What is PTSD?

By Ryan Hamann, clinician, M. Psych. Sc.

Lara was rethinking her decision. The last thing that she wanted to do was to explain her nightmares and flashbacks to a therapist. The unbreakable “tomb raider”, as she had come to be known, can scale sheer rock walls but cannot walk down the street without jumping at every sound. She breathed deeply. “It’s time to face this,” she said, “It all started on an island…”

What is post-traumatic stress?

Post-traumatic stress is a series of symptoms that emerge after exposure to life-threatening or reality-shattering events such as military combat, physical or sexual assault, natural disasters, etc. Specifically, post-traumatic stress is an over-activation of our normal and adaptive fight or flight crisis response. We may believe that we are in immediate danger even when no threat of danger is present.

Traumatic stress, and, more formally, Post-Traumatic Stress Disorder (PTSD) has three clusters of symptoms: re-experiencing, hyper-awareness / arousal, and avoidance. These symptoms are cyclical and reinforce one another, causing the PTSD to become become a stronger and stronger influence in our lives.

Re-experiencing

Those with PTSD often re-experience our trauma. In the worst of cases, we completely disassociate from our present surroundings and believe ourselves to be in the middle of our traumatic situation, as if it was really happening to us again right then and there. A combat veteran may see the battlefield and hear the gunshots that seem as real to him as anything else he’s ever seen or heard.

More commonly, those with PTSD have a lot of nightmares. These nightmares will either depict our index trauma, bringing us uncomfortably close to that which we fear most, or they will impart an unrelated but still debilitating sense of fear and dread. This not only heightens our fear-activation, but it also interferes with sleep, leaving us low on energy.

Hyper-awareness / arousal

One of the most exhausting aspects about trauma is that it leads to a state of constant hyper-awareness. Since danger can approach from anywhere at any time, we are always on high alert, checking over our shoulders and scanning for threats, especially in crowds. We may startle easily, become quite irritable, and be overly-defensive.

If you have never been exposed to a trauma yourself, imagine, for a moment, how tiring it would be to feel like you are constantly in danger of having it happen again. You are watching every other person around you, never turning your back to anyone. Now imagine going through this after only two hours of sleep. Where do you get the energy to go to work, interact with your family, and perform life’s responsibilities? This is the taxing and exhausting life of a trauma-affected individual.

With our cognitive resources constantly drained, we can expect to be irritable and will have difficulty concentrating. This will also amplify any pre-existing problems, since we cannot dedicate much of our energy to addressing our other problems.

Avoidance

When affected by PTSD, we will seek to avoid triggering situations. We will avoid certain situations or people for fear of being plunged back into one of our re-experiencing episodes. This actually makes the PTSD much worse, as it affirms to the brain that, yes, it is adaptive to remain afraid. The more that we avoid, the more the thing that we are avoiding generalizes. Someone who is triggered in large crowds (and thus avoids them) can soon become uncomfortable and begin avoiding smaller and smaller crowds until she is unable to leave her house.

There are lots of ways of avoiding. Alcohol or drug use can be a way of avoiding, for example. When the troubling feelings come up, we sometimes find that numbing the symptoms with substances removes the momentary distress. The feelings are not gone, though. They are just buried and pushed off to the side. This is still an avoidance measure, and it serves to reinforce the trauma cycle.

The trauma cycle

Ultimately, the most punishing of traumatic symptoms is re-experiencing. All of the fear and dread caused by the original incident comes flooding back, sometimes causing panic attacks or dissociative episodes. The most terrifying thing about having PTSD is that we never know what will trigger a re-experiencing episode.

Sometimes, seeing a scene in a movie or video game that is reminiscent of the original trauma will trigger a re-experiencing episode. The senses (particularly smell) have a direct line to the amygdala, the portion of the brain where emotional memories are processed, meaning that sense experiences can be huge and, more troublingly, unpredictable triggers.

Soldiers who have fought in Iraq and Afghanistan report that the heat of the summer, the smell of garbage, or seeing piles of rubbish on the side of the road remind them of their deployment on a basic, primal level. Similarly, victims of sexual assault report experiencing panic attacks when they smell scents associated with the circumstances of their attack.

Since these re-experiencing episodes are so terrible, PTSD victims are really careful to notice any potential dangers. We do not want to be victimized again. We watch for any threat that can shake up our world again. We are in a state of constant tension, ready to fight or flee at any time.

Finally, since constant hyper-vigilance is so exhausting, we go out of our way to avoid areas where potential triggers can come from. As we stated above, though, this avoidance generalizes. Did hearing a loud noise trigger an episode at the mall? We avoid the mall. Did someone walk a bit too close at the grocery store? We avoid the grocery store. We block out so many aspects of our own lives that we end up painting ourselves into a corner.

Suddenly, that anxiety and hyper-awareness is shifted onto the areas where we previously felt safe. We now find ourselves becoming triggered in previously safe spaces, and the cycle becomes tighter and tighter.

To treat PTSD, we have to break this cycle. We have no control over our environment, so we can’t directly intervene with our re-experiencing and arousal, but we can intervene in our avoidance.

How to address PTSD

While there are steps that can be taken on our own in most circumstances of mental distress, I strongly advise those struggling with PTSD to speak to a professional therapist, counselor, or social worker. The reason for this is that overcoming trauma means going through and conquering the fear and anxiety involved, and this can be an extraordinarily difficult task without someone there to guide the process, provide support, and ensure our well-being.

PTSD functions in the same way as a phobia, and the only way to overcome either is through exposure and desensitization.

Desensitization is a word that will be familiar to those who were around when worried parents and politicians were trying to block the sales of Mortal Kombat and DOOM in the 90s. They argue that exposure to so much video game violence desensitizes players to real violence. That is, as we see more and more of something in a safe environment, we become less shocked by something similar happening in real life.

This is the same approach that we want to take to overcoming PTSD. Our fear and anxiety is like a massive hill. When it is triggered and we begin running up the hill, it gets steeper and appears endless, so we turn back and run away. As far as we are concerned, the hill has no summit. We are like Mario running up Bowser’s endless staircase in Super Mario 64.

If we get out of a triggering situation, we are immediately rewarded by our anxiety dropping, but it only drops about half way. Our new baseline anxiety level is higher than it was before, and it will continue to become higher every time we avoid.

If we, in a safe way, force ourselves to stick with our fear and keep on pushing through, we will eventually reach the top of the hill. Our anxiety will eventually decrease. This gives us a valuable piece of information. We now know that the hill is not endless. We know that we can conquer it. We know how bad it gets and when to expect it to come down again. We have effectively made a map of our anxiety hill.

When we do this, our anxiety does not come down in half measures like when we avoided. Our anxiety level drops in great degrees. We have begun to become desensitized to our anxiety, and the next time we feel it, the peak of the hill will be slightly lower, and the time after that slightly lower still.

This is a technique known as exposure. We must expose ourselves to what we fear and sit with our feelings, not allowing ourselves to avoid or escape, for however long it takes for our anxiety to come down; for us to create a map of our anxiety hill. Research suggests that, at first, this can take up to 30 – 40 minutes.

Fear hierarchy

How do we expose ourselves to our fears in a safe way, though? Surely, someone traumatized by an assault should not allow themselves to be assaulted again to conquer their fear. Instead of exposing ourselves to actual danger, we want to find a safe situation that triggers our anxiety that we can conquer. As we talked about above, fear generalizes. If we were assaulted at night in the city, this soon generalizes to a fear of public places, a fear of stores, and a fear of crowds. Realistically, though, we know that many of these areas pose very little threat. We have been to the grocery store hundreds of times and nothing bad has ever happened there. Like in a game of Civilization, it is time to reclaim the land that generalization has taken away from us.

Let’s set realistic goals for ourselves. Let’s say that we want to be able to go to the mall again. On a distress scale of 1 to 10, this might be at about a 9, but sitting in our car in the parking lot might only be a 6, so let’s do that. We drive to the mall and sit in our car in the parking lot for 40 minutes until our anxiety decreases. Sitting in the parking lot is now a 2 out of 10. We feel confident enough to walk up to the building and stand outside for 40 minutes until our anxiety decreases. And this process repeats itself until we accomplish our goals and retake that space. We are like an army, pushing back on the opposing army and forcing our fear to retreat.

Get it out

Tension builds within ourselves when we have no outlet for our feelings. It can feel extraordinarily lonely to not be able to talk to anyone else about what we are going through. There are a few ways that we can work around this, though.

Talking to trusted friends or family members can be a good outlet. The most difficult thing about this, though, is that it sometimes feels like they wouldn’t understand what we’ve been through, or if they knew what we had been through, it would change what they think about us. We can work with a therapist to find ways to effectively talk about our trauma with our loved ones.

Alternatively, we can journal about our traumas. When our thoughts are bouncing around inside of our heads, we rarely think things through in a linear, cause-and-effect fashion. We fall victim to self-blame and feelings of guilt that we can challenge and disprove if we write out and review our trauma narratives linearly.

Finally, some people get a lot out of joining CPT trauma groups. Meeting with others who have experienced similar traumas can destigmatize our feelings and give us the support that we need to work through our trauma narratives together.

Games that can help with PTSD

  • Spec Ops: The Line: Addresses issues of PTSD specifically, normalizing many veterans’ experiences. Also a good way of exposing self to rather intense warfare in a safe environment. Games like Call of Duty and Battlefield, while providing some exposure to war-like environments, fail to depict some of the ugliness of war that is the true root of many veterans’ traumas.
  • Bravemind, or other clinically-oriented VR experiences: Developed by universities and clinicians specifically to treat PTSD, these virtual exposure therapies can put people back in their wartime boots like nothing else. Exposure in a safe environment.
  • Tetris: Surprisingly, a study conducted by Oxford University (published last year) found that playing Tetris relieved many of the flashback and re-experiencing symptoms of those with PTSD. Most likely, there is nothing special about Tetris, specifically, that could not also be applied to similarly engrossing spatial puzzle games like The Witness and Bubble Bobble.