Post Traumatic Stress – An NHS self help Guide
The written version of this guide was Commended at the British Medical Association Patient Information Awards 2014.
These are the thoughts and feelings of two people who have experienced traumatic incidents.
“I feel terrible, very restless and irritable. This is not like me at all. The car crash happened six months ago but I still can’t feel safe in a car, I feel so fearful I avoid travel wherever possible. Pictures of the accident come flashing into my mind, they won’t go away and even at night my dreams are more like nightmares with scenes of the crash happening again and again … I’m exhausted by it …”
“My whole view of life has changed, I keep thinking why us? I feel very guilty thinking that I should have done more to save my friend who died. I relive the experience all the time, I keep thinking, “if only I had done this”, “if only I had done that”…, I am very low and depressed some of the time…, I think I could have died …, I can’t think of the future …, I feel helpless …”
If you have suffered from a traumatic experience yourself you may have had similar feelings.
This guide is written by psychologists and aims to help you understand these and other common reactions to trauma and offers some practical suggestions to help you cope. You may find some of the other guides in this series helpful such as depression and low mood and sleeping problems.
What is a traumatic incident?
A traumatic incident can be anything that is out of the ordinary range of daily events and is deeply distressing to someone.
Many things can have this impact. It could be a fire, a serious accident, a robbery or burglary, an attack, being a witness to a traumatic event such as a death. This could happen anywhere: at home, on holiday, during a war or conflict situation. It can be physical or sexual abuse including childhood or domestic abuse. It could be torture. It can be large scale such as a major disaster involving many people or a personal event involving yourself, friends or family members. It can also be trauma related to serious health problems or childbirth experiences. Such as admission to intensive care or trauma during childbirth and neonatal death.
How do people react after a traumatic incident?
The following are some of the reactions you may experience after a traumatic event. In general people’s reactions will fall into the following groups:
- Reliving the trauma in your mind and body.
- Avoiding things to do with or related to the trauma.
- Feeling more tense, irritable or over-alert than usual.
- Feeling depressed, crying.
It may help you to check to see if you are experiencing any of these symptoms.
- Reliving the trauma in your mind and body
– Having unwanted pictures or images of the trauma (often called flashbacks) coming into your mind; these feel like the event is happening again now.
– Having upsetting dreams about the trauma or dreams about other things that frighten you.
– Feeling that the trauma is happening again – strong sensations of reliving the trauma.
– Feeling very distressed at coming across situations or feelings that remind you of the trauma.
– Having bodily physical reactions including pain or pressure but not necessarily realising that these relate to trauma.
– Experiencing distressing physical reactions, e.g. heart beating faster, dizziness etc. when you are faced with memories of the trauma or situations that remind you of it.
- Avoiding things related to the trauma and numbing
– Trying to avoid thoughts, feelings and conversations about the trauma.
– Avoiding activities, places or people that remind you of the trauma.
– Being unable to remember things about the trauma.
– Having periods of your life that you cannot recall.
– Losing interest in life, feeling detached from others or not having your usual feelings.
– Not feeling you will have a normal future – you may feel as though you are ‘living on borrowed time’
- Feeling more tense and irritable than usual
– Feeling angry or irritable
– Not being able to concentrate
– Finding it difficult to fall asleep
– Feeling over-alert all the time and easily startled.
Post-traumatic stress reactions can affect you in at least four different ways:
- How you feel.
- The way you think.
- The way your body works.
- The way you behave.
It may help you understand how you are feeling by making a note of any of these symptoms you experience regularly:
How do you feel?
- Isolated and alone
- Anxious, nervous, terrified or frightened
- Feeling guilt or shame about what has happened
- Tense, uptight, on edge, unsettled
- Unreal, strange, woozy, detached, dissociated
- Feeling emotionally numb
- Depressed, low, at a loss
- Feeling angry
- Feeling jumpy or restless
- Easily startled/on guard
What happens to your body?
- Heart races and pounds
- Chest feels tight
- Muscles are tense/stiff
- Feel tired/exhausted
- Body aching
- Feel dizzy, light headed
- Feel panicky
- Cry often
- Stomach churning
- Unable to sleep
How do you think?
- Experiencing flashbacks – pictures of the trauma coming into your mind Struggling to concentrate
- Worrying constantly
- Blaming yourself for all or part of the trauma
- Struggling to make decisions
- Having critical or angry thoughts
- Racing thoughts
- Having nightmares
- Thinking back over the event in particular having “what if….” and “why…” thoughts
What you do
- Pace up and down
- Avoid things that remind you of the trauma
- Struggle to sit and relax
- Avoid people
- Avoid being alone
- Are snappy and irritable
- Have problems in your relationships
- Drink/smoke more
- Depend on others too much
“I can’t trust people anymore”
“Other people want to harm me and the world is dangerous”
“It was my fault – I am to blame”
“I’m cracking up”
“I’m going to have a heart attack”
“It’s controlling me”
“I can’t cope”
“I should have died”
“Why did it have to happen?”
“I can’t see the point anymore”
“I can’t control the thoughts”
Why do we react so strongly to trauma?
There are many reasons why trauma leaves such a strong impact on us emotionally.
Firstly, it often shatters the basic beliefs we have about life: that life is fairly safe, secure and predictable, that life for us has a particular form, meaning and purpose. It may be that the image that we have of ourselves is shattered, we may have responded differently in the crisis from how we expected or wanted to behave.
Secondly, trauma usually occurs suddenly and without warning. We have no time to adjust to this new experience. It will usually be outside our normal range of experience and we are faced with not knowing what to do or how to behave. You may have felt you were going to die, people around you may have died, and you are shocked. In the face of this danger your mind holds on to the memory of the trauma very strongly, probably as a natural form of self protection to ensure you never get into that situation again. The result of this is that you are left with the post-traumatic reactions described.
For most people the reactions will have reduced or disappeared within a few weeks but for some people they can continue. For others the reaction does not start immediately after the traumatic event but begins after a delay.
What can I do to help myself overcome the trauma?
It is important to understand that the reactions you are experiencing are very common following trauma, they are not a sign of ‘weakness’ or ‘cracking up’. The following suggestions may help you begin to cope with the post-traumatic reactions.
Things that we describe which may help you are:
- Making sense of the trauma
- Dealing with flashbacks and nightmares
- Overcoming tension, irritability and anger
- Overcoming avoidance
- Overcoming low mood
Making sense of the trauma
Try and find out as much as you can about what really happened. This will allow you to piece together a picture and understanding of the event more clearly. This can help you in your recovery.
If others were involved, talk to them and ask them their views of events. Other victims, helpers from the rescue service, or passers-by, may all be people who would help you gain a broader view of what happened. The rescue services are usually happy to help you in these circumstances.
It may help you to think it through with other people. You may feel the trauma has altered your whole view of life, it is helpful to try and clarify how you now feel and talking can help you do this.
Some people talk to a friend, family member or partner, others may approach their doctor to seek some counselling or psychological therapy. Other people have found that it helps to write down their experiences.
Try to spend a few minutes thinking of ways that you may be able to make sense of what you have been through. Try and write down some ideas. For example:
- People to speak to in order to find out more
- People to talk it over with
- Things you may do yourself, such as writing down your experiences
Flashbacks and nightmares
People may find that they continue to be troubled by intrusive unwanted pictures of the trauma in their mind (flashbacks) and by unpleasant dreams or nightmares related to the trauma.
One of the best approaches which has been found to reduce flashbacks and nightmares is to make time each day for reviewing and going over and facing the unpleasant memories or nightmares. This may feel frightening, but research has shown that this review of memories does reduce the intensity of these experiences.
You could put 20 minutes aside each day to calmly think over, talk over or write down notes on the trauma. Unwanted flashbacks and nightmares should gradually become less powerful and less frequent. If you have nightmares, it may help to do this soon before you go to bed. You could do this until the memories or nightmares are less strong.
This process can allow you to regain some control over these thoughts rather than them intruding upon you. It is important to try and remember to focus on some of the positive parts of your current situation when looking back over the trauma you have experienced.
Try the following approaches:
- Write down details of the flashbacks or nightmares you experience
- Find a time of day when you could think over what has happened. This should be in a safe calm environment
- Think of some positive things about your current situation: for example, “I survived it and I’m still here”, I have good friends to support me”, “I can now begin to plan for a new future”.
Once you have made sense of the trauma it is important not to spend a lot more time thinking about the event. Spending a lot of time thinking “what if” or “why” can trigger flashbacks and other symptoms. You can try and reduce this ‘rumination’ by distracting yourself and focusing your attention where you choose. If you find your mind going over and over the event, try shifting your attention elsewhere. Try to look around you. Chose three objects and slowly and on purpose study each of them for 3 minutes, notice the details, the colour, shape, edges, texture of these objects. Distraction doesn’t usually work instantly, and you may need to work at this for at least three minutes before symptoms will begin to reduce.
Distraction is not about trying to push thoughts of the trauma out of your mind, which is unlikely to work, and can in in fact
make things worse. Neither is distraction about avoidance, but is a technique that can help us control where we wish to focus our mind. Another technique which may be helpful in managing flashbacks, mindful breathing, is described later in the guide.
If you are struggling with flashbacks or feeling detached from the here and now you can use grounding techniques to help you move back into the present moment. Find an object that helps to remind you that you are in the here and now, it should not connected in anyway with the trauma. The object should feel nice to hold, it could be a small seashell, a pebble or an acorn. Spend a few minutes each day looking at the object and feeling its weight, look at is colour and size and connect this with the idea that this object represents the here and now. Practice saying to yourself, that was then, this is now. When you have a flashback, take out your object and remind yourself of where you are saying, that was then, this is now. Carry the object with you.
An object that engages as many of the five senses as possible is better. Can you think of a grounding object that would work for you?
- Sight – you could focus on things around you, the colors and the textures. Or maybe a photograph of something recent to bring you back into the present moment.
- Sound – focus your attention on loud or soothing music, or birdsong or the voice of someone your trust.
- Touch – you could touch something soft and silky or something smooth and cold and focus on this.
- Smell – sniff a strong smell which can bring you in to the present – perfume or nice smelling oils can be a good choice.
- Taste – try tasting something strong – a strong mint or chilli or lemon can bring you in to the here and now.
Overcoming tension, irritability and anger
Tension, irritability and anger are common aspects of a post-traumatic reaction. There may be physical symptoms too including breathlessness, heart racing, over-breathing, dizziness and muscle tension. Try the following ways of reducing physical symptoms.
In order to reduce the severity of physical symptoms it is useful to ‘nip them in the bud’, by recognising the early signs of tension.
Once you have noticed early signs of tension you can prevent anxiety becoming too severe by using relaxation techniques. Some people can relax through exercise, yoga, listening to music, watching TV, or reading a book. Others might find relaxation classes more helpful or listening to a recording of relaxation exercises.
For others it is most helpful to have a set of exercises to follow.
The following exercise teaches deep muscle relaxation, and many people find it very helpful in reducing overall levels of tension and anxiety.
Deep muscle relaxation – it is helpful to listen to the instructions first and eventually to learn them. Start by selecting a quiet, warm, comfortable place where you won’t be disturbed. Choose a time of day when you feel most relaxed to begin with. Lie down, get comfortable, close your eyes. Concentrate on your breathing for a few minutes, breathing slowly and calmly: in, two-three and out, two-three. Say the words “calm” or “relax” to yourself as you breathe out. The relaxation exercise takes you through different muscle groups, teaching you firstly to tense, then relax. You should breathe in when tensing and breathe out when you relax. Starting with your hands, clench one tightly. Think about the tension this produces in the muscles of your hand and forearm.
Study the tension for a few seconds and then relax your hand. Notice the difference between the tension and the relaxation. You might feel a slight tingling, this is the relaxation beginning to develop.
Do the same with the other hand.
Each time you relax a group of muscles think how they feel when they’re relaxed. Don’t try to relax, just let go of the tension. Allow your muscles to relax as much as you can. Think about the difference in the way they feel when they’re relaxed and when they’re tense. Now do the same for the other muscles of your body.
Each time tense them for a few seconds and then relax. Study the way they feel and then let go of the tension in them.
It is useful to stick to the same order as you work through the muscle groups:
- Hands – clench fist, then relax.
- Arms – bend your elbows and tense your arms. Feel the tension, especially in your upper arms. Remember, do this for a few seconds and then relax.
- Neck – press your head back and roll it from side to side slowly. Feel how the tension moves. Then bring your head forward into a comfortable position.
- Face – there are several muscles here, but it is enough to think about your forehead and jaw. First lower your eyebrows in a frown. Relax your forehead. You can also raise your eyebrows, and then relax. Now, clench your jaw, notice the difference when you relax.
- Chest – take a deep breath, hold it for a few seconds, notice the tension, then relax. Let your breathing return to normal.
- Stomach – tense your stomach muscles as tightly as you can and relax.
- Buttocks – squeeze your buttocks together, and relax.
- Legs – straighten your legs and bend your feet towards your face. Finish by wiggling your toes.
Don’t try too hard, just let it happen. You may find it helpful at first to get a friend or family member to listen to the instructions with you.
To make best use of relaxation you need to:
- Practice daily.
- Start to use relaxation in everyday situations.
- Learn to relax without having to tense muscles.
- Use parts of the relaxation to help in difficult situations, e.g. breathing slowly.
- Develop a more relaxed lifestyle.
There are a wide range of relaxation CDs available to buy. There are also many websites where you can download relaxation instructions for free. Some examples can be found in the written version of this guide.
Remember, relaxation is a skill like any other and takes time to learn. Keep a note of how anxious you feel before and after relaxation, rating your anxiety 1-10.
Over-breathing is very common when someone becomes anxious, angry or irritable. This means that changes occur in their breathing. They can begin to gulp air, thinking that they are going to suffocate, or can begin to breathe really quickly. This has the effect of making them feel dizzy and therefore more anxious.
Try to recognise if you are doing this and slow your breathing down. Getting into a regular rhythm of “in two-three and out two-three” will soon return your breathing to normal. Some people find it helpful to use the second hand of a watch to time their breathing. Other people have found breathing into a paper bag or cupped hands helpful. For this to work you must cover your nose and mouth.
It takes at least three minutes of slow breathing or breathing into a bag for your breathing to return to normal.
This is a slightly different approach to managing the symptoms of PTSD. The goal of mindful breathing is to develop a calm, non-judging awareness that allows us to notice thoughts and feelings without getting caught up in them. It can help us to become more self-compassionate and kind to ourself. In mindful breathing we use the breath to anchor us in the here and now to help bring our awareness to the present moment, rather than the past or the future. Much of our anxiety is linked to thoughts and feelings about the past and the future. In PTSD these thoughts can trigger flashbacks, so learning to focus on the here and now can be very helpful.
To practice mindful breathing follow these instructions:
- Find a quiet space where you won’t be disturbed. Sit comfortably, with your eyes closed or if you struggle to close your eyes, fix them in a point on the floor in front of you.
- Try to sit as if you were paying attention to something important with your back straight. Bring your attention to your breathing. Notice where you experience the breath, in your body. It might be in your nose, tummy or chest.
- Notice the natural, gentle rhythm of your breathing as you breathe in and out, and focus only on this.
- Thoughts will come into your mind, and that’s okay, because that’s just what the mind does. Just notice those thoughts, then bring your attention back to where you notice your breathing.
- You may notice sounds, physical feelings, and emotions, but again, just bring your attention back to your breathing.
- Don’t follow those thoughts or feelings, don’t judge yourself for having them, or analyse them in any way. It’s okay for the thoughts and feelings to be there. Just notice them, and let them drift on by; bringing your attention back to your breathing.
- Whenever you notice that your attention has drifted off and is becoming caught up in thoughts or feelings, simply note this has happened, and then gently but firmly bring your attention back to your breathing.
- Thoughts will enter your awareness, and your attention will follow them. No matter how many times this happens, just keep bringing your attention back to your breathing. If you are very distracted it might help to say ‘in’ and ‘out’ as you breathe.
The more you can practice this exercise the better. Even 5 minutes a day can help your anxiety and reduce your symptoms. There are many websites where you can download mindful breathing exercises free of charge. Some examples can be found in the written version of this guide.
Whilst relaxation and breathing exercises can help reduce anxiety it is vitally important to realise that anxiety is not harmful or dangerous. Even if we did not use these techniques, nothing awful would happen. Anxiety cannot harm us, but it can be uncomfortable. These techniques can help reduce this discomfort.
It may be worth talking over your feelings of anger with those around you. Your anger is not really directed at them but may at times be ‘taken out’ on them. Let them know that the anger is because of what you have been through. Ask for their patience until the anger and irritability passes, tell them not to ‘take it personally’. If anger is a problem, you may find the guide in this series ‘Controlling Anger’ to be useful.
Some people who have experienced trauma are left feeling worthless, inferior and to blame. These feelings can be accompanied by deep feelings of guilt, shame or failure. It is very important to recognise this and to begin to develop self-compassion. Self-compassion involves becoming more kind and understanding towards yourself, recognising and being mindful of negative self-judgement. You need to accept that you are not to blame, and that you did not deserve what happened.
Avoidance following a traumatic experience can take many forms. It can involve avoiding talking about the trauma, avoiding becoming upset about the trauma, it can also be that you avoid anything, anyone or any situation that reminds you of the trauma. This avoidance prevents you from ‘moving on’ from the trauma and in some cases it can prevent you getting on with your life in a normal way.
Try to recognise the things you are avoiding. It may help to write them down.
Set yourself very small goals to tackle these fears. We call this an ‘anxiety ladder’. Those situations that we only fear a little are at the bottom and our worst feared situations are at the top.
This example may help you.
Mary was held up at gunpoint when she worked as a cashier at a bank. She can no longer go into small offices in public places, she avoids all television programs and newspapers where there may be reports about violet incidents. She has made up the following anxiety ladder.
Mary’s least feared situation, step 1, is looking at newspaper reports about the attack.
Step 2 is looking at the 6 o’clock news.
Step 3, watching ‘Crime Watch’.
Step 4, standing outside a local building society.
Step 5, going into a local building society.
Step 6, going into a bank in a busy area.
Her most feared, step 7, is going into the bank where the attack occurred.
She will begin with step 1 (looking at newspaper reports about the attack) and gradually work towards step 7 (going into the bank where the attack occurred). She will find that her anxiety will gradually reduce as she tackles each new step and she begins to overcome her avoidance.
It may help to try and make your own anxiety ladder.
Remember you may feel anxious at first, but if you are able to stay in the feared situation you will gradually begin to feel calmer. It is important not to leave the feared situation until you feel calm.
Overcoming low mood
People often experience low mood following trauma. This can sometimes give rise to feelings of low self-worth, reduced confidence, helplessness and guilt.
It is important not to let any gloomy or negative thoughts go unchallenged. Following trauma, people tend to think and expect the worst of themselves, their life and the future. If this is the case for you, don’t just accept these thoughts. Remember, a thought isn’t a fact, and thinking something doesn’t mean it’s true. To challenge your thoughts try to:
- Identify when your mood is very low.
- Write down the unpleasant thoughts you are having during that time.
- Try and counter these thoughts by writing down arguments against them. Imagine what you would say to friends if they had such negative thoughts about themselves. This is particularly important if you are feeling guilt.
It may also help to keep a diary of things you have enjoyed or achieved during the week. This can help you to concentrate on the good things rather than the bad things in your life.
Do something active
Physical activity is particularly helpful. Walk, run, cycle, skip; anything which begins to increase your activity can help to improve how you feel. Plan 15 or 20 minutes of activity every day, or every other day to begin with. This kind of physical activity can actually begin to make you feel less tired, and can lift your mood.
Find something that interests you and spend some time on it. Plan to focus on things you usually enjoy and build some time into each day for these activities. You might find it helpful to take up a new interest. Some people find that creative activities that help them to express their feelings such as painting, writing poetry or playing music, can help them to feel better.
Look after yourself
Resist the temptation to cope with your low mood or anxiety by drinking alcohol, misusing medication or turning to illegal drugs. These may give some immediate relief but quite soon create further health and psychological problems for you to cope with. Eat well; a good diet can help to keep you in good health so recovery is easier. Try and ‘treat’ yourself to things you normally enjoy.
Should I consider taking prescribed medication?
NICE (National Institute for Health and Clinical Excellence) recommends talking therapy for the treatment of PTSD, but also suggests that antidepressants and other medications should be considered for treating PTSD in adults if talking therapies, such as cognitive behavioural therapy (CBT) have not been found helpful, if you are very depressed or if you would prefer medication to a talking therapy. Prescribed medication and talking therapy can work well together. Medication could be prescribed by your general practitioner or by a psychiatrist.
What further help is available?
We hope the suggestions made in this guide are helpful to you. They are based largely on Cognitive Behavioural Therapy, one of the recommended treatments for PTSD. Distress following trauma usually fades with time. However if you feel that you are making little progress then you should seek further help to aid you in overcoming your problems. This would normally be with your GP in the first instance. Consider this in particular if your work performance or relationships are being badly affected, you feel you are no longer coping, or you have had any thoughts of harming yourself. Your GP may refer you for a talking treatment.
The talking treatments that are recommended by NICE (the National Institute for Health and Care Excellence) are Trauma-focused Cognitive Behaviour Therapy (CBT), Eye Movement Desensitization and Reprocessing for non combat related trauma (EMDR), Cognitive Processing Therapy, Narrative Exposure Therapy and Prolongued Exposure Therapy. Therapists delivering these treatments need to have special training and accreditation to practice.
Trauma-focused CBT is a talking treatment which helps clients to make sense of and come to terms with traumatic events. In this therapy you will be asked (when you are ready) to talk about what has happened. The therapy focuses on developing a shared understanding of how thoughts, feelings, behaviour and bodily symptoms interact to keep our problems going. Talking the trauma through helps people to come to terms with it, the therapy also helps manage their problems by helping them to find more helpful ways to think and behave, as described in this guide. In Cognitive Processing Therapy, people are taught to challenge their beliefs and assumptions about why the trauma occurred, as well as the effects on the way they behave and view themselves and the world.
EMDR is another trauma-focused therapy; compared to CBT it is less reliant on talking about what happened. EMDR uses eye movements to process traumatic events. The therapist will ask the person to hold the trauma in mind, and then simply instruct them to hold their head still, while they follow their fingers moving them from left to right. This process is repeated until the distress associated with a memory reduces.
Narrative Exposure Therapy is a form of therapy where the person is helped by the telling of their story and a timeline is created in which they can begin to make sense of what has happened to them. The memory is rebuilt and distress will reduce as a result.
In Prolonged Exposure Therapy the goal is to allow processing of the traumatic memory and to reduce distress and avoidance. Memories and situations that have been avoided are revisited with the help of the therapist.
You can look at the NICE website for further detail of these treatments. There are other websites, listed in the references, that might be useful such as the BABCP and the EMDR Association.
Where can I find further help?
As mentioned, your GP is the best person to talk to in the first instance. He or she will have information about local services which may be able to help.
A list of useful contacts, books and references are available in the written version of this guide.
Written by Dr Lesley Maunder and Lorna Cameron, Consultant Clinical Psychologists.
Many thanks also to Kevin Meares, Consultant Clinical Psychologist in Trauma, Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust.
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust has developed this resource with the support of NHS healthcare staff, service users and local voluntary sector groups.