Rosie McGuire PTSD stands for post-traumatic  stress disorder and this mental health difficulty   develops in some people who have experienced a  shocking, scary or dangerous event. It’s natural   to feel afraid during and after a traumatic  situation. Fear is a part of the body’s fight   or flight response, which is built into our brains  to help us avoid or respond to potential danger.   People may experience a range of reactions  after trauma and most people recover from   initial symptoms over time. Those who continue to  experience problems may be diagnosed with PTSD. Anyone can develop PTSD at any age. Mostly,  people associate this mental health difficulty   with people who’ve fought in war, but this can  happen to people who’ve experienced or witnessed   all sorts of trauma, such as physical or sexual  assault, abuse, an accident or a disaster. Lots   of things can be considered traumatic and  people define trauma in different ways. There are two main diagnostic manuals that are  used by professionals to help them categorise   and diagnose mental health difficulties. These  are the Diagnostic and Statistical Manual of   Mental Disorders, known as the DSM, and the  International Classification of Diseases,   known as the ICD. These manuals define trauma  slightly differently. The DSM specifically   suggests that trauma involves “exposure to  death, threatened death, actual or threatened   serious injury or actual or threatened sexual  violence.” The ICD simply states that the event   must have been “extremely threatening  or horrific” to be considered a trauma. There are events that might not meet these  particular criteria, but which may still   be traumatic for the individual and may lead to  symptoms of PTSD or to other significant mental   health difficulties. Not everyone with PTSD has  been through a traumatic event first-hand. You   can also develop PTSD if you’ve seen it happen to  someone else, or sometimes learning that a family   or friend has experienced trauma can cause PTSD.  It’s now also recognised that people can develop   PTSD from repeated or extreme exposure to  details of a traumatic event experienced   by people that they don’t know, for example,  people that work within Emergency Services. Symptoms of PTSD usually begin within three  months of the traumatic event, but they   sometimes can emerge later. As mentioned in my  initial description of trauma and PTSD, there   are two main diagnostic manuals that are used by  professionals to help them categorise and diagnose   mental health difficulties. These are the DSM and  the ICD. As well as being slightly different in   how they describe trauma, they’re also slightly  different in how they describe PTSD symptoms.   So, to meet diagnostic criteria for PTSD,  a person must “have symptoms for at least   several weeks” according to the ICD and “for  over a month,” according to the DSM. The DSM   also suggests that “symptoms must not be  caused by a medication, substance use or   another illness.” Both manuals state that  “Symptoms must be severe enough to interfere   with aspects of daily life and functioning,”  such as with relationships or work and school. After a traumatic event, it’s natural to  have some symptoms initially. For example,   people may have recurring distressing thoughts,  memories or nightmares about the trauma. However,   if difficulties relating to the trauma  continues a month after the trauma happened,   then a diagnosis of PTSD may be considered. A  mental health professional who has experience   helping people with PTSD, such as  a Psychiatrist or Psychologist,   can determine whether symptoms meet the criteria  for PTSD. There are three groups of symptoms that   are common in both diagnostic manuals, so these  are often considered the core symptoms of PTSD.   These are re-experiencing symptoms, avoidance  symptoms, and arousal and reactivity symptoms. The first group of symptoms, re-experiencing,  include experiencing flashbacks, which is where   a memory of the trauma comes to mind, but it  feels like you’re living the traumatic event all   over again, and it can include physical symptoms,  such as increased heartrate or sweating. Another   re-experiencing symptom is having recurring  memories or dreams related to the event. Thoughts   and feelings can trigger these symptoms, as well  as words, objects or situations that are reminders   of the traumatic event. So, it makes sense that  people with PTSD then might want to avoid those   reminders, and this is related to the second  group of symptoms, called avoidance symptoms.   These include staying away from places, events or  objects that are reminders of the traumatic event   and avoiding thoughts or feelings related to the  traumatic event and therefore, perhaps avoiding   talking about it. Avoidance symptoms can cause  people to change their routines. For example,   they might avoid driving or riding in  a car after a serious car accident. The third group of symptoms relates to arousal  and reactivity symptoms, which are often constant   and can, therefore, have the biggest impact on  daily life. These include being easily startled,   feeling tense or on edge, or feeling irritable,  having angry or aggressive outbursts,   having difficulty concentrating or difficulty  sleeping, and engaging in risky behaviours. The DSM-5, which is the latest version  of that particular diagnostic manual,   also includes a fourth group of symptoms, called  cognition and mood, and these include having   trouble remembering key features of the traumatic  event, having negative thoughts about yourself   or the world, having exaggerated feelings of  blame directed towards yourself or other people,   ongoing negative emotions, such as fear, anger,  guilt or shame, losing interest in enjoyable   activities and feeling socially isolated and  finding it difficult to feel happy or satisfied. Including this final group of symptoms does  increase the overlap with other mental health   difficulties, but it allows for a wider range  of symptom profiles to be classified as PTSD and   also, acknowledges that some of these broader  difficulties may actually be trauma related. Whilst I’ve described the diagnostic criteria  here, I think it’s important to acknowledge   that people find different kinds of meaning in  diagnosis. For some people, it helps them explain   or make sense of the difficult experiences that  they’re having and the impact that that’s having   on their lives. But for other people, they  may feel that it’s stigmatising, reductive,   meaningless, or result in them feeling like  they’re being treated as a set of symptoms rather   than a person. And this is important to consider  when discussing diagnostic labels like PTSD,   especially with the individuals that  are experiencing these difficulties. The most recent version of the International  Classification of Diseases, the ICD-11,   has included a separate diagnosis called  ‘complex PTSD’. Complex PTSD consists of   the same core symptoms of ICD-11 PTSD,  which are re-experiencing, avoidance,   and arousal and reactivity, but it also  has three additional groups of symptoms,   which are sometimes referred to as  ‘disturbances in self-organisation’. These are problems with emotion regulation,   such as marked irritability or anger or  feeling emotionally numb, poor self-esteem,   which can be accompanied by feelings of  worthlessness, shame, guilt or failure,   particularly related to the traumatic event,  and difficulties in sustaining relationships   and in feeling close to other people. Typically,  people experiencing these additional complex   trauma symptoms will have experienced multiple  long-lasting, repeated or continuous trauma. Research has indicated that the diagnosis of  complex PTSD can also apply to children and young   people, as well as adults. One study of young  people taking part in a treatment trial for PTSD   found that 40% of them had high levels of these  additional symptoms required for complex PTSD. It’s typical for children and adolescents to  have a range of reactions after experiencing   or witnessing a traumatic event. Many  of these reactions are normal and will   lessen with time. However, if they persist  for more than a month after the trauma,   it’s possible that some of these behaviours  could be considered symptoms of PTSD. Many of   these symptoms are the same as the core symptoms  of PTSD in adults, which are re-experiencing,   avoidance, and arousal and reactivity. These are  sometimes just a bit different in young people,   depending on their age and development. It’s  particularly helpful for parents and carers   to know about the behavioural symptoms  and then, they can look out for those. So, regardless of age, children and adolescents  may report having physical problems, such as   stomach aches or headaches, have nightmares  or other sleep problems, including refusing   to go to bed, have trouble concentrating,  lose interest in things they used to enjoy,   have feelings of guilt for not preventing injuries  or deaths and have thoughts about revenge. Younger children, typically aged five and below,   may have additional symptoms  related to their development.   So, they may also cling to their caregivers or  cry and be more tearful. They may have tantrums   or be irritable and disruptive. They may suddenly  return to behaviours such as bedwetting and thumb   sucking. They may show increased fearfulness, for  example, fear of the dark or monsters or being on   their own. And they might incorporate aspects  of the traumatic event into imaginary play. Older children, typically aged six and over,  and adolescents, might have more problems in   school. They might become withdrawn or socially  isolated from family and friends. They might   avoid reminders of the event. They might have  difficulty remembering the event or remember it   in the wrong order. They may use drugs, alcohol or  tobacco. They may be disruptive, disrespectful or   destructive, and teenagers especially may be more  impulsive and aggressive, and they may be angry or   resentful. If these symptoms last for more than a  month after the trauma, the family could reach out   to a healthcare provider to investigate whether  the child may be displaying symptoms of PTSD. According to the National Center for PTSD in  the US, about six out of every 100 people will   experience PTSD at some point in their lives.  Women are more likely to develop PTSD than men,   and certain aspects of the traumatic  event and some biological factors,   such as genes, may make some people  more likely to develop PTSD than   others. The cause of PTSD can vary.  Some people recover within six months,   while others have symptoms that last for  a year or even longer. People with PTSD   often have co-occurring difficulties, such as  depression, substance use or anxiety disorders. We have various theories to help us understand how  PTSD may develop. Probably the most well-known,   Ehlers and Clark’s Cognitive [audio cuts out  - 13: 44] TSD [audio cuts out 46] them   identifies “alterations in memory, cognitions  and behaviour” as critical factors which serve   to prolong the experience of PTSD. This model  suggests that a strong feeling of current threat,   despite the knowledge that the trauma they  experience is now in the past, is the key   to the development and maintenance of PTSD.  This results from three overlapping processes:   negative appraisals related to the trauma,  the sensory nature of the trauma memory,   and maladaptive cognitive and  behavioural coping strategies. For people with PTSD, the meaning they make  about the trauma, also called ‘trauma-related   appraisals’, are often very negative. These  appraisals could relate to themselves, such as,   “I’m responsible for what happened to me,”  or “I’m permanently damaged because of what   happened,” or these appraisals could relate to  people or the world around them. For example,   “The world is a dangerous place.” This leads  to poor self-esteem and a feeling of current   threat. In addition, for those with PTSD, their  trauma memories have particular characteristics,   such as being very vivid and sensory,  fragmented, involuntarily recalled   and creating a strong physical or emotional  reaction. These characteristics make the memory   feel like it’s actually happening in the present  moment, rather than being recalled as a memory. It’s thought that trauma memories have these  characteristics when they’ve not been properly   consolidated into the long-term memory, along  with this contextual narrative that helps it   integrate with other autobiographical memories.  This context is what helps us to consciously   remember events and be able to tell the story  about what happened. It’s thought this process   doesn’t happen for people with PTSD because  they’re avoiding memories of their trauma.   Instead, these trauma memories are recalled  unconsciously or involuntarily when a sensory   trigger, such as a sound or smell, reminds  them of their traumatic experience. This   leads to re-experiencing symptoms and also,  ignites that feeling of current threat. The negative appraisals and intrusive memories  are maintained by maladaptive cognitive and   behavioural coping strategies that aim to reduce  current threat, for example, avoidance of thinking   about the trauma or any associated triggers. This  is well intended and is used to prevent the stress   in the short-term, but in the longer-term, this  prevents cognitive change, for example, in how   they feel about themselves and about the threat  around them. And it also prevents change in the   trauma memory, therefore, prevents recovery from  these distressing symptoms of PTSD. Therapeutic   techniques which address these mechanisms form  the basis for effective treatments for PTSD. For some people, PTSD symptoms go away on  their own a few months after the trauma,   but for others they can persist without  psychological intervention. If symptoms   of PTSD do persist and are causing significant  impairment, individuals can work with a mental   health professional to help address and reduce  these symptoms. Treatment can involve therapy,   medication or a combination of both.  A mental health professional can   help people find the best treatment  plan for their symptoms and needs. Some people with PTSD, such as  those in abusive relationships,   may be living through ongoing trauma. In these  cases, treatment is usually most effective when   it addresses both the traumatic situation,  to ensure that they’re in a place of safety,   as well as the symptoms of PTSD. People  who experience traumatic events or who   have symptoms of PTSD may also experience panic  disorder, depression, substance use or suicidal   thoughts. Treatment for these difficulties can  also help with recovery after trauma. Research   also shows that support from family and friends  can be an important part of post-trauma recovery. The National Institute for Health and  Care Excellence put together guidance,   which is known as the NICE Guidelines,  and these are based on research   evidence to suggest what the most effective  treatments are for reducing symptoms. These   guidelines suggest that trauma-focused  cognitive behavioural therapies are   the most effective at reducing PTSD  symptoms in children and in adults. One type of trauma-focused cognitive behavioural  therapy is called cognitive therapy for PTSD,   which is derived from Ehlers and Clark’s  Cognitive Model of PTSD. Cognitive therapy   for PTSD has three key aims that address each  of the processes described in the Cognitive   Model for PTSD. So, firstly, to elaborate  and update the trauma memory in order to   reduce the re-experiencing symptoms. Then  to modify negative appraisals and to change   strategies that maintain the patient’s  sense of threat and simultaneously,   help them to reclaim activities in their life  that promote a sense of worth and meaning. So, different stages of cognitive therapy for PTSD  can include developing specific and measurable   goals for therapy. Developing a formulation which  helps Therapists and patients to understand key   symptoms and how these may be maintained by  maladaptive coping mechanisms. Psychoeducation,   which is where parents – patients learn about what  PTSD is. Encouraging patients to reclaim their   life, developing emotional regulation skills,  encouraging patients to create a trauma narrative,   meaning they’re exposed to trauma memories and  can consolidate and update these. Developing   grounding techniques that engage the senses, so  that the patient can feel more engaged in the   present moment rather than the trauma memory.  Changing probla – problematic appraisals of   the traumas and things that have followed those.  Reducing unhelpful avoidance and safety behaviour,   perhaps by visiting the location where the  trauma happened. Training patients to work out   what triggers they’re re-experiencing, and this  is sometimes called ‘stimulus discrimination’.   Summarising their learning and creating plans  to prevent relapse, and sometimes it can be   really helpful to engage the support system in  therapy sessions, particularly for children,   so that they understand PTSD and how to best  support the patient with their recovery. Sometimes it can seem daunting for someone with  PTSD to tackle their avoidant coping and address   their trauma memories. So, it’s important  for mental health professionals to explain   how thinking or talking about the trauma might  help to reduce symptoms. This can enable people   to make well informed decisions about whether to  consent to, and engage with, interventions that   focus on the trauma. An active engagement  is necessary for processing to take place. Some professionals choose to use metaphors to  explain what happens in this type of therapy   and a common one used is the wardrobe metaphor.  This suggests that you can imagine your memories   as items of clothing in your wardrobe. Usually,  memories are neatly organised, so we know where   they are and can take them out when we want them  and put them back in their right place. But trauma   memories are not neatly organised in the wardrobe.  They’ve been thrown in quickly and have created a   mess that’s going to be difficult to tidy up, so  we avoid it. But this means that the clothes keep   randomly falling out of the wardrobe because it’s  overflowing and it’s difficult to close the door. Therapy like cognitive therapy for PTSD, which  is a type of trauma-focused CBT, it’s like the   Therapist is coming along to help you tidy up your  wardrobe of memories. They help you go through   your memories like clothes and talk about them so  that you have a clear idea of what happened, and   then you can fold them up and put them away neatly  so that you know where to find them in the future.