A Traumatic Experience?
It was a Saturday night when I was 16 years old. I had a couple of my basketball friends stay over, and we decided to venture out around 10:30pm to meet up with some other friends a few streets away.
I grew up in what I felt was a safe neighbourhood in the North-East suburbs of Melbourne, and had been out plenty of times this late at night with my brother to go and get some food.
We didn’t think that we would be out long, so I didn’t tell my parents where we were going. We crept out the backdoor and meandered down the road.
When we reached the bottom of the street a shiny silver sedan with blue underlighting pulled up, and a group of older teenagers asked us if we knew of any parties in the area. We said that we didn’t, and kept walking, thinking that they were friendly enough.
They slowly started reversing the car with us as we continued down the street and said “What do you guys think of the car?”
My taller friend, impressed with the blue lighting, replied “Yeah, pretty sweet!”
“Do you want it?” the other guy continued.
“Wouldn’t mind a car like that,” my friend replied.
Suddenly the mood changed.
“How about this…” the guy stated, as the ignition was turned off and he and his four mates climbed out of the car. “You three versus us five, you beat us, and you can have it!”
Two of them began smacking long cylindrical objects that looked like trolley bars into their hands as they approached us.
“We don’t want any trouble, and we definitely don’t want to fight you!” I interjected, speaking up for the first time as I tried to de-escalate the situation. “My friend was just trying to give you guys a compliment!”
That was the last thing that I remember saying before I felt my head jolt back with a thud from the force of a fist that connected with my nose and mouth. I didn’t even see it coming.
My two friends backpedaled, turned, and started to sprint back up the hill towards my house as soon as I was hit. Blood began gushing from my nose. Before the five guys could get another punch in I ran with my friends, flew over the fence into my backyard and straight back inside where we locked the door, gasping for air while my heart beat out of my chest.
I was scared, but also relieved, because it could have been a lot worse. The bleeding eventually slowed down, and luckily my nose didn’t seem broken and my teeth were still intact. I was sore for the next few days with a tender nose and cut and swollen lips, but within a week, my physical appearance was back to normal.
Psychologically, I wasn’t quite the same after the incident. I was irritable and more emotional. I kept getting flashbacks of the incident intruding into my mind during the day, and couldn’t believe that something like this could have happened to me in my neighbourhood. I had nightmares in the month after the incident of being jumped, attacked or chased by a group of guys in the dark.
I was annoyed that my friends hadn’t tried to back me up, but understood why running was the smarter decision given the circumstances. I was also furious that the police said that there was nothing that could be done about it without any further identifying information. It didn’t seem fair, and the world no longer seemed safe, especially if I was walking at night, and especially if a car came past.
As the months went by things settled a lot more, and I was back to feeling pretty good during the day and sleeping well at night. Some lingering symptoms persisted in the subsequent years that I can now see were a direct result of this physical assault. The main ones were an elevated startle response, or being “jumpy” in response to sudden movements or loud noises, a greater sense of hypervigilance and being “on guard” when I was out at night, and the annoying habit of diving behind bushes or hiding behind trees whenever I saw headlights or heard a car approaching at night.
I had no idea why I did these things initially, and would even say that I was joking to my friends when I ran for cover whenever a car came by. But I still did it, and deep down feared that the same event would happen again, with an even worse outcome this time.
It was only after I started to study Psychology at university, and particularly trauma, that I was able to make sense of my reactions in the aftermath of this event. I was then able to research and understand how to overcome trauma, and challenged myself so that the physical assault impacted me less over time.
Through sharing this experience, I am hoping that those who have been through any traumatic experiences might be able to identify with these symptoms and experiment with the strategies that I have personally found helpful, so that they may too get long-term relief from the trauma that they have suffered.
What is Trauma?
The Diagnostic and Statistical Manual for Mental Disorders (DSM-V) describes a traumatic experience as exposure to an event that involves death, serious injury (actual or threatened), or sexual violence (actual or threatened). It usually creates intense feelings of helplessness, horror, or fear in the individual. It is mostly direct exposure to an event that causes trauma, but can also be caused by witnessing an event that happened to someone else, indirect exposure by hearing about a close friend or family member being exposed to trauma, or through extreme or repeated exposure to aversive details of an event, typically through professional duties, such as first responders to a fatal crash site, or repeated exposure to details of child abuse.
Trauma can create long-standing changes in the brain. Imaging studies have shown heightened brain-stem activity, which controls the fight-or-flight (or freeze) system. This is the brain’s in-built survival mechanism. Imaging studies also show heightened amygdala activation, which floods the body with feelings of fear. Both of these changes can be quite effective in keeping people safe in times of imminent danger, because they allow individuals to scan the environment and react quickly to anything that is perceived to be dangerous.
The problem is that once these areas of the brain become overreactive, they will respond to anything that is potentially similar to a traumatic experience from the past, without first trying to accurately assess the actual level of threat. This makes it more difficult to respond in a calm, rational manner in an individual’s everyday life.
The hippocampus, an area in the brain that is responsible for memory, can also be severely affected by traumatic events. The more extreme, unexpected and inconsistent an event is with previously held beliefs about themselves, the world or other people, the harder it is for the brain to fully process and integrate this experience. Some of it remains unprocessed or “stuck”, which then reduces the capacity to move on from the traumatic event and process and integrate subsequent information that is taken in by the senses.
Re-experiencing symptoms, such as flashbacks and nightmares, are thought to be the brain’s attempt to properly process and integrate the traumatic experience. As scary as this can be, it generally does help in healing and resolving trauma symptoms over time. Unfortunately, with Post-traumatic stress disorder (PTSD), the brain continues to be unable to fully process and integrate what has taken place, which can lead to devastating consequences and severe functional impairment for the individual that is suffering from the condition, especially if they don’t understand the symptoms or what to do with them when they occur.
How to Best Respond to Each Cluster of Trauma Symptoms:
There are four clusters of symptoms that indicate that a person is suffering from an acute stress reaction in the first month after an exposure to a traumatic event, or a post-traumatic stress reaction after a month. Even if you do not have all of these symptoms, it can still be helpful to know what is occurring at the time when you do experience these symptoms after trauma and what you can do about it.
A: Intrusion symptoms – This includes intrusive memories, traumatic nightmares, dissociative reactions, such as flashbacks, and marked physiological reactivity and intense or prolonged distress after exposure to trauma-related stimuli or reminders.
When these intrusive symptoms occur, our brain rushes back to the past and starts to think and feel the same way that it did when the traumatic event was taking place. The brain feels that it is in imminent danger, and the initial feelings of intense helplessness, horror or fear come rushing back in.
What I have found to be most effective when this occurs is a process called grounding, as it helps me reconnect with my senses in the moment, and brings my brain back from the past to the present.
Next time an intrusive symptom occurs, ask yourself the following:
- What are five things that I can see right now?
- What are four things that I can touch/feel right now?
- What are three things that I can hear right now?
- What are two things that I can smell right now?
- What is one thing that I can taste right now?
Once you are reconnected with the present, ask yourself “Am I safe right now?” If you are in danger, remove yourself from the situation. If not, then you are not at risk of harm and instead need to focus on reducing your distress and physiologic reactivity through self-soothing activities.
The more that these activities can engage you and your senses in the moment, the better, as it will help you to continue to feel present and safe. Grounding must occur first though, or the brain will want to stay in a hypervigilant state to protect you from the perceived threat, even if the threat is only a memory in your head.
B: Avoidance – Persistent avoidance of distressing external (people, places, conversations, activities, objects or situations) and/or internal (thoughts or feelings) reminders of the trauma
Avoidance of any reminders of the trauma in the first month after the incident is actually a good thing, as it can lower your arousal levels and reactivity, assisting your recovery.
Ongoing avoidance of these reminders, particularly after month, is not recommended however, and may prevent a full recovery. Chronic avoidance prevents processing and integration of the traumatic event, and sometimes means that people begin to avoid more and more things that may seem dangerous when they are logically quite safe.
Gradual exposure to the things that you fear (as long as they are relatively safe) is important in the treatment of any anxiety disorder, including PTSD. I have gone through the steps of how to do this in my first article titled “Feel the Fear and Do It Anyway”. I personally followed these steps to challenge myself to get outside at night more and stop hiding when cars came past. It did get easier with each time as I realised that my fear of being attacked was much greater than the actual probability of it occurring (it’s never happened again).
Also remember that we cannot fully run away from our thoughts and feelings. Acceptance and Commitment Therapy teaches Defusion and Expansion skills to help us better manage our thoughts and emotions. Research shows that these are more effective long-term strategies than continually avoiding internal reminders of trauma through drugs and alcohol, emotional eating, meaningless distractions or by keeping busy all the time (which only tires you out further and makes you more likely to feel out of control and react emotionally).
C: Negative alterations in cognitions and mood – including inability to recall key components of the trauma, persistent and distorted negative beliefs and expectations about oneself, others or the world, or blame of self or others for causing the traumatic event or its consequences, persistent negative emotions, including anger, fear, horror, impending doom, guilt and shame, diminished ability to experience positive emotions, as well as loss of interest and engagement in previously important activities, and feeling isolated, alienated, detached or estranged from others.
Exposure based treatments, particularly cognitive processing therapy is important for addressing the extreme shifts in cognition and beliefs that can take place after trauma, particularly if they are preventing you from doing the things that you used to enjoy.
Writing about how your beliefs and feelings have changed, or explaining these changes to a friend that you can trust can help you feel more connected and better in time, but should be done in collaboration with a therapist if you are concerned about how you may react.
If I ever felt disconnected, which happened occasionally, I found movement to be the best strategy to reconnect. This could be playing sport, doing yoga or Pilates, weight lifting, walking or running outside, or even dancing. Anything that helps you get out of your head and into your body or the world around you (as long as it is safe).
D: Alterations in arousal and reactivity – trouble falling asleep or staying asleep, difficulty concentrating, feeling jumpy or easily startled, and being super alert or watchful.
Learning emotional regulation and distress tolerance skills are both important to manage arousal levels, which then diminishes reactivity.
Emotional regulation skills include adequate rest, recovery, leisure and socialising, or ensuring that things are in the right balance. Too much work and stress without adequate breaks will slowly increase our arousal levels over time. Ensuring that we minimise caffeine and alcohol intake, eat a healthy well balanced diet and get a consistent 7 hours of sleep each night also help us to lower our arousal levels and better regulate our emotions.
Distress tolerance skills include relaxation and mindfulness skills, as well as distraction at times. By practicing these on a regular basis when you are feeling calmer, it then becomes easier to implement them when you are most distressed so that things do not become too overwhelming for too long and you are able to not panic and calm yourself down.
Diagnosis of PTSD and Recommended Treatments
All four symptom clusters must be present to a significant degree and cause significant distress or functional impairment to warrant a diagnosis of PTSD.
If you are concerned that you may be suffering from PTSD from a trauma that you have experienced more than a month ago, please complete the Post-traumatic Checklist for the DSM-V (PCL-5) questionnaire, which can be accessed for free online. If you score above 38 on this checklist, I would encourage you to visit your GP or primary care physician to discuss the matter further and collaboratively decide on which treatment path you would like to go down.
Sometimes a referral to a Psychologist and/or Psychiatrist will be important to give you the best chance of making a full recovery.
It is important to realise that the most effective psychological therapies for trauma all include some element of exposure (imaginal and/or in vivo) to the traumatic experience. This could be though trauma-focused cognitive behavioural therapy (CBT), Cognitive Processing Therapy (CPT), or Eye Movement Desensitisation and Reprocessing (EMDR) Therapy. All are considered first-line approaches for treating PTSD in Australia (NHMRC, 2007), and should be recommended before pharmacological interventions, or alongside antidepressants (SSRIs) if sufficient benefits are yet to have been obtained through psychotherapy alone.
Even 8-12 sessions of 60-90 minutes of therapy is usually sufficient in treating PTSD. Any co-morbid issues can then be addressed in further treatment once the PTSD symptoms have subsided.
Traumatic events can change the brain, and the way that we respond to situations afterwards. Often the brain can heal itself over time, especially if we are engaging in the right strategies. If it doesn’t, effective psychological help is available, and it can make a big difference in helping you to heal and grow.
You can also check out my new podcast discussing the main symptoms of PTSD and how they can be managed.
Dr Damon Ashworth