Post Traumatic Stress

A Self Help Guide

These are the thoughts and feelings two people who have experienced traumatic incidents.

“I feel terrible, very restless and irritable. This is not like me at all. The car crash happened 6 months ago but I still can’t feel safe in a car, I feel so fearful I avoid travel wherever possible. Pictures of the accident come flashing into my mind, they won’t go away and even at night my dreams are more like nightmares with scenes of the crash happening again and again ... I’m exhausted by it ...”

“My whole view of life has changed, I keep thinking why us? I feel very guilty thinking that I could have done more to save my friend who died. I relive the experience all the time, I keep thinking, "if only I had done this”, “if only I had done that” ..., I am very low and depressed some of the time...unable to relax and feeling frightened, I think I could have died ..., I can’t think of the future ..., I feel helpless ...”

If you have suffered from a traumatic experience yourself you may have had similar feelings.

This booklet is written by psychologists and aims to help you understand these reactions and offers some practical suggestions to help you cope.

What is a traumatic incident?

A traumatic incident can be anything that is out of the ordinary range of daily events and is deeply distressing to someone.

Many things can have this impact. It could be fire, an accident, a robbery or burglary, an attack, being a witness to a traumatic event such as a death. It can be large scale such as a major disaster involving many people or a personal event involving yourself, friends or family members.

How do people react after a traumatic incident?

The following are some of the reactions you may experience after a traumatic event. In general people’s reactions will fall into the following three groups:

• Re-experiencing the trauma in your mind.
• Avoiding things associated with or related to the trauma.
• Feeling more tense, irritable or over alert than usual.
• Feeling depressed, crying.

It may help you to check to see if you are experiencing any of these symptoms.

Re-experiencing the trauma in your mind

• Having unwanted pictures or images of the trauma (often called flashbacks) coming into your mind.
• Having upsetting dreams about the trauma or dreams about other things that frighten you.
• Feeling that the trauma is happening again - strong sensations of reliving the trauma.
• Feeling very distressed at coming across situations or feelings that remind you of the trauma.
• Experiencing distressing physical reactions, eg heart beating faster, dizziness etc. when you are faced with memories of the trauma or situations that remind you of it.

Avoiding things related to the trauma and numbing

• Trying to avoid thoughts feelings and conversations about the trauma.
• Avoiding activities, places or people that remind you of the trauma.
• Being unable to remember things about the trauma.
• Losing interest in life, feeling detached from others or not having your usual feelings.
• Not feeling you will have a normal future - you may feel as though you are living on borrowed time.

Feeling more tense and irritable than usual

• Feeling angry or irritable
• Not being able to concentrate
• Finding it difficult to fall asleep.
• Feeling over alert all the time and easily startled.

Post-traumatic stress reactions can affect us in at least four different ways:

• How we feel
• The way we think.
• The way our body works.
• The way we behave.

It may help you understand how you are feeling by placing a tick next to those symptoms you experience regularly:

How do you feel?

• Anxious, nervous, worried, frightened.
• Feeling something dreadful is going to happen.
• Tense, uptight, on edge, unsettled.
• Unreal, strange, woozy, detached.
• Depressed

What happens to your body?

Heart races and pounds.

• Chest, feels tight.
• Muscle, are tense/stiff.
• Feel tired/exhausted.
• Body aching.
• Feel dizzy, light headed.
• Feel panicky.
• Feel depressed, low, at a loss.
• Feel angry.
• Cry.

How do you think?

• Worrying constantly.
• Can’t concentrate.
• Experience flashbacks - pictures of the trauma coming into your mind.
• Blame yourself for all or part of the trauma.
• Think it will happen again.
• Unable to make a decision.
• Feel regret, shame or bitterness.
• Thoughts racing
• Feel jumpy or restless.
• Stomach churning.
• Have sleep problems/nightmares.
• Easily startled.

What you do

• Pace up and down.
• Avoid things that remind you of the trauma.
• Can’t sit and relax.
• Avoid people.
• Avoid being alone.
• Are snappy and irritable.
• Spoil relationship.
• Drink/smoke more.
• Depend on others too much.

Common thoughts

“It was my fault”.

“I’m cracking up”.

“I’m going to have a heart attack”.

“It’s controlling me”.

“I can’t cope”.

“I’m going to faint”.

“Why did it have to happen?”.

“I can’t see the point anymore”.

Why do we react so strongly to trauma?

There are many reasons why trauma leaves such a strong impact on us emotionally.

Firstly, it often shatters the basic beliefs we have about life: that life is fairly safe and secure, that life for us has a particular form, meaning and purpose. It may be that the image that we have of ourselves is shattered, we may have responded differently in the crisis from how we expected or wanted to behave.

Secondly, trauma usually occurs suddenly and without warning. We have no time to adjust to this new experience. It will usually be outside our normal range of experience and we are faced with not knowing what to do or how to behave. You may have felt you were going to die, people around you may have died, and you are shocked. In the face of this danger our mind holds on to the memory of the trauma very strongly, probably as a natural form of self protection to ensure you never get into that situation again. The result of this is that you are left with the post traumatic reactions described above.

What can I do to help myself overcome the trauma?

It is important to understand that the reactions you are experiencing are very common following trauma, they are not a sign of “weakness” or “cracking up”. The following suggestions may help you begin to cope with the posttraumatic reactions. Things that we describe which may help you are:

• Making sense of the trauma
• Dealing with flashbacks and nightmares
• Overcoming tension, irritability and anger
• Overcoming avoidance
• Overcoming low mood

1. Make sense of the trauma.

Try and find out as much as you can about what really happened. This will allow you to piece together a picture and understanding of the event more clearly. This can help you in your recovery.

If others were involved, talk to them and ask them their views of events. Other victims, helpers from the rescue service, or passers by, may all be people who would help you gain a broader view of what happened. The rescue services are usually happy to help you in these circumstances.

It may help you to think it through with other people. You may feel the trauma has altered you whole view of life, it is helpful to try and clarify how you now feel and talking can help you do this.

Some people talk to a friend, family member or partner, others may approach their doctor to seek some counselling. Other people have found that it helps to write down their experiences.

Try to spend a few minutes thinking of ways that you may be able to make sense of what you have been through. Try and jot down some ideas: People to speak to in order to find out more. People to talk it over with. Things you may do yourself, eg write down your experiences.

2. Flashbacks and nightmares

Many people try to put the experience of trauma behind them by attempting not to think of it. Although this may seem a natural thing to do, it does not always help them to overcome the problem. People may find that they continue to be troubled by intrusive unwanted pictures of the trauma in their mind (flashbacks) and by unpleasant dreams or nightmares related to the trauma.

One of the best approaches which has been found to reduce flashbacks and nightmares is to make time each day for reviewing and going over the unpleasant memories or nightmares.

Many people have found that if they put 20 minutes asidecalmly to think over, talk over or jot down notes on the trauma, that their unwanted flashbacks and nightmares will gradually become less powerful and less frequent. If you have nightmares, it may help to do this soon before you go to bed.

This process can allow you to regain some control over these thoughts rather than them intruding upon you. It is important to try and remember to focus on some of thepositive parts of your current situation when looking back over the trauma you have experienced.

Try the following approaches: 1. Write down details of the flashbacks or nightmares you experience. 2. Find a time of day when you could think over what has happened. This should be in a safe calm environment. 3. Think of some positive things about your current situation: for example, “I survived it and I’m still here”, “I have good friends to support me”, “I can now begin to plan for a new future”.

3. Overcoming tension, irritability and anger

Tension, irritability and anger are common aspects of a posttraumatic reaction. There may be physical symptoms too including breathlessness, heart racing, over-breathing, dizziness and muscle tension. Try the following ways of reducing physical symptoms.

In order to reduce the severity of physical symptoms it is useful to “nip them in the bud”, by recognising the early signs of tension.

Once you have noticed early signs of tension you can prevent anxiety becoming too severe by using relaxation techniques. Some people can relax through exercise, listening to music, watching TV, or reading a book.

For others it is more helpful to have a set of exercises to follow. Some people might find relaxation or yoga classes most helpful, others find tapes useful. You can obtain a relaxation tape from your GP, and there are also a wide number of relaxation tapes available in the shops.

Relaxation is a skill like any other which needs to be learned, and takes time. The following exercise teaches deep muscle relaxation, and many people find it very helpful in reducing overall levels of tension and anxiety.

Deep muscle relaxation - it is helpful to read the instructions first and eventually to learn them. Start by selecting a quiet, warm, comfortable place where you won’t be disturbed. Choose a time of day when you feel most relaxed to begin with. Lie down, get comfortable, and close your eyes. Concentrate on your breathing for a few minutes, breathing slowly and calmly: in, two-three and out, two-three. Say the words “calm” or “relax” to yourself as you breathe out. The relaxation exercise takes you through different muscle groups, teaching you firstly to tense, and then relax. You should breathe in when tensing and breathe out when you relax. Starting with your hands, clench one tightly. Think about the tension this produces in the muscles of your hand and forearm.

Study the tension for a few seconds and then relax your hand. Notice the difference between the tension and the relaxation. You might feel a slight tingling, this is the relaxation beginning to develop.

Do the same with the other hand.

Each time you relax a group of muscles think how they feel when they’re relaxed. Don’t try to relax, just let go of the tension. Allow your muscles to relax as much as you can. Think about the difference in the way they feel when they’re relaxed and when they’re tense. Now do the same for the other muscles of your body. Each time tense them for a few seconds and then relax. Study the way they fee land then let go of the tension in them.

It is useful to stick to the same order as you work through the muscle groups:

• Hands -clench first, and then relax.
• Arms - bend your elbows and tense your arms. Feel the tension, especially in your upper arms. Remember, do this for a few seconds and then relax.
• Neck - press your head back and roll it from side to side slowly. Feel how the tension moves. Then bring your head forward into a comfortable position.
• Face - there are several muscles here, but it is enough to think about your forehead and jaw. First lower your eyebrows in a frown. Relax your forehead. You can also raise your eyebrows, and then relax. Now, clench your jaw, notice the difference when you relax.
• Chest - take a deep breath, hold it for a few seconds, and notice the tension, then relax. Let your breathing return to normal.
• Stomach - tense your stomach muscles as tightly as you can and relax.
• Buttocks - squeeze your buttocks together, and relax.
• Legs - straighten your legs and bend your feet towards your face. Finish by wiggling your toes.

You may find it helpful to get a friend to read the instructions to you. Don’t try too hard, just let it happen.

To make best use of relaxation you need to:

• Practice daily.
• Start to use relaxation in everyday situations.
• Learn to relax without having to tense muscles.
• Use parts of the relaxation to help in difficult situations, eg breathing slowly,
• Develop a more relaxed lifestyle.

This relaxation exercise may be available on tape from your GP.

Remember, relaxation is a skill like any other and takes time to learn. Keep a note of how anxious you feel before and after relaxation, rating your anxiety 1-10.

Controlled Breathing

Over-breathing is very common when someone becomes anxious, angry or irritable. This means that changes occur in their breathing. They can begin to gulp air, thinking that they are going to suffocate, or can begin to breath really quickly. This has the effect of making them feel dizzy and therefore more anxious.

Try to recognise if you are doing this and slow your breathing down. Getting into a regular rhythm of "in two-three and out two-three" will soon return your breathing to normal. Some people find it helpful to use the second hand of a watch to time their breathing. Other people have found breathing into a paper bag or cupped hands helpful. For this to work you must cover your nose and mouth.

It takes at least three minutes of slow breathing or breathing into a bag for your breathing to return to normal.

Distraction

If you take your mind off your symptoms you will find that the symptoms often disappear. Try to look around you. Study things in detail, registration numbers, what sort of shoes people are wearing, conversations. Again, you need to distract yourself for at least three minutes before symptoms will begin to reduce.

Whilst relaxation, breathing exercises and distraction techniques can help reduce anxiety it is vitally important to realise that anxiety is not harmful or dangerous. Even if we did not use these techniques, nothing awful would happen. Anxiety cannot harm us, but it can be uncomfortable. These techniques can help reduce this discomfort.

Anger

It may be worth talking over your feelings of anger with those around you. Your anger is not really directed at them but may at times be ‘taken out’ on them. Let them know that the anger is because of what you have been through. Ask for their patience until the anger and irritability passes, tell them not to ‘take it personally‘.

4. Overcoming avoidance

Avoidance following a traumatic experience can take many forms. It can involve avoiding talking about the trauma, avoiding becoming upset about the trauma, it can also be that you avoid anything anyone or any situation that reminds you of the trauma. This avoidance prevents you from “moving on” from the trauma and in some cases it can prevent you getting on with your life in a normal way.

Try to recognise the things you are avoiding, it may help to write them down.

Set yourself very small goals to tackle these fears. We call this an ‘anxiety ladder‘. Those situations that we only fear a little are at the bottom and our worst feared situations are at the top.

It may help to look at this example. Mary was held up at gunpoint when she worked as a cashier at a bank. She can no longer go into small offices in public places, she avoids all television programmes and newspapers where there may be reports about violent incidents. She has made up the following anxiety ladder: Least feared: 1.Looking at newspaper reports about the attack. 2.Looking at the 6 o’clock news. 3.Watching ‘Crime Watch‘. 4.Standing outside local building society. 5.Going into local building society. 6.Going into bank in busy area. 7.Going into bank where attack occurred. Most feared She will begin with step 1 and gradually work towards step 7. She will find that her anxiety will gradually reduce as she tackles each new step and she begins to overcome her avoidance.

Remember you may feel anxious at first, but if you are able to stay in the feared situation you will gradually begin to feel calmer.

5. Overcoming low mood, following trauma

People often experience low mood following trauma. This can sometimes give rise to feelings of low self worth, reduced confidence, helplessness and guilt.

It is important not to let any gloomy or negative thoughts go unchallenged. Following trauma people tend to think and expect the worst of themselves, their life and the future. Don’t just accept these thoughts. Try to:

• Identify when your mood is very low.
• Jot down the unpleasant thoughts you are having during that time.
• Try and counter these thoughts by writing down arguments against them. Imagine what you would say to friends if they had such negative thoughts about themselves. This is particularly important if you are feeling guilt.

It may help to keep a diary of things you have enjoyed or achieved during the week. This can help you to concentrate on the good things rather than the bad things in your life.

Do something active

Physical activity is particularly helpful. Walk, run, cycle, skip; anything which begins to increase your activity can help to improve how you feel. Plan 15 or 20 minutes of activity every day, or every other day to begin with. This kind of physical activity can actually begin to make you feel less tired, and can lift your mood.

Find something that interests you and spend some time on it. Plan to focus on things you usually enjoy and build sometime into each day for these activities. You might find it helpful to take up a new interest. Some people find that creative activities that help them to express their feelings such as painting, writing poetry or playing music, can help them to feel better.

Look after yourself

Resist the temptation to cope with your low mood by drinking alcohol, misusing medication or turning to illegal drugs. These may give some immediate relief but quite soon create further health and psychological problems for you to cope with. Eat well; a good diet can help to keep you in good health so recovery is easier.

Try and ‘treat‘ yourself to things you normally enjoy.

6. When should I ask for further help?

We hope the suggestions made in this booklet have been helpful to you. Distress following trauma usually fades with time. However if you feel that you are making little progress then other help is available to aid you in overcoming your problems. Consider this in particular if your work performance or relationships are being badly affected, you feel you are no longer coping, or you have had any thoughts of harming yourself. It is also worth considering seeking further help if your feelings are not improving after some months.

7. Where can I find further help?

Your GP is the best person to talk to in the first instance. He or she will have information about local services which maybe able to help. Your practice nurse or health visitor will also be able to help.

Victim support is an organisation which offers support and practical help to people who have experienced trauma.

Victim Support line: 0845 3030900

[email protected]

The following organisations and help lines may be useful:

• CRUSE Bereavement Line - help line for bereaved people and those caring for bereaved people. Tel: 0870 1671677
• Disability - DIAL - UKnetwork of disability information and advice services run by people with direct experience of disability. Tel: 01302-310123.
• Domestic Violence - Refuge - 24 hour crisis line providing practical advice and emotional support for women experiencing domestic violence. Tel: 0870 5995443
• Claims Line Direct - for people who have suffered an injury in an accident. Will refer onto local solicitors if appropriate. Free call: Tel: 08700 667545.
• Mind Info line: 08457 660163.
• NHS Direct - Telephone help line/information. Talk confidentially to a nurse. Calls at local rate, tel: 08 45 46 47.
• Rape and Sexual Abuse. Rape Crisis Centre - help line for women and girls who have been raped or sexually assaulted. Tel: 0207-8371600.
• Relate - help with marital or relationship problems. Tel: 0845 1304010 (local rate)
• Samaritans. Tel: 08457-909090. Confidential support for anyone in a crisis.

8. Some useful books that you may like to buy or borrow from your library

• Herbert, C., Wetmore, A (1997) Overcoming Traumatic Stress. Robinson London.
• David Burns (1980). Feeling Good, the New Mood Therapy. New American Library. New York.
• Gilbert, Paul (1997) Overcoming Depression. Robinson London
• Hodgkinson, P.E., and Steward, M. (1991). Coping with Catastrophe. Routledge.
• Kinchin, D. (1994). Post Traumatic Stress Disorder – A Practical Guide to Recovery. Thorsons.
• Matsakis, A. (1992). I can’t get over it - A handbook for trauma survivors. Harbinger.
• Parkinson, F. (1993). Post Trauma Stress.

Thank you to Victim Support in Northumberland for helpful comments and suggestions on this booklet.