PTSD

PTSD stands for Post Traumatic Stress Disorder.

PTSD is a psychiatric disorder. It can affect anyone who has been exposed to violent incidents. This may both be something that the person has witnessed or been exposed to personally. Typical incidents that can lead to PTSD are car accidents, acts of war, torture, rape, assault and fire.

A common feature of these incidents is that they have been of such a violent nature that the person has felt that his or her life was in danger Some have actually been in a life-threatening situation, while others have felt that they were. What their experience is does not really matter. What matters is how the danger felt and how the person’s brain has reacted.

A significant characteristic of a person with PTSD is a constant fear of ending up in a traumatic situation again. Therefore, they do everything in their power to avoid anything that reminds them of the trauma.

Another typical feature is that the PTSD sufferer is constantly ‘disturbed’ by reliving the trauma. This produces a myriad of thoughts and feelings that cannot be controlled. Many PTSD sufferers are short tempered and are prone to exaggerated anxiety or anger. However, this does not apply to everyone. Other symptoms may also manifest themselves, such as depression and pain.

The symptoms can make PTSD sufferers feel like they are no longer in control of themselves.  Many PTSD sufferers also find that they are no longer able to recognise the person they used to be. Their belief in their ability to lead a normal everyday life vanishes, and they isolate themselves. This is why it is important to seek professional help – initially from your own doctor. Professional help can alleviate the symptoms of PTSD.

Some people are at greater risk of developing PTSD than others. Although two friends experience the same trauma, it is not certain that they will both develop PTSD. There is no simple explanation of this.

The nature, extent and duration of the trauma are of importance. But the individual person’s interpretation, vulnerability and handling of the trauma also affects the risk of developing PTSD.

Biological, psychological and social factors affect how vulnerable persons are. The more susceptible you are, the less trauma it takes to trigger PTSD.  Abuse, bullying and devastating losses in childhood may increase susceptibility. In adult life, previous experience of many traumatic events may aggravate such susceptibility.

Facts about PTSD

• 20–50% of the population (depending on the country in which they live) will experience at least one serious trauma at some point in their lives. But far from all of them will develop PTSD. 
  
  
• Danish soldiers who have been at war may develop PTSD. Approx. 8% of male and 20% of female soldiers deployed are affected by PTSD.
  
  
• Many refugees who come to Denmark are traumatised as a result of war, persecution or torture.
  
  
• People working in certain sectors are particularly at risk of developing PTSD. These include social workers, police and firefighters.
• In people’s personal lives, rape and domestic violence are the most common cause of PTSD.

Most people will react to a traumatic event, for example with anxiety, sadness or anger. These are perfectly normal reactions to a tough situation.

If the symptoms do not recede within a month, there is a risk of developing PTSD. It is therefore important for family, friends and colleagues to keep an eye on any changed behaviour. If necessary, they can intervene and arrange for professional help.

The first symptoms of PTSD usually manifest themselves 1-6 months after the violent incident. But PTSD may not be triggered until several years later. However, there will generally have been symptoms of anxiety or the like before then. In approximately one in three people who develop PTSD, the condition will become chronic.

To understand PTSD, it is necessary to know a little about the workings of the brain. The brain is the seat of our thinking (consciousness/intellect) and feelings (instincts/impulses). The fact that we have a consciousness capable of thinking and understanding things is unique to us humans compared to other animals, but we share the part of the brain that is the seat of our instincts and feelings – also known as the reptilian brain or brain stem – with animals. The reptilian brain ensures our survival and tells us when something is nice, and when something is unpleasant – or perhaps even threatening enough to require fight or flight.

What characterises a traumatic experience is that a person feels in mortal danger and that there is nothing they can do about it. Thus, the crucial part is not whether the person actually is in mortal danger, or whether they really can get away, but how they perceive the incident at the moment it occurs.

Threats to your life are a matter of survival, so the alarm sounds directly in our reptilian brain. There is no time for when someone has PTSD? rational considerations when someone only has a few seconds to act. The alarm releases large amounts of energy, including stress hormones. Stress hormones prepare the body to be able to run fast, if it needs to flee, or to hit hard if it needs to fight the enemy.

As humans, we were highly dependent on this activation of energy when our forefathers lived as hunters and had to hunt to ensure survival, or combat threats that could destroy us. Wild animals constantly live by these instincts. Animals usually expend this energy through fight or flight – i.e. through violent physical activity.

If there is no possibility of fight or flight, the nervous system has a third survival strategy: “playing dead” or “freezing the body". The hunted animal goes into a kind of paralysis and becomes rigid. The internal driving force – hormone production – continues, but the brakes hold back the reaction. Not until the moment a way out is seen is the storedup energy released from the nervous system, and the animal has extra strength to make its escape.

Whether a violent incident is experienced as traumatic will depend on whether the person is able to emerge from the state of alarm that is still activated in the brain. The more you have felt that your life was threatened, the harder it may be to switch off the state of alarm again. This entails a greater risk of developing PTSD.

The reptilian brain can thus keep a traumatised human in a ‘state of survival’. In this state, you do not recognise rational signals that the dangerous situation has passed. The internal alarm button is activated more quickly, and stress hormones are pumped around in the body. The alarm may be triggered by a thought, an emotion or a memory of what happened.

A state of constant alertness may be extremely tiring. It makes it harder to remember and concentrate. Leading a normal daily life may therefore seem almost impossible.

Things like writing shopping lists, being with friends or watching a film may feel overwhelming. It is as if the balance has shifted so that the past traumatic experiences outweigh the experience of life in the present.

Treatment of PTSD is therefore primarily about restoring the balance so that it becomes possible once again to relate to the present reality and feel safe in it.

Not everyone is affected in the same way by PTSD. PTSD affects people’s emotions, body, way of thinking, behaviour and motivation. Some are affected to a mild extent and experience minor discomfort in their day-to-day lives.

Others may have crippling reactions and suicidal thoughts. Depending on the number, nature and severity of the symptoms, PTSD is classified as mild, moderate or severe. The symptoms of PTSD may be:

• Intrusive memories and flashbacks
  One of the most striking symptoms of PTSD is that the PTSD sufferer is involuntarily taken back to relive the traumatic event. This may happen suddenly and virtually without warning. For example, a smell or sound associated with the trauma can take the person’s thoughts back to the violent event and conjure up moments in his or her mind's eye 
  
  
• Memory and concentration problems
  Some find that their memory and concentration deteriorate, one reason being that all their energies are focused on ‘life, death and survival’. Being constantly in a state of alertness towards sounds and other things that may trigger the return of the trauma is extremely exhausting You forget important everyday routines, cannot remember appointments and have difficulty planning things.
  
  
• Sleep problems and nightmares
  PTSD sufferers may have difficulty falling asleep, or perhaps they wake up frequently or very early. Many wake up with their head full of churning thoughts. They also have nightmares – often several times a night. No matter how much they sleep, they are still tired and out of sorts.
  
  
• Depression
  Depression is often accompanied by feelings of guilt and shame. Self-esteem is low and you have negative thoughts about yourself. Many PTSD sufferers develop a moderate depression. Others are severely affected. Depression may increase the tendency to isolation, making it even more difficult to fight the disease. Suicidal thoughts are also often present.
  
  
• Vigilance and avoidance
  Many experience anxiety. The anxiety may range from easily triggered anxiousness to persistent severe anxiety. PTSD sufferers may tend to flinch at the slightest sound. Their threshold tolerance for noise and sound is therefore very low. They may consequently have a short fuse.
  
  
• Personality changes
  Many experience personality changes after onset of the disorder. This may manifest itself in angry outbursts, irritation or anxiety that the PTSD sufferer is unable to control. These outbursts may seem unprovoked and disproportionate to others and make it difficult for a PTSD sufferer to be around other people. PTSD sufferers may lose the desire to do the things they used to enjoy doing. This is accompanied by a lack of libido.
  
  
• Dissociative disturbances and hallucinations
  Dissociative disturbances are a feeling of unreality. For example, some may feel that their body is unreal. Others act in a trance, where they suddenly wake up in an unknown place, not knowing how they got there. They may also experience hallucinations where they hear voices of people who were involved in the traumatic event. Others experience partial or full memory loss regarding the traumatic event. They have done all they can to repress the event and now they have lost the ability to recall it. However, even though they have temporarily ‘put a lid on it’, they still carry their anxiety within themselves.
  
  
• Physical symptoms
  There are often severe physical symptoms that can be difficult to diagnose and that consequently entail many examinations by the PTSD sufferer’s own doctor and possibly specialists.  The trauma condition and long-term anxiousness are a strain on the body and may have far-reaching consequences. Frequent symptoms are palpitations, chest pain, difficulty swallowing, stomach trouble and bodily aches and pains. There is also an increased risk of diabetes, high blood pressure and arthritic conditions.
  
  
• Abuse problems
  Substance abuse – especially of alcohol or anti-anxiety drugs – is quite frequent. It complicates treatment as it diminishes the ability to solve problems. Substance abuse is also documented to be damaging to health.

PTSD can be difficult to diagnose. The reason is that many people with PTSD go to their doctor to be treated for something else such as anxiety, incapacity for work, palpitations, stomach aches and other physical symptoms.  

The cause of these symptoms cannot be directly explained and it is not immediately linked to the traumatic events. This is especially the case if the traumatic events happened many years ago. To make the diagnosis, the psychological strain to which the person has been exposed must also have been of a life-threatening nature.

Central Denmark Region has one specialist clinic for treatment of PTSD: Clinic for PTSD and Anxiety in Aarhus. The clinic also has a department in Herning. The Aarhus clinic treats people who have developed PTSD as a result of sexual assault and violence.

PTSD is a complex diagnosis. The persons’ emotional life, body, thoughts and behaviour are affected. To achieve the best possible treatment, it is therefore necessary for specialists from several different disciplines to contribute their knowledge.

Some of the healthcare professionals you will meet in connection with your treatment are:

• Specialists
• Psychologists
• Physiotherapists
• Nurses
• Educators
• Cultural workers/interpreters

The diagnosis is made on the basis of in-depth consultations, special interviews and physical examinations. The physical examinations include blood tests, scans etc. During the interview, your symptoms, their degree of severity and duration are identified and assessed.

It is also examined whether you have previously had physical or psychological traumas. You are also asked if you have other mental disorders. This may be anxiety, depression, compulsive thoughts or compulsive actions. Next-of-kin can often contribute important information in this connection.

Unfortunately, there is no easy solution, and there is no single special type of therapy that everyone can point to and say: “That’s what works”.

A thorough diagnosis is therefore important in order to be able to start the correct treatment. The objectives of the treatment are:

• to reduce your psychological and physical symptoms and improve your quality of life.
• to establish a good basis for future support from your own doctor, specialist and social services.
  
  

Contents of the treatment
A course of treatment at the Region's clinics typically starts with a preliminary consultation to assess whether you have PTSD.  The nature and severity of your symptoms are identified. We then prepare a course of treatment tailored for you.

The course of treatment may be a combination of several approaches, which will often include:

• Consultations
• Teaching
• Psychotherapeutic treatment
• Medical treatment
• Physiotherapy
• Social counselling
• Educational guidance

When treating refugees and other people of a different ethnic background, there is also focus on cultural aspects that require special consideration. A specialised course of treatment typically lasts 4–6 months with 1-2 sessions per week.

You and your relatives will be offered training in relevant aspects of PTSD. It is important to know as much as possible about the disease. This makes it possible to deal with the symptoms, manage them and, if possible, reduce their recurrence.

There are many types of psychotherapy. Cognitive therapy and exposure therapy have proved to be particularly effective in treatment of PTSD.

Cognitive therapy focuses on your thoughts, feelings and behaviour. The psychologist will help you identify what creates negative thought and behaviour patterns. Together, you will systematically try to challenge and change them, including through small homework assignments.  The homework assignments are to help you try out other ways of thinking and acting. 

In exposure therapy, you learn to confront your traumatic memories under controlled conditions. By repeatedly confronting the feared situation, whether imagined or real, your anxiety is reduced, and you gradually regain a greater sense of control. This will give you a more realistic view of the trauma and enable you to adjust your reactions accordingly.

The physiotherapist adopts a physical approach to the treatment of PTSD. A well-documented treatment method for the relief of tension and pain is Basic Body Awareness Therapy (B-BAT).

B-BAT aims to create harmony and peace in body and soul. It can give you increased self-confidence.

The work includes:

• Breathing techniques
• Balance training
• Relaxation 
• Massage

B-BAT exercises are done lying down, seated and standing and are adapted to your needs. By learning how to recognise your body’s signals, you become better at recognising your own limits and needs. You become better at stopping, being present in the moment and mindful. This reduces stress, anxiety and agitation.

Medicine is often needed to treat PTSD. Anti-depressants and sedatives act on some of the chemical imbalances in the brain.

One effect of the medicine is to normalise the level of the stress hormone cortisol. The medicine can also create a balance of the level serotonin and norepinephrine, which are the neurotransmitters of the brain. They are important to concentration, memory, anxiety and depression. A normal level of these substances is also important in normalising your daily rhythm.

It may take up to 4–6 weeks to establish whether the medicine is working. It is sometimes necessary to increase the dose or try a new type of drug if the desired effect is not achieve or you experience unpleasant side effects.

There is a risk that symptoms of PTSD will return later in life. It is therefore important to prevent recurrence. Prevention is part of the professional treatment, but there are also some things you can do yourself to minimise the symptoms:

• Be aware of pressures and early warning signs
  It is important to talk in depth about your traumatic experiences. This will enable you to put them behind you. It may also make it possible for you to try to avoid similar difficult situations, or you can learn to handle them in a new way. 

  If you are able to identify early signs of the symptoms that manifest themselves, this will make it easier to seek help in time. Early signs of PTSD may be that you start having anxiety attacks, that you find it difficult to remember things or that you notice changes in your personality. You can get help to recognise early warning signs, triggering situations and useful strategies via consultations with a doctor, nurse or psychologist.

• Involve your family
  

  Your family plays a key role in the preventive work. Family members can participate in consultations while you are being treated. They can acquire knowledge about the disease, its course and treatment. It is also a good idea that they receive guidance on how best to act in the different phases of the course of treatment. 

  Your family can also contribute important knowledge. They are often the first to notice initial changes in behaviour. If any new symptoms of PTSD start to manifest themselves, they can support you by responding appropriately and helping you seek help. 

• Medicine
  

  Medicine can help reduce the risk of recurrence. It is common to consider whether to stop taking the medicine once you feel better again. However, it is important that you follow your doctor’s instructions about both the dose and length of treatment. If you experience any unpleasant side effects, you must seek a solution in consultation with your doctor.

  It is generally advisable to continue with your medical treatment for at least six months to a year after the symptoms have receded. Recommendations as to the duration of treatment depend especially on the severity of the condition. Some PTSD sufferers need medical treatment for several years. Others need medicine for life.

Make use of your network

• Seek support among the people you feel safe with. A feeling of safety is essential in getting better.
  
  
• Do not be afraid to tell them what you need, whether it is practical help or a good listener.
  
  
• Tell them what happened, once you are ready to do so. Dealing with negative thoughts and nightmares on your own is unpleasant.
  
  
• Do not worry about being a burden and do not avoid saying something that can upset others.
• Do not keep it to yourself if you continue not to feel well. You may risk having chronic after-effects in a worst-case scenario. Take stock of your situation after a month: if you are still not feeling well, you need to ask for help.

Seek professional help

• Use the professional help available to you. A consultation with a psychologist, for example, can help you make sense of your many scattered thoughts, and many experience that they feel better afterwards.
  
  
• Comply with your medical treatment. Do not stop taking your medicine without having discussed this with your doctor.
  
  
• Learn to recognise your disorder. Your doctor and psychologist can help explain your symptoms and give you tools to deal with them.

Accept that you are having a hard time

• Allow yourself to fail. Everyone makes mistakes.
  
  
• Accept your reactions. You may feel that you have lost ‘control’ of your life. Your feelings may be more overwhelming than any you have experienced before. Your body may react with pain, discomfort and agitation.
  
  
• Demand less of yourself and take it easy. You will have less energy for a while. Find places and experiences that can give you ‘peace of mind’. Include breaks and rest in your everyday routine.
  
  
• You should address attention and memory problems. Write notes, use your diary, tablet/iPad or mobile phone and tell other people about your difficulties.
• Slowly return to your everyday routines. Managing small, practical tasks can give you a feeling that it is possible to get back to normal.

Try to lead a healthy life

• Exercise and do other activities that interest you This could help alleviate negative thoughts and reduce stress and discomfort.
  
  
• Avoid euphoric substances and large amounts of alcohol. It can prevent your treatment from working and increase the risk of more symptoms.
• Make sure to sleep well and eat a healthy diet.

It can be a challenge being close to someone who suffers from PTSD. It is often very difficult to watch someone you love having a hard time. Sadness, frustration and anxiety are common responses among family members. They want to support the person who is ill, but at the same time they have to take care of their own daily lives. The result may be that they end up feeling tired and exhausted.

What can you as a relative do for yourself?

If you are to support someone suffering from PTSD, you also need to take care of your own needs. You must therefore try to lead as normal a life as possible. You must accept that you will not always have the energy to provide help. No one can be present, positive and available all the time.

You may need to take a short or longer break at times. It helps if you can share the responsibility with other relatives so that you do not have to shoulder the responsibility alone. As well as contact with therapists, you might benefit from attending patient and carer associations.

If you feel emotionally overburdened or that you are developing symptoms of depression, you should consult your own doctor for help. In some cases, you can get a referral to a practising psychologist with health insurance reimbursement. Relatives of soldiers can seek help from the Danish Veteran Centre.

How you can help:

• Make it clear that you are available, and that the PTSD sufferer is not a burden. 
  
  
• Be patient. At times, the person may be withdrawn and dismissive. That does not mean that your help is not needed.
  
  
• Do not force the PTSD sufferer to talk about the traumatic events if he/she does not want to.
  
  
• Take time to listen if there are any signs that he/she is ready to talk about what happened. Make sure you can talk without being disturbed.
  Keep listening. The PTSD sufferer may need to tell his/her story many times. It is part of the healing process.
  
  
• Do not hold back because you are afraid the PTSD sufferer may start to cry. Crying is perfectly natural and serves as a release mechanism.
  
  
• Do not hide your feelings because you are supposed to be the strong one. It is OK to show that you are affected by the situation.
  
  
• Avoid saying things like “It will all work out” and “Well, life goes on”.
  
  
• Help the PTSD sufferer remember important information and structure his or her everyday life. Take care of daily chores. They can seem overwhelming and irrelevant to the PTSD sufferer.
  
  
• If there are children in the family, it will be a big help if you are able to take care of them.
  
  
• Offer to help with contact to doctor, psychologist and social services.
  Search for information about PTSD, learn about the disorder, key symptoms and treatment options.