Post-traumatic stress disorder (PTSD)

Post-traumatic stress disorder is characterized by

• Distressing thoughts: The person relives the experience over and over again. They are often suddenly overwhelmed by vivid memories that they can’t control, known as flashbacks. The images and feelings during flashbacks are so real that it’s as if they are experiencing the traumatic event all over again. A lot of people with PTSD have recurring nightmares. Flashbacks and dreams can make them feel scared, helpless, threatened, guilty and ashamed again, and also cause physical symptoms such as pain.
• Hyperarousal: People who have PTSD are particularly alert and often constantly on edge: They have trouble sleeping and concentrating, and are irritable and impulsive. They also react very strongly to things that remind them of the traumatic experience, such as certain smells, sounds or images. This can lead to a racing heart, chest tightness, shortness of breath and trembling.
• Avoidance: People who have PTSD avoid situations, places or people that remind them of the traumatic experience and could trigger memories and flashbacks. This also includes certain activities, thoughts or conversations. Some people become withdrawn or lose interest in things that used to be important to them. Many feel like a stranger in their own life. Some suppress the memories so much that they can no longer remember significant parts of the traumatic experience. PTSD can also make you feel emotionally numb. It is often not possible to make sense of and process what happened.
• Negative thoughts and mood: Many people lose faith in themselves and others. They often have very low self-esteem, and consider themselves to be weak and helpless. Many torture themselves with questions such as the following: Why did it happen to me? How could I have prevented it? Was it (partly) my fault? Some are also very irritable or constantly angry. They may be angry with the person who was responsible for the trauma, or with people who they feel didn’t help them enough, such as police officers or hospital staff.

Children with PTSD often have different symptoms than adults do. It is common for them to keep re-enacting the traumatic event through play. Many have behavioral problems. For instance, they may be aggressive or very anxious.

The trauma may result in other psychological problems such as depression, anxiety disorders or addiction. It can also lead to a “dissociative disorder,” where unbearable memories are erased or you have two or more distinct personalities. Some people develop chronic pain, an eating disorder or psychosis too.

Others have milder symptoms, or the symptoms only occur temporarily in certain situations that remind them of the traumatic event. Those people can live an almost normal life. But more severe cases can lead to psychological problems that affect everyday life so much that they need to be treated. Some people develop a condition known as “complex PTSD.” In this form of PTSD, people have several of the above-mentioned symptoms over a number of years, and the symptoms are very severe. Complex PTSD often develops after extreme or repeated traumatic experiences.

The severity of the symptoms doesn’t only depend on the traumatic event itself, though. The person’s ability to deal with what they experienced also plays a role.

People who have post-traumatic stress disorder always develop it after being in a situation where they thought that they and/or other people might die, or where they and/or other people were badly hurt – either physically or mentally. Examples of such experiences include violent crime, war, sexual abuse, road accidents, natural disasters and medical emergencies such as a heart attack or almost bleeding to death. Receiving bad news can be traumatic too – for instance, finding out that a close friend or relative has died or is fatally ill.

Stressful events such as getting a divorce, losing your job or being bullied do not lead to post-traumatic stress disorder. But they can cause certain symptoms that are also typical for PTSD, and sometimes lead to depression or anxiety disorders too.

Whether or not someone develops PTSD – and how severe it is if they do – will depend on

• what exactly happened. For instance, whether the psychological trauma was a result of violence or a tragic event like an accident or a natural disaster,
• how intense the experience was and how long it went on for,
• whether there were several traumatic events,
• how susceptible the person is to psychological problems, and
• whether they have things in their life that help them deal better with stressful events (“protective factors”).

PTSD is more likely to develop if the person felt very scared, helpless or like they had no control over the traumatic situation, if they thought they might die, and if they were victims of violence. The way the person perceives and feels about the traumatic event has a big impact on whether they develop PTSD.

People who already have psychological problems such as depression, anxiety disorders or addictions are more susceptible. Some people are generally better able to deal with horrific events than others are. They are less likely to develop PTSD. Emotional and social support can make it easier to deal with traumatic experiences. Without this kind of support, the risk of PTSD is higher.

The likelihood of PTSD developing very much depends on the type of traumatic event. Post-traumatic stress disorder occurs in about

• 50% of all victims of war, rape and torture,
• 25% of all victims of violent crime,
• 20% of all soldiers who have fought in a war, and
• 10% of all people who have had a serious car accident or a life-threatening disease.

About 2% of the German population have post-traumatic stress disorder at least once in their life.

The likelihood of someone developing PTSD greatly depends on their personal circumstances: People in certain professions tend to be confronted with dramatic situations more often. Examples include police officers, firefighters, train drivers and rescue workers. PTSD is also much more common in war-torn areas.

But distressing events don't always lead to PTSD. A lot of people who have been through a traumatic experience may be very sad or feel down when they think about what happened, but it doesn’t negatively affect their everyday life in the long term. And these feelings often fade as time goes on.

The way in which post-traumatic stress disorder develops over time can vary greatly from person to person. The symptoms may already appear during or shortly after the traumatic experience. But they sometimes only appear quite a lot later. The symptoms may improve after a few weeks, or they may last many years and become chronic. There are phases where the symptoms are weaker, and phases where they are stronger.

In some cases the memories of the traumatic experience only become distressing a long time after it happened, leading to post-traumatic stress disorder years later. This kind of delayed reaction is often seen in soldiers. Another example is wartime experiences that occurred in childhood and puberty, which sometimes only become a problem in older age.

A lot of people manage to process what happened and live with the memories. Some already feel much better within one year – even without treatment. About 30% of people with PTSD have the symptoms for three years or longer, and often go on to develop other problems such as an addiction.

If the symptoms are severe, it may become difficult to cope in everyday life. Some people lose their job because they can no longer work effectively due to lack of sleep and trouble concentrating. Or they may be constantly reminded of the traumatic event while at work, which can make it hard to carry on working there. People may also develop sexual problems, particularly if they were sexually abused.

People with the typical symptoms are only diagnosed with PTSD if the symptoms have lasted longer than four weeks. This is because it’s normal for people to be very upset after traumatic experiences, and it always takes some time to process what happened. Symptoms that arise shortly after a traumatic event are described as an “acute stress reaction” at first.

Post-traumatic stress disorder can be diagnosed by talking with a doctor or psychotherapist. The main aim of such talks is to find out how severe the symptoms are and how much they are affecting your everyday life. The doctor or therapist asks about your personal circumstances, such as your family, job and living situation. You may be asked to fill out a self-assessment questionnaire. Children may be asked to paint pictures or play certain games to help them access their traumatic experiences.

Post-traumatic stress disorder is often overlooked because physical injuries are dealt with first, for instance following a serious accident. Some people don’t recognize that there’s a link between their psychological problems and distressing past experiences. It can also be very difficult to talk about certain experiences and problems. So it's very important that the person feels comfortable and is able to talk openly.

Doctors and therapists are very careful when asking about upsetting past events. The memories are only touched upon briefly – there's no need to talk about them in detail.

Traumatic experiences can trigger other psychological illnesses too, such as depression and anxiety disorders. These also need to be considered when trying to diagnose the problem.

Immediately after a traumatic event, it’s important that those affected receive emotional and practical support to help them deal with what happened. They need a safe space where they are protected from further trauma and are given support. The best type of help will depend on what kind of traumatic experience they had and whether they mostly need to be comforted, feel safe or be given practical help. Medication generally isn’t suitable for preventing PTSD.

When planning treatment, the first step is to define the person’s needs and the treatment goals. What are their main symptoms? Which goals can realistically be reached using the currently available treatment options? What other kinds of support are needed? Is treatment even necessary? Talking to a psychotherapist can help to figure out these things.

Some people can only return to “normal life” after having psychological treatment. Others find that the support of their family and friends or psychological counseling is enough. Medication is only used in specific situations. Things like body therapy, art therapy and music therapy are often offered in addition to these treatments – particularly in rehabilitation hospitals.

A key part of psychological treatment for PTSD is known as trauma-focused therapy. The aim is to face and process the traumatic experience. This can be done using various psychological treatment approaches:

• Cognitive behavioral therapy (CBT): CBT involves re-assessing your thoughts and feelings about the traumatic event. It is the most commonly used psychological treatment for post-traumatic stress disorder.
• Psychodynamic therapy: This is a form of depth psychology that focuses more on current and past relationships and experiences.

A technique known as eye movement desensitization and reprocessing (EMDR) may also be used during psychological treatment. This involves using certain guided movements while recalling the traumatic incident, to help the person process memories. For instance, the therapist may move a finger rhythmically from side to side while the patient follows the movement with their eyes.

If the patient has other psychological illnesses on top of PTSD, the treatment should focus on the main problem first.

Traumatic experiences can greatly affect your life. Some people eventually manage to deal with what they went through. But they may need a lot of support, care and attention before they reach that point.

People who have had traumatic experiences often find it hard to trust others, so social relationships may also be affected. It then becomes difficult to make friends or stay in relationships. PTSD can greatly affect your sex life too. Some people become very withdrawn. It is then all the more important that their friends and family stick by them, even if their relationships have become more difficult.

Sometimes people who have, for instance, been involved in an accident or a violent crime have to fight legal battles for years afterwards. This can cause even more stress. They then need good legal advice and support to make things easier.

Various other types of support are available for people who have PTSD, to help them return to work and everyday life. In Germany, these include a stepwise return-to-work plan known as the “Hamburg model,” as well as psychological and social rehabilitation programs.

The crisis hotline "Telefonseelsorge" offers support in acute crises and provides information about where to find further help. Various other organizations also offer support and advice in Germany.

The German Federal Chamber of Psychotherapists (Bundespsychotherapeutenkammer) have a database that you can use to find a therapist anywhere in Germany. The German-speaking Society for Psychotraumatology (DeGPT) offers a database to help you search for psychotherapists with special training in trauma therapy.

The following organizations may also be helpful:

• The Germany-wide telephone hotline "Gewalt gegen Frauen" is a free, 24-hour helpline for women who are victims of abuse. Specially trained female counsellors offer advice in 17 different languages.
• Sexual Abuse Help Portal(Hilfeportal Sexueller Missbrauch)
• Association of Victim Support Workers in Germany (Arbeitskreis der Opferhilfen)