Post-Traumatic Stress Disorder (PTSD)
I became interested in trauma and PTSD after working in conflict zones like Iraq and Gaza. But I soon learned that the condition goes well beyond military experience or combat violence. PTSD can result from all manner of traumatic experiences that could happen to anyone, anytime. My research looks at how the general public understands PTSD, and what happens when people with PTSD return to the scene of a traumatic event. I have also worked extensively in the NHS with trauma patients who have experienced everything from car accidents to surviving murder attempts.
What is PTSD?
Post-Traumatic Stress Disorder or PTSD is a collection of symptoms that can result following exposure to a traumatic event. This is often an incident where the person felt their life was at risk, but can be much broader, for example witnessing violence towards others, or repeatedly hearing about or seeing traumatic events (as might happen if you were an ambulance worker or child abuse investigator, for example). The key symptom of PTSD is flashbacks: moments where a memory of the event comes to your mind and it feels like the incident is happening again. This sense of 'current' danger (even though the event was in the past) can produce intense reactions for people, including panic attacks. This typically leads to people avoiding other people or places that might trigger off flashbacks. Similar experiences can occur in the form of nightmares. People with PTSD are often constantly watching out for signs of danger in their environment, and develop negative beliefs about themselves, others and the world generally. Many people with PTSD also experience depressed mood and around half of all people with PTSD would also meet criteria for a diagnosis of depression.
How the general public (mis)understands PTSD
I mentioned earlier that I used to associate PTSD with war - combat and conflict. This is a stereotype shared by many members of the public. I ran a study in 2013 with Professor Adrian Furnham at UCL and Dr Ian Tharp at Greenwich University. Thanks to Tweets about the study from celebrities including Riz Ahmed, Dara O'Briain and Al Murray, we received over five thousand responses. The survey gave members of the public a description of a person suffering all the sypmtoms of PTSD, without saying that it was a case of PTSD. Each person taking the survey was randomly allocated a slightly different version, however. In one third, the person in the description had been serving in Afghanistan as a soldier. In another third, they were an engineer electrocuted at work. In the final third, they were the victim of a rape. Identical symptoms, different causes. Over 70% of those shown the soldier story said it was PTSD, dropping to 60% for the industrial accident, and dropping below 50% for the sexual assualt. Our stereotypes about who experiences PTSD and what causes it can affect our ability to recognise it. And that means that some people suffering from PTSD may not be getting the care they need.
Also around 2013, the American Psychiatric Association revised its definition of PTSD to include cases where people had not been exposed directly to the trauma, but had sustained exposure to accounts, images, eyewitness statements and other indirect representations of the trauma. For decades PTSD had been something only those directly experiencing the trauma were thought to develop. Now, we recognise that indirect exposure can lead to it too. This is particularly important for professionals such as emergency service staff or health and other care workers who may need to investigate issues like child abuse or domestic violence regularly. In 2016 I collaborated with Prof Furnham again alongside a UCL Psychology student, Cheuk Yan Lee, to investigate public understanding of this direct versus indirect exposure difference. 59% of people shown a story about direct exposure said the person had PTSD. Change the story to give the person indirect exposure only, and despite experiencing all the same symptoms only 25% of people believed that was PTSD.
Both of these pieces of research show the need for greater education around who experiences PTSD, and what can cause it - the factors are much broader than we might think.
Returning to the scene of a trauma
I have also worked clinically in the NHS with many people who have experienced PTSD.
One type of psychological treatment proven effective for reducing the symptoms of PTSD is Trauma-Focussed Cognitive Behavioural Therapy (TF-CBT). This treatment asks the client to talk through the trauma in detail, in the first-person present tense, ‘re-living’ the event in a safe space. As this unfolds, the therapist prompts the client to label emotions, thoughts, beliefs and physical reactions as they tell the story of what happened. For some people, it is the first time they have talked through the event since it happened.
The aim of this process is to access the raw, emotional memory, and process it verbally to reach a state where reminders of the event do not trigger ‘flashbacks’ or panic attacks. Towards the end of treatment it is advised – where possible and safe – to visit the scene of the trauma, accompanied by the therapist for support. I joined Dr Hannah Murray and Dr Nick Grey to investigate what happens when people return to the scene of a trauma – to our knowledge the first research on this issue. We interviewed 25 trauma patients who had returned to the scene with their therapists.
We found that a visit to the trauma site was – contrary to what you might think – really helpful for the majority of clients who undertook it. People found that the visit enabled them to access new information and correct inaccuracies in their memory. For example, a person might be angry with themselves because they didn’t react differently during the trauma (“The door was only a couple of metres away, why didn’t I get out?”), but visiting the site can show them that there was no alternative to what they did (“The door was ten metres away and my attacker was blocking my path to it.”). People often remember new details about an event that help them process the trauma, filling the gaps in fragmented memories. They can also be encouraged to spot differences between the site of a trauma now and how it was at the time of the event – this helps put the trauma in the past. Put all this together, and the visit left people with a sense of closure and being ready to move on with their lives.
PTSD is a disorder of memory and anxiety reactions, which can occur in response to both direct and indirect exposure to traumatic events. Though often associated with military combat, PTSD can arise from experiencing or witnessing car accidents, muggings, sexual assaults, other serious accidents and natural disasters, in addition to many other causes. There are effective evidence-based treatments for it, including TF-CBT. Going back to the scene of a trauma as part of a structured TF-CBT course can be a powerful therapeutic experience. We need to do more to educate people about PTSD: its symptoms, range of causes, and the potential for indirect trauma exposure to produce PTSD symptoms.