action and prepares the body/mind to defend itself.
It also records information from our senses (sight, sound, smell, touch, taste) about any dangerous situation. It all happens so quickly and automatically that sometime the amygdala has set off the alarm before we are even consciously aware of what is happening.
For example, if we are in a forest and see something move on the ground we might feel scared and quickly step back, before we realize that it is a harmless bird. This reaction is the amygdala keeping us safe and acting quickly, before the ‘thinking’ part of the brain identified the movement as something harmless.
What happens when the threat system is activated?
The main purpose of the threat system is self – protection. Our survival instincts tend to make us do one of four things: fight, flight (run away), freeze, or appease (try to calm down the threat). When the threat system is activated a hormone called adrenaline is released into the bloodstream.
The adrenaline flows round our bodies very quickly, getting different body streams ready to quickly respond to the threat. The adrenaline increases heart rate so that there is more blood and oxygen going to our muscles. The adrenaline makes our muscles tense, making them ready to fight or to run away.
The adrenaline speeds up our thoughts, so we can make quick (potentially lifesaving) decisions. All of these changes can affect how we are feeling. The diagram below shows some of the effects activations of the threat system can have.
Remember that when we feel under threat it is common to act automatically. We tend to act first and think later, and may behave in a way that we would not have if we were feeling safe or calm. We have very little, if any, control over these instinctual reactions and we rarely get to choose which ones we employ when we feel scared. Common instinctive reactions include:
These are all sensible and age – old ways of dealing with danger.
- Fight = fight a danger off
- Flight = run away from danger
- Freeze = stay still and the danger might go away
- Appease = bargain to try and make the danger spare us
The slow, deliberate, rational, ‘thinking’ part of the brain often takes a back seat when we rely on our basic survival instincts. This is very important to keep in mind as we can often blame ourselves for the way we may have reacted during the traumatic event and wish that we had done or said something different. However, we probably just reacted automatically to protect ourselves in the best way we could at the moment.
How does all of this relate to PTSD?
Our brain (and particular our amygdala) doesn’t care and can’t distinguish whether a trauma is happening now in the present, or whether we are remembering a past event in our minds – it reacts in the exactly the same way. The threat system is activated and the body reacts as if a real threat were occurring, it doesn’t realize that it is reacting to a memory. This is why memories of the trauma feel so fresh and why people often feel the exact same emotions they felt when the event was happening
The tricky thing for people who have experienced traumatic events is that the threat system often remains extra sensitive, and is always on the lookout for possible signs of danger. During the trauma, the amygdala was busy collecting sensory information so that it can detect any warning signs that further trauma might happen again later in life.
This means that anything that reminds you (even vaguely) of the trauma can trigger the threat system and result in an emotional reaction. It’s common to see reminders everywhere, and some people feel that with their threat system triggered frequently they can’t escape from unpleasant feelings.
Do you recognize any of these reactions?
Normal Memories vs. Trauma Memories
‘Trauma’ memories are different from ‘normal’ memories. To understand more, we need to know about another bit of the brain, the hippocampus, and to learn about how our memories are formed.
Do you remember the job of the amygdala? Its role was to detect threats and to set off an alarm in the body to prepare it for action. In contrast, the hippocampus collects and sifts through factual information, such as who, what, when and where. Like a librarian filing books away in a library, it records information about when and where the event happened, and files the memory away in the right place so that you can retrieve it easily later.
The hippocampus is like a librarian who files memories away in their proper place in a filing cabinet
The hippocampus works best when we are a bit emotional, but not too stressed. For example, we are more likely to remember happy or sad events compared to boring events: a bit of emotion tells the hippocampus that the event is worth remembering.
When the hippocampus and amygdala work together, a complete memory with sensory, emotional, and factual information is formed.
However, when we feel under threat, hormones like adrenaline are released. This perks up the amygdala and it becomes more active in order to do its job. In contrast, the hippocampus shuts down and becomes less effective at its job.
This means that memories formed during these times of stress are filled with intense emotions and vivid sounds and images because the amygdala was so active. Because the hippocampus became inactive these memories sometimes lack precise details about where and when things happened, and in what order they occurred.
Think of a nice memory from your life, such as a fun day out. It is normal to be able to do certain things with this memory. If you were asked to tell someone about the memory, it will most likely be organized so you would start at the beginning, go through the main points, and finish the story at the end.
You probably have all the words you need to describe the memory, and can choose what bits you talk about. This memory came into your mind because you were asked to think about a nice time, it did not just pop into your head from nowhere. In this sense ‘normal’ memories are mostly under our control, and we can choose when to think about them. After we talk or think about them we can ‘put them away’ and are not bothered by intrusive memories of the event for the rest of the day.
Importantly, when you think or talk about this normal memory you will know the event you are thinking about happened in the past and you do not feel as if you are re-living the moment all over again. You don’t feel the same intensity and level of emotion you did at the time. For example, Alex may remember being excited the morning of his 21st birthday, but he would be unable to feel the same amount of excitement as he did on that day.
Lastly, our ‘normal’ memories and the meaning that we give to events can change and get updated when we receive new information. Taking Alex as an example, he felt extremely annoyed that his best friend did not attend his 21st birthday party. At the time, he thought that his friend didn’t care about him and felt angry every time that he thought of this.
Later, though, Alex found out the reason his friend did not come was that he had to rush his mother to hospital as she had suddenly fallen ill. Because of this new information, Alex felt differently about what had happened and his memory and understanding of the event was updated to include this new piece of information. Because of this, Alex’s feelings towards his friend also changed and he no longer felt anger towards him.
Summary of normal memories
‘Normal’ memories are like files in a well-organized filing cabinet. They are under our control (we can open a drawer, pull out a file for a particular memory, then put it away and not think about it):
- They are organized – they don’t just come in bits and bobs
- They are just memories. We can talk about them without feeling overwhelmed with emotion
- We can talk about them in a complete way: the memory is like a story with a beginning, middle and end
- We know and feel as though the memory and the event happened in the past – like it has a ‘time tag’
- We can change and update the memory when we learn different things
- It contains both emotional and sensory information (collected by the amygdala) and factual information (collected by the hippocampus)
When we experience a traumatic event, the thinking part of the brain shuts down (including the hippocampus) and the threat system is activated (the amygdala). The amygdala triggers the release of adrenaline and our body reacts to protect itself. With the hippocampus less effective and the amygdala hyper-sensitive, the memories that are created during a trauma are flooded with highly emotional content and vivid sensory detail. Our ‘trauma’ memories are therefore different to our normal memories.
The first thing you may notice about trauma memories is that they are not under our control. Memories about the event may pop into your mind at any time ‘out of the blue’. Little things around us, like a noise, a sight, a smell, or a feeling can mean you think about the event even if you don’t want to. It is as if the files in an overstuffed and jumbled filing cabinet are spilling over. Even though we try and close the cabinet drawer, the files keep popping out.
The other thing you have probably noticed about your trauma memories is that they are often in bits and pieces rather than a whole story. People often say they remember a part of the traumatic event, hear a sound, or feel a certain sensation, rather than remembering a whole story with a beginning, middle and end. It is like all the papers in one file have not been stapled together and different pages are popping into your memory, or like isolated pieces of a jigsaw puzzle.
When we remember bits of the traumatic event, we feel the same intensity of emotion as we did at the time of the trauma itself. This is one of the hardest things about trauma memories. So, for Alex, every time an image of his attacker came into his mind he felt the same intensity of fear as when the attack happened. This is very distressing and frightening.
This happens because the brain has not recognized that the event is over, and in the past. The trauma memory is filled only with information from the threat system and it lacks factual and contextual information. It is as though no new information that you have learnt since the event has been filed away with the rest of the memory.
So, when Alex experiences an intrusive memory of the attack he believes that he is going to die, even though he knows rationally that he did not die and is safe now. His brain has not put this piece of information with the rest of the memory about the attack.
Summary of trauma memories
‘Trauma’ memories are like a messy and disorganized filling cabinet. The memory is in fragments so we may remember just a specific part, such as a smell or physical sensation, without remembering the rest of the event. We only remember the worst bits.
We don’t have control over when and where the files will pop out, or what pieces of paper from which files will come to mind
We have not filed away the memory properly in the past so it feels as if it is happening all over again when we remember it
Trauma memories are filled with sensory information and we can re-experience memories in any of our five senses
Trauma memories are easily triggered and brought into our mind by ‘triggers’: noises, smells, or sometimes small things that remind our brain in some way of the traumatic event
Why do trauma memories persist?
Our brains were not able to file away the traumatic memory at the time because they were so busy keeping us safe that they let all the paperwork pile up. Later on, because all the paperwork is disorganized, the brain gets confused when it tries to file it away. If a bit of information about the traumatic event pops out, the brain thinks the traumatic event is happening all over again, then stops filing and works on keeping us safe instead.
The job of trauma therapy is to help the brain file away the memory without going in to ‘threat mode’. In other words, one of the main aims of any trauma-focused therapy is to try and help make trauma memories into ‘normal’ memories. It is important to remember that ‘normal memory’ does not necessarily mean ‘good memory’.
Most of us will have had distressing events in our life that do not come back to us in the same way as our trauma memories. With ‘normal memories’ we might feel some distress when we remember unhappy memories. However, we don’t continue to experience the same intensity of emotion, or continue to feel as if we are reliving the worst part of it repeatedly.
Summary of differences between normal and trauma memories
|Normal memories||Trauma memories|
|Have a beginning, middle, and end||Are often fragmented and ‘bitty’|
|We have control and can rewind, fast-forward, or pause easily||Are less controllable – they are triggered by reminders in the world around us|
|Are just memories, we can talk about them without becoming overwhelmed||Can be overwhelming – often feels like they are happening again in the present|
|Have a ‘time tag’ – we know the event happened in the past||Feel fresh – as though it just ‘happened yesterday’|
|Can be changed and updated when we learn new information||Seem ‘stuck’ – the memory just repeats and doesn’t change|
Now that the differences between normal and trauma memories have been described, what do you think might be the key tasks in helping ‘trauma memories’ become ‘normal memories’?
Flashbacks, Nightmares & Dissociation
Most people who have been traumatized experience flashbacks or nightmares, and some others may also experience periods of dissociation. What do these terms mean?
What is a flashback?
‘Flashback’ is commonly used to describe a sort of remembering that is characterized by a vivid intrusion of memory. Survivors of trauma are often troubled by unexpected intrusive memories of what happened. Sometimes these memories are so vivid it feels like the mind is ‘flashing back’ to the trauma.
These can be very upsetting, particularly at night-time when the memories can be especially vivid and difficult to manage. A flashback is not necessarily a complete memory and can represent a single aspect of the event (e.g. physical sensation of the incident, the sound of a voice, a particular smell, or a powerful feeling of danger).
Characteristics of flashbacks
- The sense that you are re-living the experience all over again
- A powerful ‘sense’ of something familiar and upsetting
- Sometimes re-experiencing physical sensations that were felt at the time
- It may be like watching a film of what you went through, or maybe still images of the key points
- We can re-experience the event in any of our senses
- Sometimes you might lose touch with your surroundings
Flashbacks are triggered by something that reminds your brain of the trauma (i.e. ‘matching trigger’), such as an image, noise, smell, or physical sensation. For instance, one of the men who mugged Alex was wearing a green jacket. Later, when Alex saw a similar jacket (or items of green clothing), he had a flashback of the mugging and felt very scared.
Sometimes it may feel that flashbacks ‘come out of the blue’, but they will always have been triggered by something that reminded our brain of the traumatic event, even if it’s so subtle we are not consciously aware of what the trigger is. We may have to do some detective work to identify our matching triggers.
Another way of thinking about flashbacks is comparing them to our experience when we watch a horror film. Which bits of horror films do you remember most? When you think back to the movie, you probably don’t remember everything in the correct order. Chances are that you remember the worst and most terrifying bits – it is these images which pop into your mind whenever you are reminded of the film.
It’s like these images don’t have any context and they seem to be more vivid and intense then the rest of the movie. Flashbacks are like this – the worst and most horrific parts, all jumbled up, that pop into your mind.
What about nightmares?
‘Normal memories’ get consolidated/processed when we sleep. At night, your brain is busy processing what you experienced that day, and moving memories into long term storage: filing the memories neatly away in the correct place in the filing cabinets. One theory about dreaming suggests that the content of a dream reflects this memory consolidation process – the brain trying to make sense of the event and file it away.
Nightmares can occur when the brain tries to process unpleasant memories. During the day, we often try to push distressing memories from our mind and feel that they are just below the surface. However, when we are asleep we can’t suppress these memories and they re-surface in the form of vivid and intense nightmares.
It might be that nightmares in PTSD keep recurring because it isn’t possible for the brain to process and ‘file’ the memory properly. This is often because we wake up at the ‘worst point’ stopping any further processing from occurring.
Nightmares often replicate aspects of the traumatic event and can contain images of the ‘worst bits’. However, sometimes the content of the nightmares do not relate to actual events, but rather contain themes of threat, violence and fear.
What flashbacks or nightmares do you experience? How often do you have them?
What is dissociation?
After surviving a traumatic event, some people might experience:
- Periods of time when they feel ‘spaced out’
- Time passing without noticing
- Periods of time that feels unreal or dreamlike
- Talking with someone and not being able to remember what they just said
- Finding themselves in places and being uncertain how they got there
- Finding they have belongings that they can’t remember buying
These are all examples of dissociation. Dissociation is a normal process and these experiences happen to everybody from time to time. ‘Dissociative experiences’ can range from daydreaming and being on ‘automatic pilot’ to observing yourself do things as if from the outside (an ‘out-of-body’ experience).
Dissociation is more likely to happen during trauma if a person experienced a high level of stress and could not escape. When the threat system is strongly activated some people may dissociate – mentally remove themselves from the threatening situation. Dissociation is like a safety valve on a pressure cooker – it is our mind’s way of protecting ourselves. Some might experience the event as unreal or dreamlike, and things may seem to go in slow-motion.
For others, it might seem as though they are watching the event without them actually being there. When dissociation happens in day-to-day life it can be frightening. It is helpful to remember that it is a normal process, and certainly nor an indication that you are going mad. Gaining control is a step-by-step process, which takes time but the first step may be recognizing whether this may be an issue for you.
Feeling Scared or Under Threat all of the Time: What Keeps This Going?
Traumatic events, and their aftermath, can also lead us to change the way we think about ourselves, other people, or about the world. For example, we might start to think that we are horrible, worthless, or powerless people as a result of what others have done to us. Some people develop the belief that others cannot be trusted, or that the world is a dangerous place.
If these thoughts and beliefs are rehearsed and not “checked out”, they become stronger and stronger, reinforcing the feeling of danger.
It is natural to want to avoid the things that scare us. We might do this physically by avoiding certain places or certain people or any reminders of the traumatic event. Alternatively, we might mentally try to avoid a scary memory by pushing thoughts out of our minds, or by distracting ourselves. We do this because avoiding whatever scares us is often the most obvious way of coping with it. This can lead to unintended consequences though.
For instance, after the mugging Alex stopped going out. As a result, he lost confidence in managing day-to-day tasks and stopped socializing with friends unless they came to his flat. This left him feeling low in mood and he would get frustrated with himself for feeling unable to do the things he used to. The memories still bothered him, and he stared to feel more distant from his friends.
How Alex’s trauma affected him:
The unintended consequences of trying to stay safe
We make our best efforts to cope with danger. The difficulty is that our instinctive best efforts to cope can often come with unintended negative consequences. For example
- If we avoid doing anything except ‘safe’ activities we never learn that we are capable of coping with normal levels of risk
- Fighting back or becoming angry as a way of defending ourselves may unintentionally push people away, or create conflict in our lives
- Appeasing others can, unintentionally, lead to the frustration of our own needs never being met
- Cutting off from people can, unintentionally, mean that others don’t understand what you are going through
- Drinking alcohol to cope (or to sleep) can feel like it is helping in the short term but tends to make things worse in the long run
These are just some examples of unintended consequences resulting from our best efforts to cope with distress. You may experience others that are not listed here.
How do you try to cope with distress caused by PTSD? Can you think of any unintended consequences to your best efforts to cope?
Coping with PTSD
Techniques to Cope with the Symptoms of PTSD
The techniques in the rest of this booklet are designed to help you to cope with some of the troubling symptoms of PTSD. We don’t expect that all of these techniques will be helpful for everyone, but would expect some to suit you more than others. Try them out, and see which make the biggest difference to your life.
Tips for practicing
- Don’t overload yourself. Pick one technique at a time and focus on that one for a while
- Try writing down a technique on a small card to take out with you. We don’t get much choice over what sets off our threat system and we need to be prepared to calm it in different situations
- If you feel comfortable, you could also ask friends or family to help you put some of these ideas into practice
- Don’t beat yourself up! These techniques are all about learning to calm yourself Do persevere, but if you find that a technique does not appear to be working for you, don’t worry and move onto another technique. Not every technique will be for you. Be kind to yourself and remember that you are doing the best you can
Understanding PTSD: My PTSD symptoms
The first step in coping with PTSD is to understand how it affects you. Look at the symptoms below, and tick any that have affected you at least twice in the last week.
[ ] Upsetting thoughts or memories about the event that have come into your mind against your will
[ ] Upsetting dreams about the event
[ ] Acting or feeling as though the event were happening again
[ ] Feeling upset by reminders of the event
[ ] Bodily reactions (such as fast heartbeat, stomach churning, sweatiness, dizziness) when reminded of the event
[ ] Difficulty falling or staying asleep
[ ] Irritability or outbursts of anger
[ ] Difficulty concentrating
[ ] Heightened awareness of potential dangers to yourself and others
[ ] Being jumpy or being startled at something unexpected
Understanding PTSD: My thoughts and beliefs
Trauma affects how we think about ourselves, other people, and the world around us. These thoughts and beliefs can powerfully affect how we live our lives. It is helpful to reflect on how trauma has affected us. Write down your answers to the following questions.
Things I thought as I was experiencing trauma
How my trauma has affected the way I think about myself
How my trauma affected the way I think about other people
How my trauma affected the way I think about the world
Calming the threat system: Relaxed Breathing
Controlling your breathing sends a signal to your threat system that everything is ok. Calm breathing is slow, relaxed, and from the diaphragm (‘belly breathing’), whereas anxious breathing is quick, tense, and high up in the chest.
- Begin by sitting somewhere comfortable but supported
- If you feel comfortable to do so close your eyes, otherwise stare off into the middle distance
- Breathe in slowly and steadily for a count of 3
- Breathe out slowly and steadily for a count of 5. Our bodies relax most on the out-breath
- Repeat for a few minutes. It’s normal for your attention to wander off. If it does, just gently bring it back to focus on your breathing.
Calming the threat system: Colored Breathing
Another technique for slowing your breathing and calming your mind is to use imagery while you breathe. Some people find it helpful to imagine breathing colored air. You can memorize these instructions, you could ask someone to read then slowly for you, or you could record yourself speaking them and then listen to the recording.
- Imagine a color representing tension, or tense feelings
- As you breathe, calmly and steadily, imagine breathing out air tinged with that tense color
- See the colored air in your mind’s eye, and watch as you breathe it out and it floats away
- Allow the tense colored air to become paler and paler, as you breathe out all of the tension
- Now bring to mind a color representing calming, soothing feelings
- Imagine breathing in this relaxed colored air
- Just notice what happens in your body as you imagine breathing in the relaxed air
- Continue breathing this way for a few minutes
Calming the threat system: Swing Breathing
Swing breathing is another imagery technique for slowing your breathing and calming your mind. You can memorize these instructions, you could ask someone to read then slowly for you, or you could record yourself speaking them and then listen to the recording.
Allow your breathing to become slower … and more regular. Just focusing your attention on your breath … on the air flowing in … and out … of your mouth and nose.
Your breathing finding a steady rhythm. Breathing gently from low down in the belly. Taking slow steady breaths. Breathing in gently … and slowly and smoothly exhaling … Breathing in gently … and slowly and smoothly exhaling.
And as you continue to breathe slowly and gently … in a rhythm that’s comfortable to you … I’d like you to imagine … and then begin to feel … that you’re on a swing. Gently swinging backwards … and forwards … backwards … and forwards … finding that you’re swinging in rhythm with your breathing … just gently swinging … relaxed and peaceful. Pay attention to how it feels to swing gently forwards … and backwards … peaceful … relaxed … at ease. Just swinging gently … and smoothly … smoothly .. and gently.
And you can carry on breathing calmly and gently for as long as you like. Relaxing into this gentle rhythm more and more as time goes by.
Calming the threat system: Muscle relaxation
When we feel under threat our muscles tense up – ready to fight or take flight. Keeping the muscles tense is one of the body’s ways of trying to keep you safe. One way of letting your body know that you are safe is to deliberately relax all of your muscles.
Progressive muscle relaxation involves tensing, then relaxing, all of the muscle groups in turn. Find a comfortable spot, sitting or lying down. Then, for each of the muscle groups in turn, follow this pattern:
- Tense the muscles
- Notice the tension for a few moments
- Notice the sensation of relaxation as the tension drains away
Relax each of the muscle groups in turn:
- Upper arms
- Shoulders (lift up slightly)
- Upper back (shoulders back slightly)
- Lower legs / calves
- Neck (gently move neck back)
- Muscles around eyes (scrunch face up)
Calming the threat system: Creating a safe place
A safe place is somewhere that you create using your mind and imagination. It is a place that you can go anytime, wherever you are. For some people, it is a place that they remember from their past as being particularly safe and calm.
For others, they cannot easily remember a time like this from their past and so they work on creating one for themselves now. Either way, the same process applies. You can have more than one safe place and it can change over time as you wish. It is your creation and your own personal ideal.
It is useful for your safe place to have certain qualities though: it needs to be a place you feel calm, not judged, warm, free and above all safe.
How to create a safe place:
- If you feel comfortable enough, close your eyes and take a deep breath in and count to three. Then breathe out slowly to the count of five. Do this several times. As before, spend some time slowing down and controlling your breathing until you reach a calm and soothing rhythm. As you breathe in, imagine you are breathing in a sense of safeness and relaxation. As you breathe out, imagine you are breathing out all of the tension in your body.
- Begin to imagine a place where you feel calm – where are you?
- Focus on what you can see, take a minute to look all around you in your mind. You may perhaps even turn around to see what’s behind. Concentrate on any objects that you can see, the colors around you and areas of lightness and darkness.
- Focus on what you can hear, take your time to notice the noises, even the subtle ones. What noises can you hear close by? What noises can you hear in the distance?
- Focus on what you can smell. Again, take a minute to really notice the smells around you.
- What can you feel? Is it hot or cold? Are there textures under your feet?
- Focus on any taste in the image and notice this for a minute or two.
- Now focus on how you feel in your body, feelings of calm and safety in this image. Focus on the release of tension. Where do you feel this feeling in your body?
- Keep imagining your safe place in as much detail as possible and revisit that feeling of calm and safeness over and over, noticing where you feel it in your body.
- Is there a word that might remind you of your safe place? If so, what is it? If you have a word, repeat it in your mind over and over as you keep your safe place in your mind.
- When you are ready, take some deep breaths in again and slowly open your eyes, trying to hold onto that calm feeling.
Remember, you can come back to it whenever you want to. The easiest way to do this is to start by slowing down and controlling your body and to repeat the word that you picked that reminded you of your safe place. In doing so, it will be easier to return to your safe place whenever you would like.
Write a description of your safe place in as much detail as you can. Remember to include information from all your senses. What word have you chosen to remind you of your safe place?
Coping with memories: Use all of your senses
When we are having a flashback, or as we wake up from a nightmare, our awareness of the things around us in the here-and-now can be diminished. Just as we can re-experience traumatic memories in all of our five senses, we can use those five senses to try and ‘ground’ us back in the present.
Look around you and use those sights to remind yourself that you’re in the present and that you are safe.
It can be helpful to carry an object with us that remind us that we are safe, such as a stress ball, a pebble, or a flower.
Focus on all of the noises around you in the present moment. Use them to remind you of where you are.
Smell can be one of the most powerful ways of learning to soothe and comfort yourself Try using essential oils, your favorite plants, or any comforting aroma.
Strong tastes such as chewing gum can be helpful. For people who re-experience ‘taste memories’ it can be helpful to focus on the absence of taste in the present moment.
Coping with memories: 5-4-3-2-1
When our minds and bodies feel as if they are fully immersed in the past, using all of our senses at once can be a very effective way of bringing ourselves back into the present. Focus on:
5 things you can see
4 things you can feel / touch
3 things you can hear
2 things you can smell
1 thing you can taste
Coping with memories: Reminding yourself it was in the past
When a memory is triggered it can feel as if the traumatic event is happening all over again. Our minds and bodies can feel like we are back in the moment the trauma took place, rather than recognizing that we are revisiting a memory.
During a flashback, we often describe what we can see or sense in the present tense. For example, Alex said “he’s standing right in front of me and I can see him” whilst he was having a flashback.
To help put the memory in the past, it is useful to practice rephrasing your common thoughts about the event in the past tense, particularly whenever you have a flashback memory or after having a nightmare. This technique is most helpful while we are in the midst of a flashback. It may seem simple but it can be a powerful technique to help your brain, in the heat of the moment, remember that it is not happening all over again. Here are some examples
|Current thinking||Remembering it is in the past|
|He’s here in the room||He was in the room when I was attacked|
|I hear the gun fire||I heard the gun go off when I witnessed the robbery|
|I can see the headlights||When I was in the car accident I could see the headlights coming toward me|
|I can feel him behind me breathing down my neck||When I was assaulted I could feel the man behind me and I could feel his breath on my neck|
Write your most common thoughts when you’re having a flashback and then rephrase them so they are in the past. Practice saying them to yourself often.
|Current thinking||Remembering it is in the past|
Coping with memories: It’s just a memory
Remember, our brains (particularly our amygdala) don’t care whether something is happening in real life or whether it is a memory – our minds and bodies react in the same way by activating the threat system.
A simple yet effective technique is reminding yourself that you are responding to a memory rather than the actual event. This can be helpful in reminding your brain that you are not, in fact, back in danger. Try writing a statement down on a card to carry round with you.
For example, Alex would write down and look at the phrase:
When I was attacked the man stood right in front of me, he is not in front of me now. I am just remembering the memory of when I was attacked. THIS IS MY MIND AND BODY REACHING TO A MEMORY. IT IS NOT HAPPENING AGAIN.
If you feel comfortable with it, you may also consider asking your partner or a friend to gently remind you that you are responding to a memory, that the trauma is not happening again, and that you are safe.
Coping with memories: Fast forward to safety
When we are bothered by flashbacks we often forget that we can have control over the memories and that we can control our own minds. It is very important to remind ourselves that we are safe, and that the events are over. One way to do this is to think of our memories as being like a video tape, and to remember that we can fast forward it.
Here are some steps in helping you train your mind to ‘fast forward to safety’
1) Think of your traumatic event
2) Think about the first time you felt safe afterwards – really picture this scene as clearly as you can in your mind. Where were you? What were you doing? Who were you with? How did you know that you were safe? Don’t forget to think of all five of your senses.
3) Write down a description of this moment of safety.
4) When you have a flashback, practice ‘fast forwarding’ to this safe time. Quickly see everything that happened after the moment in the flashback, and then focus on the feeling of safety telling yourself that it is in the past. Try and focus on how this safety feels in your body. Try and stay with that feeling of safety for as long as possible.
The more you practice this, the better your brain will get at putting these memories in the past.
Coping with memories: The differences between then and now
Remind yourself of things that have changed since the time of the trauma. For example, if you have had your birthday you can remind yourself “I am 45 now and was 44 when I was in a car accident”. You may have changed your physical appearance and remind yourself “I have long hair now but it was short when I witnessed the robbery”
What has changed for you since you experienced the traumatic event?
Coping with memories: Grounding the date
Remind yourself the current date, where you are, the time of day etc. For example, “today is Thursday 5th May 2017. I am at work. It is 10:55am. It is spring and it is sunny outside. I am safe. I survived”. You may take this further by writing down and reminding yourself that the traumatic event took place at another time. For example, it took place on a winter afternoon in December.
When did the traumatic event take place? What is the current date? Can you describe the here-and-now?
Coping with memories: Noticing triggers for flash backs
Flashbacks and intrusive memories can be triggered by reminders that are linked to the traumatic event: someone who has been in a car accident might be triggered by the sight of certain cars, the sound or traffic, or sirens.
Like trauma memories, the mind and body doesn’t seem to be able to recognize that these things (i.e. sights, sounds, smells etc.) are no longer signs of danger. Instead, the mind and body react as if they are under threat. It is important, therefore, to try to train the brain to break the link between then and now and to help the brain recognize that these things are no longer signs of danger.
The first part is to first identify what might trigger your flashbacks and intrusive memories.
Some of Alex’s triggers were:
- People standing behind me
- Dark streets
Some of my triggers are:
Coping with memories: Flashback triggers – breaking the link
Next, systematically think about the differences between what you experienced during the trauma and how different things are now.
|Similarities||Feeling scared||Feeling scared|
I was 25 then
I was 32 now
Helping with self-harm
People self-harm for a variety of reasons. Sometimes it is to cope with powerful emotions, to distract from something overwhelming, or to feel something instead of feeling numb. Unfortunately, it can come with severe unintended consequences, such as causing lasting physical damage to our bodies. This can be a dangerous way of trying to cope.
Self-harm often serves a purpose, so just trying “nor to do it” can feel impossible. It can be helpful to find out more about the reasons why you self-harm and then try a different behavior instead of harming yourself.
Working out why I self-harm
[ ] To express pain and strong emotion
[ ] To deal with anger
[ ] To feel something when I feel numb and disconnected
[ ] To calm down
[ ] To see blood
Any other reasons:
What are my triggers?
What could I substitute instead of self-harm?
If you self-harm to… express pain and intense emotion, try writing down your feelings, drawing or painting how you feel, writing down difficult feelings then ripping them up, or listening to music which expresses how you’re feeling.
If you self-injure to… deal with anger that you cannot express openly, try working through those feelings by doing something different – running, dancing fast, screaming, punching a pillow, throwing something, ripping something apart.
If you hurt yourself in order to… feel something when you feel numb inside, hold ice cubes in one hand and try to crush them, hold a package of frozen food, take a very cold shower, chew something with a very strong taste (like chili peppers, raw ginger, or a grapefruit peel), wear an elastic rubber band around your wrist and snap it (in moderation to avoid bruising).
If you inflict physical pain to… calm yourself, try taking a bubble bath, doing deep breathing, writing in a journal, drawing, or doing some yoga.
If you self-harm to… see blood, try drawing a red ink line where you would usually cut yourself, in combination with any of the other suggestions above.
Remember, understanding and knowledge are key. Try to make a note of every time you feel the urge to harm yourself. Write down what was happening at that time and what was going through your mind. Also, make a note of what you did to cope, taking care to write down which behaviors you found helpful and which ones were less helpful to channel and soothe your feelings of distress.
Sleeping better: Sleep hygiene
PTSD often affects our ability to sleep. We may have difficulty getting to sleep if we lie in bed thinking about how our life has changed and wondering if things will get better. We may avoid going to sleep for fear that we might have more nightmares. If we do manage to get to sleep we may then wake up after experiencing nightmares. It is normal to have difficulty getting back to sleep.
The tips and ideas below have been selected to try and help you increase the chance of getting better sleep.
1. Bed is for sleeping and sleeping happens at night-time
- Try and keep your bedroom and bed for sleeping only
- Avoid sleeping in the day
- Develop a routine before bed time such as having a relaxing bath or listening to some relaxing music and go to bed at around the same time each night. Try and wake up around the same time each morning. Small children find habits and routines comforting, and the same things work for adults too. As adults, we forget that these things apply to us as well
- If you cannot sleep after 30 minutes, get up and try an activity such as listening to some music. Do this for about 15 minutes then return to bed and try and sleep. Repeat this as often as is necessary until you go to sleep
- Make your bedroom a nice place to sleep – try smells or flowers (or some new bed sheets!)
2. Be kind to your body
- Do not go to bed hungry
- Try and avoid spicy food late in the day as this can act as a stimulant in our bodies
- Reduce caffeine but definitely avoid caffeine after 4pm- remember caffeine is also found in tea and fizzy drinks like pop. You can buy de-caffeinated versions of these drinks if needed
- Although alcohol can initially make us feel sleepy, it stops us from experiencing restful sleep and is not great for PTSD or Adrenal Fatigue. It can also make it harder to fall asleep again, if you wake up in the middle of the night
Sleeping better: Coping with nightmares
Practice calming yourself down after a nightmare by using any of the previous techniques.
Having a card with the information from the tips previously tried may help ground you back in the moment. For example, you may have a card with the phrase ‘I am safe, it is May 2011 and I am in my bedroom’ by your bedside to read after you wake from a nightmare.
Having a picture that reminds you of the present can also be useful to have by your bedside if waking from a nightmare as it will help your brain focus on the present and calm your threat system quicker.
Taking a smell to bed and having it ready can, again, be a useful way to help your brain remember where you are following a nightmare. A calm and soothing smell can also help you get off back off to sleep after a nightmare.
Try: Any of the other grounding strategies that you have developed can be helpful if you wake from a nightmare
Sleeping better: Re-scripting nightmares
If you experience frequent nightmares, especially the same or similar dream over and over, then research has shown that you can ‘rescript’ the nightmare to make it much less powerful. For example, someone who had nightmares about being in a road traffic accident imagined that the road was made of marshmallows and was soft and bouncy.
Spend time in the day thinking of the nightmare but practicing a different ending: an ending you would prefer and that makes you feel safe. Practice the repeat ending over and over in your imagination. The more you can rehearse new ending the better chance your brain has of remembering it. It might also be helpful to talk through your nightmares with someone else. It doesn’t matter how odd the new ending might be, or that it didn’t really happen.
Think about your nightmare from the perspective of a Hollywood script writer:
- Write down your nightmare as though it were a story
- Think about how you would want to feel different if you could change the nightmare
- Change some of the events in the nightmare that would lead to the new feeling
- Write the new ‘script’ for the nightmare. Rehearse it to yourself.
Recovering from PTSD
What we know about PTSD is that symptoms continue because the trauma memory only contains information from the threat system, instead of information from the thinking part of the brain. Because of the distress caused when our threat system gets set off we do our best to avoid thinking or talking about the trauma, or avoiding certain people and places.
Whilst this makes us feel better in the short term, avoidance keeps the trauma memory stuck and means that our threat system continues to get set off at even the smallest sign of danger.
Therapy for PTSD involves reprocessing trauma memories – approaching them instead of avoiding them – and making sense of what they mean. This is often best done with a skilled therapist, when you feel safe and ready enough.
Treatments for PTSD
Many different treatments have been developed for PTSD. Research has shown that they can be extremely effective. The National Institute for Health and Clinical Excellence (NICE) recommends a few therapies :
- Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) Involves talking in detail about the events you experienced. Your therapist will go through the events with you and will help you to make sense of what happened.
- Narrative Exposure Therapy (NET) is suitable for people who have experienced multiple traumas
- Compassion-Focused CBT is helpful for people who experience a lot of shame or self-criticism.
- Eye Movement Desensitization Reprocessing (EMDR) – Involves holding an image of your trauma in mind while your therapist guides you in making specific kinds of eye movements. This method can be effective but the previous 3 methods are the most effective for processing trauma.
Your coach or therapist will be able to talk you through different treatment options.