What is PTSD: Post-Traumatic Stress Disorder

Table of Contents

• What is PTSD?
• How do you know if you’re experiencing PTSD?
  • Criteria 1: Traumatic Events
    • The Fight, Flight, or Freeze Responses
  • Criteria 2: Intrusive Memories/Re-Experiencing
  • Criteria 3: Feeling Keyed Up/Hyperarousal
  • Criteria 4: Changes in Our Thoughts and How We Feel
  • Criteria 5: Avoidance
• If I have gone through a trauma, does that mean that I have PTSD? Could it also lead to depression or anxiety?
• What do I do if I have just experienced a traumatic event?

What is PTSD?

After a traumatic event, it is normal to have a hard time adjusting.

You may notice increased stress, tearfulness, or difficult memories coming up in your day-to-day life. While this is a normal part of the healing process, some individuals continue to experience these symptoms long after the trauma passes.

If these symptoms last more than 3 months, you may be experiencing something known as Post-Traumatic Stress Disorder (PTSD). While PTSD is most often talked about in the military, anyone who has gone through a traumatic event could be diagnosed with PTSD if they are still struggling with symptoms 3 months after the event.

How do you know if you’re experiencing PTSD?

When diagnosing PTSD, I look for five main criteria based on the Diagnostic and Statistical Manual - 5th Edition, or DSM-5 (this is what mental health providers use to diagnose). For some individuals, these symptoms start right after the traumatic event. For others, symptoms may show up years later. While you must meet each of these criteria to be diagnosed with PTSD, each individual may meet the criteria in different ways. I also look to see to what extent these symptoms are impacting your ability to function across different areas of your life (i.e. relationships, work, hobbies, etc.). If the symptoms are significantly getting in the way of you living your life, a diagnosis of PTSD may be warranted.

Criteria 1: Traumatic Events

The DSM-5 defines trauma as an event where you directly experience a serious threat or danger to yourself or someone else. Traumatic events can be events such as major car accidents, sexual/physical assault, witnessing someone else in danger, natural disaster, birth trauma, jobs that expose you to traumatic events (e.g. first responders), a dangerous work accident, or the sudden death of a loved one.

To understand the second criteria, we first need to understand how trauma impacts the body.

When we experience a traumatic event, our body automatically activates its fight, flight, or freeze response to help us survive. We don’t get a choice in which response we go into, our body simply goes into one of the responses and releases hormones to help keep us safe.

The Fight, Flight, or Freeze Responses

For example, if I am on a hike and a bear attacks me:

• My body’s fight response might release hormones to help increase my strength and speed as I try to fight off the bear.
• My freeze response might help me hide, keep still, or feel numb if I am injured.
• My flight response might release adrenaline so that I could get back to the safety of my car as quickly as possible.

When these hormones are released, things that help me survive are turned on (run fast, breathe quickly to get air to muscles, numb feelings to help me cope with possible pain), while systems that are not crucial to survive (such as sex drive and digestion) are turned off.

More recent research has also revealed the fawn response, where an individual may try to placate or go along with an assailant as a way of protecting themselves or others. This has been particularly important in understanding trauma with strong power dynamics (such as childhood trauma, trauma with an authority figure, trauma in cults, etc.).

Criteria 2: Intrusive Memories/Re-Experiencing

Now that we understand the body’s response to trauma, we can return to the second criteria: re-experiencing symptoms.

In PTSD, the memories of the trauma do not stay in the past.

Instead, memories find ways of haunting us in the present. This isn’t the same as when I think about what I had for lunch yesterday. These thoughts are intense and come up when we don’t want them there. Oftentimes, these unwanted memories are triggered by something that reminds us of the event (sight, sound, smell, etc.).

For example, let’s go back to the example of being attacked by the bear. Intrusive memories could be things like:

• having nightmares of the bear attack
• memories that I can’t get out of my head when I see my hiking boots
• thoughts about the bear that comes up whenever I smell a pine candle burning at my office
• feeling a phantom pain in my arm where I was injured even after it has healed
• suddenly feeling like I am back in time reliving the trauma again after a dog growls at me on my evening walk (also called a flashback).

When these memories come up, I like to tell my clients it means there is some unfinished business we still haven’t worked through.

And just like the trauma itself, when these memories come up, our bodies fight, flight, or freeze start to activate again (which leads us to our third criteria).

Criteria 3: Feeling Keyed Up/Hyperarousal

When these memories come up, our body begins to react as if the trauma were happening again.

Let’s imagine, I wake up from a nightmare in my bedroom about the bear attack. What do you expect my body to feel like? Fast heart beats, sweaty, tense all over. My fight, flight, or freeze response is going into overdrive again to try to keep me safe.

The problem here, though, is that I don’t have a bear in my bedroom! Instead of being in actual danger, just the thought of the bear is triggering my fight, flight, or freeze response. And if this is happening all day, of course I am going to have trouble relaxing or even sleeping at night. Who would be able to sleep with all those hormones running through their body?

For this reason, individuals diagnosed with PTSD often experience:

• difficulty relaxing (who can relax when it feels like a bear is always around the corner?)
• feeling on edge or like they must always be on guard
• difficulty concentrating
• becoming easily startled
• feeling irritable/angry (think fight response)
• difficulty with hunger cues, digestion, etc.
• decreased sex drive
• difficulty sleeping
• risky/impulsive behavior (overindulging with substances, binge eating, driving fast)
• feeling numb or checked out (think freeze response when it is trying to keep us from noticing pain)

And while the fight, flight, freeze, or fawn response was helpful during the trauma, it is much less helpful when I am trying to sleep, pay my bills, go to dinner with friends, or do a presentation at work.

Criteria 4: Changes in Our Thoughts and How We Feel

After a traumatic event, we are put in the terrible position of trying to put back together our shattered assumptions about the world.

While the world may once have felt safe, now we know how quickly things can change. Even if we aren’t aware of it, part of us may also be trying to desperately figure out why this terrible thing happened so we can prevent it from happening again. If we are not careful, we may start blaming ourselves or someone else inappropriately for what happened. Afterall, it may feel less scary to have someone to blame than to come to grips with the fact that sometimes terrible things happen, and we can’t always prevent it.

I like to call this type of thinking “would have, should have, could have” thinking because we are going back in time and telling ourselves how we could have prevented the trauma from happening.

In “would have, should have, could have” thinking, we may tell ourselves things like:

• If I had just gone left instead of right, I would not have been mugged
• If I had just fought harder, I could have gotten away
• If I said something sooner, then this wouldn’t have happened
• If I hadn’t worn that outfit, I wouldn’t have been assaulted

And while we know on some level that this logic may not make sense, our mind may find a type of comfort in it because it gives us the illusionary control to believe we can prevent the trauma from happening in the future.

A cousin to “would have, should have, could have” thinking are thoughts where we minimize or pretend the trauma did not happen. These thoughts, however, are just another attempt to keep from having to accept that sometimes terrible things happen.

In addition to blaming ourselves, we may also notice that the way we think about ourselves, others, and the world has shifted. After trauma, it is not uncommon to start believing things like:

• The world is a dangerous place
• I can’t trust others
• I must keep my guard up at all times
• If things aren’t in my control, something bad will happen
• I can’t trust myself to take care of myself
• People who look like my assailant are always dangerous
• If I really feel my emotions, something bad will happen

And of course, thoughts like this will have a significant impact on how we feel as we try to grocery shop, apply for a new promotion, or go to a crowded concert. It also may make it difficult for us to build or nurture relationships, particularly as we may be feeling unsafe and distrustful. This is part of the reason why we see that individuals diagnosed with PTSD often have difficulty in relationships. Why would we open up and be vulnerable if we are afraid of the world around us? And if we are afraid of our own emotions and thoughts (which makes sense because they activate the fight, flight or freeze response), then how are we going to be connected enough to ourselves to communicate how we feel?

Criteria 5: Avoidance

The final criteria of PTSD is avoidance. If you have gone through something terrible, it makes sense that you want to avoid things that remind you of it. It is just like when a kid falls off a bike. Of course you don’t want to get hurt again and so you may start avoiding the bike all together. Avoidance, however, doesn’t work in the long term. If we are not careful, our life can start becoming a lot more about avoiding than actually about living.

Let’s go back to our example of the bear attack. Let’s say that after a long night of nightmares about the bear I wake up and I spot the hiking shoes I was wearing.

What do you think happens? The memory comes back to my mind (re-experiencing symptoms) and all the sudden my heart starts racing as my fight, flight, or freeze activates (hyperarousal).

What do you think I do with those shoes? Throw them out of course! Why would I want something in my life that brings up such painful memories?! And at first, I may feel a sense of relief but it quickly fades as something new takes its place.

Let’s say the next night, I wake up and then see my running shoes, which just happen to be the same color and brand as my hiking shoes. What do you think happens? Yep, they bring up memories of the trauma (re-experiencing) and I throw them out too.

While avoidance may feel better in the moment, I have just given away something that I love. Maybe hiking is how I connect with nature and my family. Maybe running is how I take care of myself and find joy in my body. Now I have just given away something that made my life vibrant and meaningful.

Other ways of avoiding can include:

• avoiding people, places, or things that remind us of the trauma
• drinking or using substances so that we don’t think about what happened
• drinking or using substances so we loosen up in social situations where we are feeling unsafe
• eating to comfort ourselves
• intentionally not eating as a way of feeling more “in control” of our bodies
• throwing ourselves into work and keeping ourselves so busy that we don’t have time to think about what happened
• listening to podcasts non-stop to keep our mind so occupied we can’t think about the trauma

The tricky part with avoidance is that it doesn’t usually stop with one thing. Avoidance often grows until all the sudden we are avoiding the things that make our life vibrant and whole. All of a sudden, our life becomes more about avoiding memories than actually living.

The good news is that if you are experiencing symptoms of PTSD, there are many effective evidence-based treatments to help you work through your trauma. Remember, these memories are coming up because there are things to work through.

With the help of a trained clinician, you can get your life back and create a life that is driven by your values instead of by fear.

If I have gone through a trauma, does that mean that I have PTSD? Could it also lead to depression or anxiety?

Even though you may have experienced a trauma, that doesn’t mean that you will automatically meet criteria for PTSD. In fact, many people experience a traumatic event and don’t meet criteria for a mental health diagnosis.

That being said, a traumatic event (or multiple traumatic events) may increase your risk for PTSD and other mental health concerns. While PTSD is one possible diagnosis linked to trauma, trauma is also a risk factor for depression, anxiety, substance use disorders, personality disorders, acute stress disorder, and psychosis.

If you are having a hard time adjusting after a traumatic event, reach out to a trained trauma specialist who can help you understand what is going on and develop a plan to help you heal.

What do I do if I have just experienced a traumatic event?

If you have just gone through a trauma, it is important to remember that that doesn’t mean you automatically have PTSD or another mental health diagnosis. In fact, some of the symptoms described above can be part of a normal recovery process. It is expected and normal for you to be feeling a lot of emotions.

At the same time, taking steps now can help reduce the likelihood of developing PTSD or another mental health condition down the road. Learn more about suggestions for coping with a recent trauma here.

To learn more about PTSD and research-based interventions, see the following resources:

• STAIR: Taking the First Step Towards Trauma Recovery
• CPT: Cognitive Processing Therapy
• PE: Prolonged Exposure for PTSD