PTSD Awareness Day
27th June 2022

National Posttraumatic Stress Disorder (PTSD) Awareness Day falls on the 27th of June every year and started in 2010. Working as a clinical psychologist, I have engaged with many people who had experienced trauma, both with and without a diagnosis of PTSD. I thought it might be useful to give a short history of PTSD, discuss the differences between trauma and PTSD, and provide some approaches that might help you better understand trauma.

Although trauma has been a part of human existence for thousands of years, the idea that exposure to traumatic events might impact a person’s functioning only really started in the last century. A lot of people have heard of “shell shock”, a condition that was noted in returned soldiers during World War 1. The use of the term “shell shock” in 1915, was the first time the medical profession began to describe the effects of death on a person’s mental health. It wasn’t until 1980 that PTSD was recognized as a mental health disorder and was included in the Diagnostic and Statistical Manual of Mental Health Disorders, 3rd Edition. Current research suggests that between 5% and 10% of Australians will experience PTSD at some point in their lives. This means that at any one time about 1 million Australians have PTSD.

 

What is the difference between Trauma and PTSD?

Trauma in psychology is a traumatic event that causes extreme distress and involves a sense of “intense fear, terror, or helplessness” (Perry & Winfrey, 2021). According to the current version of the Diagnostic and Statistical Manual of Mental Health Disorders, the DSM 5-TR, a traumatic event must involve actual or threatened death, serious injury, or sexual violence (APA, 2022). Some examples of traumatic events are exposure to war, actual or threatened physical assault, kidnapping, being taken hostage, terrorist attacks, torture, being held as a prisoner of war, disasters (natural or man-made), and severe motor vehicle accidents. Sexual trauma includes actual or threatened sexual violence or coercion. Not everyone who experiences a traumatic event will develop PTSD.

PTSD is when a person develops certain symptoms following exposure to one or more traumatic events (APA, 2022). In addition, PTSD may occur when a person works in a job where they are indirectly exposed to the negative effects of war, rape, genocide or abusive violence. Here is a summary of the different types of symptoms that people with PTSD experience, following exposure to one or many traumatic events (APA, 2022):

Symptom type

Examples

Intrusive symptoms • Involuntary and intrusive memories of the event
• Distressing dreams about the event
• Flashbacks where the person feels as if the traumatic event is happening again
• Extreme distress when exposed to cues related to the traumatic event
• Extreme physical reactions to cues related to the traumatic event

Avoidance of things that are associated with the traumatic event

• Trying to avoid distressing memories, thoughts, and feelings about the traumatic event
• Trying to avoid reminders that might evoke the distressing memories, thoughts, and feelings about the traumatic event

Changes in thinking and mood

• Unable to remember parts of the traumatic event
• Exaggerated negative beliefs about yourself, others, and the world (e.g., “the world is completely dangerous”
• An Exaggerated sense of self-blame for causing the traumatic event
• Persistent negative emotions (e.g., fear, terror, horror, anger, or shame)
• Significantly decreased interest and/or participation in activities
• Feeling detached from other people
• Inability to feel positive emotions

Changes in arousal

• Irritable behaviour and anger outbursts
• Reckless behaviour or self-destructive behaviour
• Hypervigilance
• Exaggerated startle response
• Difficulty concentrating
• Sleep difficulties

Trauma in psychology is a traumatic event that causes extreme distress and involves a sense of “intense fear, terror, or helplessness” (Perry & Winfrey, 2021). According to the current version of the Diagnostic and Statistical Manual of Mental Health Disorders, the DSM 5-TR, a traumatic event must involve actual or threatened death, serious injury, or sexual violence (APA, 2022). Some examples of traumatic events are exposure to war, actual or threatened physical assault, kidnapping, being taken hostage, terrorist attacks, torture, being held as a prisoner of war, disasters (natural or man-made) and severe motor vehicle accidents. Sexual trauma includes actual or threatened sexual violence or coercion. Not everyone who experiences a traumatic event will develop PTSD.

PTSD is when a person develops certain symptoms following exposure to one or more traumatic events (APA, 2022). In addition, PTSD may occur when a person works in a job where they are indirectly exposed to the negative effects of war, rape, genocide or abusive violence. Here is a summary of the different types of symptoms that people with PTSD experience, following exposure to one or many traumatic events (APA, 2022):

Four things that can help us understand trauma

1. Understanding how trauma affects the mind and body:

There has been a plethora of research into how the brain changes in response to a traumatic event over the last 20 years. The fear centre of the brain (the amygdala) triggers a response known as the fight/flight/freeze/appease reaction during exposure to a traumatic event. This reaction is a primate response to any threat that mobilises the body for action in an attempt to essentially remain alive. Humans originally needed this reaction when faced with threats such as wild animals, in order to survive. In today’s world, we are less exposed to wild animals and more exposed to psychological threats, like pandemics, relationship arguments, parenting challenges, and work pressures.

People generally tend to respond to threats in one of the four ways – fight, flight, freeze or appease. The following summary table is adapted from Psychology Tools Limited (2020):

Response to trauma/fear How the response is helpful What happens in the body What happens in the mind
Fight:

fight the threat


• Winning comes with a greater chance of survival
• A person looking aggressive and ready to fight might be enough to stop an opponent
• Release of adrenaline
• Heart rate and breathing increases
• Muscles tense
• Focus of attention becomes restricted to the threat.
Flight:

run away from the threat

• Escaping can mean survival, often with little or no injury  

• Release of adrenaline
• Heart rate and breathing increases
• Muscles tense

 

• Focus of attention is on escape routes

Freeze: become less obvious to the threat  

• Makes us less noticeable and gives us time to evaluate the situation

 

• Thinking becomes quicker initially
• Later – dissociation, feeling out of your body, numbing of emotions and inability to move

 

• Initially, the focus of attention is on escape routes
• Later on attention decreases

Appease / Please / Fawn:

please the threat

 

• Giving the other person what they want might decrease the threat

 

• Submissive pose
• Body cringes to appear smaller
• Head down, eye contact averts

 

• Focus of attention is on options that might reduce the immediate threat
• Might not see other options that appear obvious later on

When the fear centre switches on, the main thinking part of the brain (the prefrontal cortex) that regulates decision-making, problem-solving, planning, and emotional regulation goe offline, which means these skills no longer work as well as they normally do. Dr. Dan Siegel, clinical professor of psychiatry, calls this process “flipping your lid”, and has created a hand model of the brain to help people understand this. This clip shows a short explanation of the hand model of the brain by Dr. Siegel: https://www.youtube.com/watch?v=gm9CIJ74Oxw

When any one of us is in a threat response mode, our thinking skills decrease. This is important to remember when we consider one of the most common modern-day threats that can switch on our fear centre are interpersonal conflicts, including between partners,  children and parents, and between work colleagues. Sometimes we need to take a break from a heated discussion and return to it later when everyone’s brains have returned to full working order.

2. Shift our thinking from “What’s wrong with you?” to “What happened to you?”

Dr. Sandra Bloom began the trauma-informed care approach known as the Sanctuary Model in the 1980s in the USA and developed the idea of asking a person “what happened to you?” instead of “what’s wrong with you?” (Bloom, 2017). This began a significant movement in psychiatric care, which has flowed into child protection, human services, and disability services across the world. We do not blame the person for their behaviour, nor do we see them as broken or flawed. Instead, we seek to understand what is happening to the individual, believing that every behaviour has meaning. We can reflect on what must have happened to this person to have led them to respond to the world in the way they do now.

We can all incorporate this understanding into our everyday language by asking “what’s happening?” instead of “what’s wrong?” or “what have you done wrong now?” or “what the hell is wrong with you?” when our child/parent/partner/sibling/work colleague does or says something that we don’t agree with or that triggers us to feel annoyed. Asking “what’s happening?” or “what happened?” shifts the focus away from judgement, shame and blame and can help the person open up and communicate with us.

If you are interested in learning more about this way of thinking, Dr. Bruce Perry, one of the world’s leading experts in childhood trauma, has written a book with Oprah Winfrey entitled “What happened to you”. In the book, published in 2021, they explain the impact of childhood trauma on a person’s life, using theoretical knowledge and their personal stories.

3. Integration, dis-integration, and re-integration:

Psychological therapy for PTSD and trauma is about integration. When a person has experienced trauma, either a one-off incident or repeatedly over many years, the mind develops ways to survive the overwhelming impact by splitting off memories, images, sensations, ways of thinking, and ways of feeling. A previous client of mine described this process beautifully when they said that they felt like therapy had helped them to “put the pieces back together”.

Dr Dan Siegel researches, writes and trains practitioners across the world on neural integration (how different parts of the brain link with each other). His website has a wealth of resources, including recordings of previous presentations – https://drdansiegel.com/video-clips/

When we know that someone has been through a lot of significant traumatic events in their life, it can help to remind ourselves to be patient with them, as they are going through a period of re-integration after feeling dis-integrated for many years.

4. Post-traumatic growth – what doesn’t kill me makes me stronger:

It is important to recognize that when people have re-integrated the impacts of trauma, they often experience a phenomenon known as post-traumatic growth. This experience of personal growth and positive psychological change following a single or multiple traumatic events began to become a focus of research in psychology in the 1990s (Calhoun & Tedeschi, 2006). Prior to this, the focus was solely on the negative effects of trauma on a person. There are various domains of post-traumatic growth including a person realizing that:

• They have personal strengths they didn’t appreciate before the trauma,
• They have a life filled with new possibilities given what they have survived through,
• They have a different way of relating to others,
• They have a greater appreciation for life, or
• Their spiritual beliefs have changed.

In other words, people who have experienced post-traumatic growth tend to be more resilient and better able to adapt to life’s stresses. We can appreciate the strength of a person who has experienced a lot of trauma in their lives, as we try to understand that they may respond or behave in certain ways because of what has happened to them.

It is interesting that the National PTSD Awareness Day only began 12 years ago. We still have much to learn from people about the impacts of trauma on all aspects of their lives. It certainly is a positive step in the right direction that we can pause every year on the 27th of June to learn from and educate each other about trauma and PTSD.

References

Perry, B. D. & Winfrey, O. (2021). What Happened to You? Conversations on trauma, resilience and healing. Australia: Pan Macmillan UK.
Bloom, S. L. (2017). The Sanctuary Model: Through the lens of moral safety. In J. Cook, C. J. Dalenberg, & S. Gold (Eds.), Handbook of Trauma Psychology. Washington, D.C.: American Psychological Association. Retrieved January 5, 2022, from https://sandrabloom.com/publications/
Calhoun, L.G., & Tedeschi, R.G. (Eds.). (2006). Handbook of Posttraumatic Growth: Research and Practice (1st ed.). Routledge. https://doi-org.ezproxy.ecu.edu.au/10.4324/9781315805597
Psychology Tools Limited (2020). Responses to threat: freeze, appease, flight, fight. Retrieved June 20, 2022, from https://www.psychologytools.com/resource/responses-to-threat-freeze-appease-flight-fight/

Eimear Quigley

General Manager – Psychological Services
BSc(psych)Hons, MclinicPsych

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