Post Traumatic Stress Disorder (PTSD) and War-Related Stress

Post Traumatic StressDisorder (PTSD) andWar-Related Stress

AcknowledgementThis information has been adapted fromthe publication Post-Traumatic StressDisorder (PTSD) and War Related Stress,an information handbook producedby the National Centre for War-Related PTSD which is a collaborativepartnership between the CommonwealthDepartment of Veterans’ Affairs, theUniversity of Melbourne and the Austinand Repatriation Medical Centre.Veterans Affairs Canada wishes to thankthe National Centre for providingus with permission to reproduce theinformation.How to Use this BookA large amount of information andadvice is contained in these pages whichmeans that you may want to read asmall bit at a time, slowly and carefully,rather than trying to master it all in onego. You may also feel more comfortablereading this book with your partner,other family members or close friends.This will allow you to share informationas you read so that you can better discusshow it may apply to you or the peopleyou care about.La présente publication est disponible enfrançais sous le titre Le syndrome de stresspost-traumatique (SSPT) et le stress lié à laguerre.This publication is available upon request in other formats.Web site: www.vac-acc.gc.caToll free: 1-866-522-2122Reprinted February 2008© Copyright Her Majesty the Queen in Right of Canada, represented by the Minister of Veterans Affairs, 2006.Cat. No.: V32-95/2006EISBN: 0-662-42626-6Printed in Canada

Post-Traumatic Stress Disorder (PTSD) andWar-Related StressTable of ContentsInformation for Veterans and their FamiliesBackground Information ....................................................................... 1What is PTSD? ......................................................................................... 1What is a Traumatic Event? ....................................................................... 2Common Symptoms of PTSD .......................................................... 3Intrusive Symptoms ................................................................................. 3Avoidance Symptoms ................................................................................ 4Arousal Symptoms .................................................................................... 5Why do Traumatic Stress Symptoms Develop? .......................................... 5Associated Problems ............................................................................ 7Depression .................................................................................................. 7Anxiety ...................................................................................................... 8Alcohol and Drugs ...................................................................................... 9Impact on Relationships and Work ............................................................. 9Family Functioning ..................................................................................... 10Occupational Functioning .......................................................................... 11

Coping .................................................................................................. 12Coping Yourself ............................................................................... 12Coping Within a Family .................................................................. 15Sleeping Better ................................................................................. 16Treatment ........................................................................................... 17Stabilization and Engagement .......................................................... 17Education and Information ............................................................. 18Symptom Management .................................................................... 19Anxiety Management ....................................................................... 20Anger Management ......................................................................... 20Management of Depression ............................................................. 21Medication Self-Management .......................................................... 21Substance Abuse .............................................................................. 22Sleep Disturbance ............................................................................ 22Relationship Difficulties .................................................................. 22Exposure Therapy – Confronting Feared Situations ......................... 23Exposure Therapy – Confronting the Memories .............................. 24Cognitive Restructuring ................................................................... 24Psychodynamic Psychotherapy ......................................................... 25Relapse Prevention ........................................................................... 26Alternative and Adjunctive Treatments ............................................. 26

Background InformationWhether in the military or as a civilian,at some point during our lives nearly allof us will experience a traumatic eventthat will challenge our view of the worldor ourselves. Depending upon a range offactors, some people’s reactions may lastfor just a short period of time, while othersmay experience more long-lasting effects.Why some people are affected more thanothers has no simple answer. In Canada,it is estimated that up to 10% of war zoneVeterans — including war service Veteransand peacekeeping forces — will go on toexperience a chronic condition known aspost-traumatic stress disorder (PTSD),while others may experience at least someof the symptoms associated with thiscondition.What is PTSD?PTSD is a psychological response to theexperience of intense traumatic events,particularly those that threaten life. Itcan affect people of any age, culture orgender. Although we have started to heara lot more about it in recent years, thecondition has been known to exist at leastsince the times of ancient Greece and hasbeen called by many different names. Inthe American Civil War it was referred toas “soldier’s heart,” in the First World Warit was called “shell shock,” and inthe Second World War it was knownas “war neurosis.” Many soldiers werelabelled as having “combat fatigue” whenexperiencing symptoms associated withPTSD during combat. In the VietnamWar, this became known as a “combatstress reaction.” Some of these peoplecontinued on to develop what becameknown, in 1980, as post-traumatic stressdisorder.Traumatic stress can be seen as part ofa normal human response to intenseexperiences. In the majority of people, thesymptoms reduce or disappear over thefirst few months, particularly with the helpof caring family members and friends.In a significant minority, however, thesymptoms do not seem to resolve quicklyand, in some cases, may continue to causeproblems for the rest of the person’s life.It is also common for symptoms to varyin intensity over time. Some people gofor long periods without any significantproblems, only to relapse when they haveto deal with other major life stress. In rarecases, the symptoms may not appear formonths, or even years, after the trauma.www.vac-acc.gc.ca

What is a Traumatic Event?Trauma is a very personal thing. Whattraumatizes one person can be of lesssignificance to others. This variation inpeoples’ reactions occurs because of theirindividual personality, beliefs, personalvalues, and previous experiences (especiallyof other traumatic events in their life).It also occurs because each person’sexperience of the incident is unique.However, in all cases the individual hasexperienced a threatening event that hascaused him or her to respond with intensefear, helplessness, or horror.For military Veterans, the trauma mayrelate to direct combat duties, being ina dangerous war zone, or taking part inpeacekeeping missions under difficultand stressful conditions. For civilians, thetrauma can stem from either man-madeevents (such as physical or sexual assault,accidents, and witnessing the death orinjury of others) or natural disasters(such as fires, earthquakes, floods, and icestorms). There are no hard and fast rulesto define trauma.www.vac-acc.gc.ca

Common Symptomsof PTSDPTSD is characterized by three maingroups of problems. They can beclassified under the headings of intrusive,avoidance and arousal symptoms.Intrusive SymptomsMemories, images, smells, sounds,and feelings of the traumatic event can“intrude” into the lives of individualswith PTSD. Sufferers may remain socaptured by the memory of past horrorthat they have difficulty paying attentionto the present. People with PTSD reportfrequent, distressing memories of theevent that they wish they did not have.They may have nightmares of the eventor other frightening themes. Movement,excessive sweating, and sometimes evenacting out the dream while still asleepmay accompany these nightmares. Theysometimes feel as though the events werehappening again; this is referred to as“flashbacks” or “reliving” the event. Theymay become distressed, or experiencephysical signs such as sweating, increasedheart rate, and muscle tension whenthings happen which remind them ofthe incident. Overall, these “intrusive”symptoms cause intense distress and canresult in other emotions such as grief,guilt, fear or anger.Intrusive Symptoms ofPTSD:• Distressing memories or imagesof the incident;• Nightmares of the event or otherfrightening themes;• Flashbacks (reliving the event);• Becoming upset when remindedof the incident; and• Physical symptoms, such assweating, increased heart rate, ormuscle tension when remindedof the event.www.vac-acc.gc.ca

Avoidance SymptomsMemories and reminders of traumaticevents are very unpleasant andusually lead to considerable distress.Therefore, people with PTSD oftenavoid situations, people, or events thatmay remind them of the trauma. Theyoften try not to think about, or talkabout, what happened, and attemptto cut themselves off from the painfulfeelings associated with the memories.In their attempts to do this, they oftenwithdraw from family, friends, andsociety and begin to do less and less.This may help them to shut out thepainful memories, but it can also leadto a feeling of not belonging to the restof society and no longer taking part inactivities they used to enjoy. In this waythe person can become “numb” to theirsurroundings and not experience normaleveryday emotions such as love andjoy, even toward those close to them.Such reactions can lead to depression,feelings of isolation and problems withinthe family. They can also lead to severeproblems with motivation — peoplewith PTSD often find it hard to makedecisions and get themselves going. Theymay have difficulty making the effortto help themselves or even to do thingsthat they would previously have foundenjoyable or easy. This can be very hardfor family and friends, who often thinkthat the sufferer is just being lazy ordifficult.PTSD Avoidance/Numbing Symptoms:• Trying to avoid any remindersof the trauma, such as thoughts,feelings, conversations activities,places and people;• Gaps in memory - forgettingparts of the experience;• Losing interest in normalactivities;• Feeling cut-off or detached fromloved ones;• Feeling flat or numb; and• Difficulty imagining a future.www.vac-acc.gc.ca

Arousal SymptomsOften people who have experienced atrauma have been confronted with theirown mortality. Their assumptions andbeliefs that the world is safe and fair, thatother people are basically good, and that“it won’t happen to me,” may be shatteredby the experience. After the event, thesepeople often see danger everywhereand become “tuned in” to threat. As aconsequence, they may become jumpy, onedge, and feel constantly on guard. Thiscan lead to being overly alert or watchfuland to having problems concentrating(for example, not able to read a bookfor long, getting only a small amount ofwork completed in a few hours, easilydistracted). Disturbed sleep is verycommon.Anger is often a central feature in PTSD,with sufferers feeling irritable and proneto angry outbursts with themselves, othersaround them, and the world in general.Many Veterans feel let down, abandoned,and judged by others. They may havea sense of betrayal about the way theywere treated by a range of people on theirreturn home or about things that havehappened since. These feelings of betrayaloften result in bitterness and anger. Somepeople only express their anger verbally(which can still be very damaging). Othersbecome physically aggressive and violentto property or people, even to those whoare closest to them. Often Veterans feelunable to control their anger. The powerof their anger may be frightening for themand they often feel considerable remorseafterward. Such symptoms frequentlycause major problems at work, as well aswith family and friends.Arousal Symptomsof PTSD:• Sleep disturbance;• Anger and irritability;• Concentration problems;• Constantly on the look-out forsigns of danger; and• Jumpy, easily startled.Why Do Traumatic StressReactions Develop?It is important to understandthat PTSD often is linked to anoverwhelming experience, or seriesof events, that is hard to accept orunderstand. It doesn’t fit with our viewof the world or ourselves — the way wethink things are or should be. Humanbeings have a natural tendency to tryand make sense of things that happenaround them. When people experiencea trauma, the event keeps comingback into their mind in an attemptto make sense of what happened.This is a natural way of trying to dealwith, or come to terms with, difficultexperiences and seems to work well forwww.vac-acc.gc.ca

many stressful life events. However, dueto the high level of distress associatedwith memories of more severe trauma,the thoughts and feelings tend to bepushed away to protect the person fromthis distress. The result is that while thememory may go away for a period oftime, the need for it to be dealt with hasnot been addressed and it keeps comingback. The movement backward andforward from intrusive thoughts andfeelings about the trauma to avoidanceand numbing can then continue almostindefinitely unless the cycle is addressedin some way.Throughout this, alternating betweenshort bursts of painful memories andperiods of avoidance and numbing, thesense of feeling keyed-up persists. Thetraumatized person has been through anevent that potentially threatened theirlife, or the life of someone else, so themind and body stay on alert to makesure that it won’t miss any sign in thefuture that such an event may recur. Itis safer to get it wrong by overestimatinga potential threat than to risk thepossibility of missing any future threat.The persistent activation of this threatdetection system, however, leaves thetraumatized person feeling keyed-up oron edge much of the time. In addition,the threat detection system is so sensitivethat it is constantly going off when thereis no danger, in a way that interfereswith the person’s capacity to live anormal and happy life.A similar explanation exists with regardto anger. Anger was useful in battle orother situations of threat. It hypes usup and promotes our survival — it mayoften be an adaptive way to respond toa life threatening situation and certainlybetter than being immobilized with fear.Again, however, it is no longer useful forour survival once the danger has passed.In fact, as we all know, it starts to causeserious problems in our day-to-day lives.Traumatic stress reactions are, therefore,sensible and adaptive both as part ofsurvival during the trauma and inattempts to come to terms with thetrauma afterward. Once we recognizewhere these symptoms come from,it is easier to understand the typicaltraumatic stress reactions. The difficultpart is letting go of aspects of thesereactions that have ceased to providebenefit and are primarily interferingwith the traumatized person’s qualityof life.Traumatic stress reactions are,therefore, sensible and adaptive both aspart of survival during the trauma andin attempts to come to terms with thetrauma afterward. Once we recognizewhere these symptoms come from,it is easier to understand the typicaltraumatic stress reactions. The difficultpart is letting go of aspects of thesereactions that have ceased to providebenefit and are primarily interferingwith the traumatized person’s qualityof life.www.vac-acc.gc.ca

Associated ProblemsPTSD is not the only psychologicalresponse to trauma. People may developa range of other problems that canaffect their quality of life, their ability torelate to other people and their capacityfor work. These problems may occuron their own or as part of the PTSD.Many of these problems are thought tobe the result of people trying to controleither themselves and their symptoms(such as alcohol and drug abuse) or theirenvironment (such as avoidance behaviourand angry outbursts). Also, many of thesigns are directly related to stress (suchas skin complaints and general achesand pains). Overall, the most commonlyassociated problems in PTSD are thoserelating to anxiety, depression, and alcoholor drug use. These can be very disabling tothe person suffering from them and mayaffect family members and co-workers.DepressionDepression is a general state of lowmood and a loss of interest or pleasurein activities that were once enjoyed. Lifebecomes flat and grey, and nothing seemsfun, exciting, or enjoyable anymore.These depressed states can be very intense,leading to a total withdrawal from othersand a state of numbness, or they can belower in intensity - just feeling “down inthe dumps.” They may last for as littleCommon Symptomsof Depression:• Feeling low, down in thedumps, miserable;• Feelings of worthlessness,helplessness, and hopelessness;• Lack of energy, easily tired;• Lack of enthusiasm, difficultieswith motivation;• Loss of interest and pleasure innormal activities;• Lack of appetite and weightloss;• Loss of sexual interest;• Difficulty sleeping or sleepingtoo much;• Poor concentration, memory,and decision making; and• Thoughts of suicide or death.www.vac-acc.gc.ca

as a few hours or as long as months oreven years. In more severe cases, theperson may believe that life is no longerworth living. Around 50% of peoplewith chronic PTSD also have significantproblems with depression.Depression is often associated with guilt.People with PTSD often report strongfeelings of guilt, shame, and remorse. Thismay be about the fact that they survivedwhile others did not; it may be aboutwhat they had to do to survive; it may berelated to things they did about whichthey now feel ashamed. The nature of waris such that there are often no acceptableor “good” options: all options are bad (forexample, kill or be killed). Sometimes theguilt results from trying to apply civilian,or peacetime, standards to a combatsituation. If we judge our actions then byour standards now, we may end up feelingguilty and ashamed. For some Veterans,those feelings can be very damaging andcan get in the way of recovery. They arehard to work on, but it is important totry and reduce the intensity and strengthof guilt by challenging the thoughts andbeliefs associated with those feelings.AnxietyAnxiety is best described as a state ofapprehension and worry that somethingunpleasant is about to happen. It is oftenaccompanied by a range of physicalsymptoms which are, in themselves,very frightening. Sometimes peopleexperiencing these symptoms believe thatthey are going to die from a heart attackor go crazy.Anxiety can be specific to certainsituations (such as social events, crowdedplaces, or public transport), or it can bea general state of worry. It can becomevery disabling, as people tend to avoida wide range of situations that makethem anxious. The symptoms are veryunpleasant and may cause a great deal ofdistress.www.vac-acc.gc.ca

Common Symptomsof Anxiety:• Apprehension, fearfulness, orterror;• Shortness of breath and tightnessin the chest;• Palpitations and increased heartrate;• Sweating;• Shaking, trembling, or dizziness;• Fear of losing control or goingcrazy;• Excessive worry;• Feeling restless and on edge;• Muscle tension; and• Physical disorders (e.g., skincomplaints, stomach upsets,aches and pains).Alcohol and DrugsIn an attempt to cope with the unpleasantsymptoms, many people turn to alcoholor other drugs. Around 50% of males and25% of females with chronic PTSD havemajor problems with alcohol and drugs;the figures for Veterans are even higher.The most common problem drug isalcohol but many people also abuse otherillicit drugs (for example, marijuana)or prescription medications. Drug andalcohol abuse impairs the person’s abilityto function effectively and to relate toother people. It can cause great difficultiesin areas such as relationships, work,finances, and can cause violent behaviour.Impact on Relationshipsand WorkTraumatized people can become“consumed” or overwhelmed by theirfeelings. They may become preoccupiedwith survival in situations that theyperceive as threatening. This may leadothers to believe that individuals withPTSD are selfish, thinking only ofthemselves. This “egocentric” behaviour,together with the symptoms of PTSD, canimpact on relationships with family andfriends, as well as on the person’s abilityto function at work, hobbies, or other lifeareas.www.vac-acc.gc.ca

10Family FunctioningPTSD can directly affect family life ona number of levels. A common sign ofPTSD is the inability or difficulty to feeland express emotions (for example, loveand enthusiasm). This may lead partners,family members, and friends to feel“pushed away” and rejected. This, in turn,can leave the sufferer feeling isolated andunloved.In an attempt to reassure themselvesthat they are normal, traumatized peoplesometimes become sexually demanding,yet still find it difficult to be emotionallyintimate. On the other hand, feelings ofworthlessness, anxiety, and depressionmay result in a complete loss of interestin sex and difficulties becoming aroused.This tends to compound feelings ofinadequacy or guilt and their partner maybecome resentful and hurt.Traumatized people often feel a moregeneral sense of detachment - feelinggenerally “cut-off” from other people.This often leads to reduced participationin activities and hobbies that they usedto enjoy before the trauma. This absenceof shared enjoyable activities makes itdifficult to have a normal family life. Thepartner is often left with the full burdenof running the family. In some cases, agreat deal of time is spent focussing onthe Veteran’s problems at the expense ofthe partner’s needs.Traumatized people are often tired, due todisturbed sleep and depression, and canbecome cranky and irritable. The inabilityto get a good night’s sleep frequentlymeans that the person simply has lessenergy to offer the relationship. Theymay say hurtful things without reallyconsidering the implications of what theyare saying.Traumatized people may try tocompensate for their feelings of fear andvulnerability by using anger to pre-emptany perceived potential threat. As oneVeteran stated “the best form of defenceis attack.” This fear can also motivatetraumatized people to act in controllingways toward family members in attemptsto protect them from perceived dangers.Over a period of time, these problemswith family and friends can severelyerode trust and intimacy. Eventually, itmay become too much for those closeto the individual. Following trauma, thelikelihood of separation and divorce isconsiderably increased.www.vac-acc.gc.ca

11Occupational FunctioningThe traumatized Veteran may havedifficulty coping with pressure at work.Irritability, jumpiness, mood swings, poorconcentration, and memory problemsmay lead to disputes in the workplace andfrequent job changes.They may be intolerant of other peoples’inefficiency, comparing civilian lifewith the organized, military way. SomeVeterans with PTSD adopt a workaholicpattern, shutting themselves away in theirwork and putting in very long hours.This seems to be part of the avoidancecomponent of PTSD — keeping verybusy helps to prevent the memories andunpleasant thoughts coming back. OtherVeterans find that their problems prohibitthem from working effectively at all.The decision to stop work is a difficultone. The Veteran needs to weigh upthe personal cost of remaining in theworkforce against the benefits of tryingto continue work, perhaps with reducedhours or responsibility (for example, senseof belonging, achievement, self esteem,and financial well-being). Althoughthe benefits of a regular pension andretirement from the workforce may seemvery appealing, this is not a decision thatshould be taken lightly.Problems such as irritability,mood swings, poor concentration,and memory disturbance canoften interfere with the Veteran’scapacity to work effectively.Alternatively, the Veteran may usea “workaholic” pattern as a way ofattempting to avoid the unpleasantmemories.www.vac-acc.gc.ca

12CopingIt is not very helpful to think of“curing” PTSD in a black-and-white,all-or-nothing manner. Everyone whoexperiences trauma will be affected by itdifferently. Some of those changes may bepositive — for example, the survivor maybecome stronger in some ways, perhapsmore caring and understanding of others’misfortune. They may find that theexperience has better equipped them todeal with future life stress. Unfortunately,some of the changes will be negative,especially in cases of PTSD, and copingwith even the smallest frustrations anddifficulties becomes a major challenge.Some people who develop PTSD seem torecover completely and are left with littleor no on-going distress and impairment.For others, the symptoms may persistand the individual must learn to manageand cope with them in order to minimizethe effects on their lives. There is muchthat people with PTSD can do to helpthemselves deal with the disorder.Coping YourselfThe following is a list of tips that somepeople have found to be useful. Many ofthem are basic common sense, but thatdoes not mean they are unimportant.On the contrary, if you can do the basics(which is not easy) you will go a longway to successfully managing your PTSDsymptoms.Do not try to do everything at once.When you have read the followingsections, you may wish to stop for a whileand work out a “plan of action.” Whichstrategies sound particularly useful foryou? Which ones are you prepared totry? We suggest that you select only oneor two to begin with. Work out a planto achieve them, one at a time, and setyourself some realistic goals for the nextweek. At the end of the week, review yourprogress: modify your goals if necessaryand/or try some additional strategiesfor the following week. Over time, youwill gradually develop a range of copingstrategies and changes to your lifestylethat will help you to feel more in controlof your symptoms and get more out oflife. You may be able to find programsin your local community to assist withsome of these areas. Here are some simplestrategies to help you cope:www.vac-acc.gc.ca

• Eat healthy meals. This sounds sosimple, but how many of us actually doit? A poor diet will increase your stresslevels - if in doubt, talk to your doctoror a dietician.• Get regular aerobic exercise likewalking, jogging, swimming, or cycling.You might want to take the opportunityto go for regular walks with yourpartner. Exercise is vital in effectivelymanaging stress. If you have PTSD,your body is almost constantly gearedup for “fight or flight.” Exercise helps toburn up those chemicals that are hypingyou up and will help you to becomemore relaxed.• Get enough rest, even if you can’t sleep.Rest will help to increase your reservesof strength and energy. You may wish totry some kind of meditation, yoga, orrelaxation exercises.• Establish daily routines (e.g., go to bedat a set time, get out of bed at a set time,plan activities for the day). Routine isvery important in helping us to feel incontrol and to function effectively.• Set small, realistic goals to help tackleobstacles. At first, things may seeminsurmountable but broken downinto small steps they are manageable.Some people like to keep lists of tasksto accomplish when they feel capable,crossing them off as they are completed.This can be very rewarding, and helpyou to acknowledge that you areachieving something.• Redefine your priorities and work outwhat is, and is not, achievable. Try to berealistic - expect neither too much nortoo little of yourself. Then focus yourenergy and resources on those priorities.• To help stop the constant streamof worrying and anger-producingthoughts, set aside a specific timeeach day for thinking. Give yourselfpermission to reflect and deal withissues related to the trauma atappropriate times for a defined period(perhaps 30 minutes each day). Ifunwanted thoughts come into yourmind at other times, gently remindyourself that you will be thinking aboutit later in the day.• Ask for support and help from yourfamily, friends, church, or othercommunity resources when you needit. This is not a sign of weakness. Ingeneral, other people are very keen tohelp as long as you let them know whatyou want.• Join or develop support groups - sharingexperiences with others who understandis often useful.• Continue to educate yourself and yourfamily about reactions to trauma. Agood understanding of PTSD andrelated disorders is important in comingto terms with your experiences andbeginning to deal with your problems.13www.vac-acc.gc.ca

14• Look after your partner, if you haveone. Try to clarify your feelings andassumptions about him or her, andcheck out whether those feelingsand assumptions are accurate. Manyproblems are caused by one partnerjumping to conclusions or assuming thatthey know what the other is thinking.Remember that men and women tendto react differently. Women tend to becaretakers and put others first. Men tendto have more difficulty acknowledgingand expressing feelings of sadness andhelplessness and believe in “toughing itout.” We all like our partners to say anddo things that show that they value andcare for us — make an effort to do thisfrom time to time.• Acknowledge unresolved issues and behonest with yourself: what do you stillfeel hurt, frightened, angry or guiltyabout? Recognizing, and admittingto, the issues is an important first stepto recovery. Use the hurt and painas a motivator to make the necessarychanges to heal (i.e., if you don’t want tocontinue feeling like that, what can youdo about it?).• Talk to your children. Try to besupportive and patient. Obviously, thisis not always easy, but losing control andgetting angry only makes things worse.Set an example by expressing yourfeelings gently, controlling your anger,and showing problem solving skills indealing with family difficulties as theyarise. (What exactly is the problem? Let’swork out a plan to handle it).• When you’re feeling rotten, rememberthat those around you are probably alsounder stress.• Focus on your strengths and copingskills. It may not feel like it at times,but you have many strengths andstrategies to deal with difficult times.• Try not to use your PTSD or yourwar experiences as an excuse forhurting yourself or others. There is noexcuse for being violent, aggressive,or otherwise mistreating other humanbeings. It is important that you takeresponsibility for your own behaviour.• Remember that you are not alone. Lotsof other Veterans over the centurieshave experienced these kinds ofproblems. There is always hope.Simple Strategies:• Eat healthy meals;• Exercise regularly;• Get lots of rest;• Establish a daily routine;• Identify priorities and set realisticgoals;• Allow yourself a little time each dayto reflect on the trauma;• Ask for support;• Educate yourself about PTSD;• Care for your partner and yourchildren;• Acknowledge unresolved issues;• Focus on your strengths;• Take responsibility for your illness; and• Remember you are not alone.www.vac-acc.gc.ca

Coping Within a FamilyPartners and close friends are often ata loss as to how to help someone withPTSD. There are several things that lovedones can do to help the traumatizedperson and you may find the followingsuggestions useful:• If possible, listen and empathize whenthe traumatized person wants to talk.Remember that it may be very hardfor them to express what they’re goingthrough. A sympathetic listener isimportant in minimizing the tendenciesof people with PTSD to withdraw and“shut down.” It is best not to say “Iunderstand what you’re feeling” (youprobably don’t, since you haven’t beenthrough the same experiences). Instead,show your empathy by comments suchas: “It must be really difficult for you;I can see that it upsets you; is thereanything I can do to help?”• Spend time with the traumatizedperson. There is no substitute forpersonal presence. Just keep doing theusual things that people do together. Donot feel that you have to talk about thetrauma or be their counsellor. Just beingwith people who care about them is veryimportant for traumatized individuals.Equally, try to respect the person’s needfor privacy and private grief at times.• Don’t tell survivors that they are “luckyit wasn’t worse” or to “pull themselvestogether and get over it.” They are notconsoled by such statements. Tell them,instead, that you’re sorry they wereinvolved in such an event, and that youwant to understand and assist them.• Reassure them that they are now safe.• Care about each other. Give hugs. Telleach other how much you appreciatethe other. Offer praise. Make a pointof saying something nice to eachother every day. Good relationshipsare characterized by lots of positiveinteractions, but they take a lot of hardwork.• Don’t be afraid to suggest that they seea clinical psychologist, psychiatrist, orcounsellor, or that they seek supportfrom peer groups. But remember to dothis in a tactful and caring manner - notin the middle of an argument!• Laugh. Use humour (although notabout the traumatic event).15www.vac-acc.gc.ca

16Sleeping BetterSleep disturbance is very common inPTSD and in depression. Medicationsometimes helps, but it should be usedwith caution and only as directed byyour doctor. There are several simple“non-drug” strategies you can try that canbe very helpful in improving sleep:• Get into a regular routine. In particular,get up at the same time each morningeven if you haven’t slept well.• If you are not asleep within 30 minutes,get up for a while before returning tobed. If you don’t drop off within 30minutes, get up again and so on.• Try to avoid caffeine (coffee, tea, cola,chocolate) after 6 p.m. Avoid alcoholand, if possible, cigarettes after yourevening meal. Try not to eat a mealwithin a couple of hours of going tobed.• Start a gentle exercise routine. Losing abit of weight often helps with sleep.• Don’t do anything in bed except sleep(and, perhaps, sex): don’t watch TV,read, do crosswords, or think worrisomethoughts.• Get into the habit of doing somethingrelaxing before bed: listen to a relaxationtape or some soothing music, have awarm bath, slow down!• Try not to worry about not sleeping:the more you worry about it, the lesslikely you are to drop off to sleep. Youcan survive without much sleep, eventhough you will be tired.• Sleep, like any habit, takes a whileto change. Try to stick to the aboveguidelines for at least two weeks beforedeciding whether or not they help.www.vac-acc.gc.ca

17TreatmentObtaining appropriate treatment forPTSD is not always as straightforward asone might think. First, the person has toaccept that there is something wrong andsee the benefit of seeking help. Gettinghelp is often frightening — for many,it is a leap into the unknown — butwithout this first step, progress is notpossible. Secondly, it is not always easyto find a professional who understandsPTSD and to whom you can relate andtrust. Sometimes it may be necessary totry a few different sources of help untilyou find the right one for you. Try askingyour doctor, community health centre,or Veterans’ organization for advice orprofessional references. There are manydifferent aspects to treatment and manydifferent approaches. However, thissection will deal predominantly withthe most common forms of treatmentand the ones that have been shown to beeffective. Most require the services of anexperienced mental health professional.It is important to remember thattreatment can be painful and hard work.Unfortunately, there is no easy way toget rid of the memories or make themless distressing. There is no magic wandand no “sweet oblivious antidote.” Butthe long term gains can be enormous:effective treatment can dramaticallyassist your recovery, helping you to live anormal life once again.Treatment for PTSD often involvesseveral stages:• Crisis stabilization and engagement;• Education about PTSD and relatedconditions;• Strategies to manage the symptoms(such as anxiety, anger, depression,alcohol abuse, sleep problems, andrelationship problems);• Trauma-focussed therapy (confrontingthe painful memories and fearedsituations);• Cognitive restructuring (learningto think more realistically andre-evaluating the meaning of the event);and• Relapse prevention and ongoingsupport.Stabilization of a Crisis andEngagement in TreatmentPTSD symptoms are not usuallyconstant in their intensity. Rather, theytend to fluctuate and there may betimes when they “flare up” or worsen.Although this can occur at any time, it ismost likely to be triggered by things suchas anniversaries or other reminders of thetrauma and stressful life events such asfamily arguments, problems at work, orthe death of a friend or relative. Becausecrises can occur at any time of the day orwww.vac-acc.gc.ca

18night, PTSD sufferers and their familiesshould know how to access 24-hourtelephone counselling services. Althoughtalking on the telephone to someone youdo not know may not sound like muchhelp, it can often be very effective. Itmay help you get through the night orweekend until other support is available.During especially difficult times it maybe necessary for the Veteran to attendhospital as an in-patient. During his orher stay, the crisis may be treated withmedication, psychotherapy, and generalcounselling. As well as stabilizing thesymptoms, a brief in-patient stay alsoprovides a “time-out” period for both theVeteran and their family to refocus ontheir direction.It is important that any current lifecrises are resolved, or at least put “onhold,” before the real treatment ofPTSD can begin. It is not possible todevote the necessary concentration,time, and energy to your recovery ifyou are constantly worried about yourjob, your relationship, your children, orother important life areas. That is not tosay that you have to be able to solve allthose problems before you can work onyour PTSD, but you will need to be ableto put them to one side for a while toconcentrate on your treatment. Therapyis hard work — there is no easy way todo it — and you will need to devote allyour personal resources to the task.The first part of treatment will oftenbe devoted to developing a relationshipwith the therapist (or the treatmentteam if you are taking part in a groupprogram). You will need to spend sometime getting to know each other, andbuilding trust, if you are to work onthe difficult issues. We call this process“engagement.” For many Veterans withPTSD, this is a very difficult process— it may have been a long time sincethey really trusted another person,particularly someone who is not aVeteran. In many cases, you will need totell your therapist about experiences andfeelings that you have never discussedwith anyone before. We need to recognizethat this is a difficult process that will takea lot of courage, but it will be worth itand it is the only way to recovery.Education and InformationTrauma can sometimes feel like anincomprehensible cloud that hangs overall areas of the person’s life. The first stepin treatment is to understand exactly whattrauma is, why you have the symptomsyou do and, therefore, why it is treatedthe way it is. In this regard, it is hopedthat this information is a first step inunderstanding the disorder.You need to know what the commonsigns and symptoms are, and you need torecognize that you are not alone - manypeople who have experienced traumaticevents have responded in exactly the sameway as you have. You need to understandwww.vac-acc.gc.ca

why the symptoms have appeared- the fact that they were very useful forsurvival while the traumatic events werehappening, but that they are no longeruseful. They have become “maladaptive”and now only serve to create problems anddistress for you.You need to understand what treatmentwill involve and how it may affect you.It is very important that you feel able toask your therapist questions about thenature of your problems and the processof treatment. He or she will not haveall the answers, but together you willreach a better understanding of what hashappened and how you will recover.Sometimes, people who have beenthrough a traumatic event have troubleunderstanding what happened and whyit happened. This is because, when weare under threat, our attention is veryfocussed on the source of the danger andwe do not take in all the other things thatare happening around us. We may end upwith a distorted and confused memoryof the experience, so that it becomesdifficult to understand and make senseof the event. This confusion often stopsus from being able to put the experiencebehind us. For this reason, your therapistmay help you to find out more about whathappened during the event. (Althoughwe have put this under the headingof “Education and Information,” it isactually something that may happen atseveral stages throughout treatment.)This process is important in beingable to “put the pieces of the jigsawpuzzle together” and make sense ofyour experience. A good understandingof exactly what happened and why ithappened often facilitates recovery.Unfortunately, of course, this is not alwayspossible. Sometimes you may never findout exactly what happened or, morecommonly, why it happened and you haveto learn to live with that uncertainty.Symptom ManagementAs already noted, PTSD has manysymptoms that interfere with thetraumatized person’s daily functioning.Part of treatment usually involvesproviding the person with strategies tocope with and manage these symptoms.Medication will often play a part in thisstage of treatment. Unfortunately, suchstrategies rarely make the symptoms goaway altogether. However, they helpsufferers to carry on with their day-to-dayfunctioning, no longer being “helplessvictims” of the symptoms. A range ofstrategies may be used and some ofthe more common are outlined below.However, it is important to keep in mindthat the following is just a guide; anexperienced and qualified therapist canhelp you accomplish these techniques.19www.vac-acc.gc.ca

20Anxiety ManagementTechniques aimed at reducing levels ofanxiety and arousal are an important partof treatment.Anxiety ManagementTechniques:• Relaxation training to reduceoverall levels of anxiety;• Breathing techniques to reducepanic-like symptoms;• Thought-interruption methodsto break the tendency to‘ruminate’ or think excessivelyabout the past;• Rational self-talk to help managehigh anxiety situations anddepressing thoughts;• Techniques to help you organizeyour time effectively, schedulingenjoyable and productiveactivities and providing somestructure to your days.Anger ManagementTechniques to reduce levels of anger andirritability with others are important.Strategies that are commonly usedinclude:• Education to understand the natureand purpose of anger;• Methods of identifying early warningsigns of stress and irritability;• Methods of identifying high risksituations and how to prepare forthem;• Methods of realistically re-evaluatingthe situation, keeping it in perspective;• Strategies to reduce arousal and staycalm in difficult situations;• Effective communication methods(verbal and non-verbal);• Differentiating assertive fromaggressive behaviour;• Problem solving strategies to effectivelydeal with disagreements;• Distraction and removal techniques toavoid “flare-ups”; and• Practice in imagined and real-lifesituations.www.vac-acc.gc.ca

21Management of DepressionPeople with PTSD frequently developsymptoms of depression.Strategies to Reduce andManage Depression:• Increasing positive, enjoyableevents and scheduling these intodaily living;• Resolving the underlyingassumptions and beliefs aboutthe self (e.g., “I’m a worthlessfailure”) or the world (e.g.,“Nobody cares about me”) thatcan lead to feelings of sadness anddepression;• Identifying patterns of depressivethoughts on a day-to-day basis;• Realistically evaluating andchallenging negative beliefs andthoughts; and• Rational, realistic copingself-talk.Medication Self-ManagementMedication is frequently used tohelp manage severe PTSD symptoms(although, on its own, it will not changethe underlying problems and shouldbe combined with other treatments).To minimize unintended difficultiesassociated with medication, thefollowing strategies are frequently used:• Education about the use and effect ofthe substance;• Education about possible side-effectsand activities or substances to avoid;• Methods of keeping track ofmedication use;• Discussing the effects and desireto change medication with yourpsychiatrist; and• Methods of reducing and stoppingmedication intake.www.vac-acc.gc.ca

22Substance AbuseMany people with PTSD attempt tocope or “self-medicate” with excessiveamounts of alcohol and inappropriatedrug use (including prescribed drugs).Treatment for SubstanceAbuse:• Education about the use andeffect of the substance;• Decisions regarding totalabstinence versus controlled useof the drug;• Recording “danger” times andidentifying patterns of use;• Developing coping strategies forhigh risk times;• Assertiveness training for whenothers are applying peer pressure;• Planning and scheduling activitiesnot associated with the substance;and• Response prevention - methods ofresisting the ‘urge.’Sleep DisturbanceMany sufferers of PTSD reportdisturbances of sleep. Several strategiesmay be useful in addressing the difficultyof going to sleep, waking repeatedlythroughout the night, or waking early inthe morning. It is common for therapiststo assist clients in developing a healthysleep routine in line with the suggestionsprovided above. Other strategies,including medication, may be adoptedwhen those are not proving effective.Relationship DifficultiesPeople who have been traumatized oftenlose track of who and what they cantrust in the world. This often has a majorimpact on relationships. To address thedifficulties that can occur between couplesand family members, PTSD sufferersare frequently taken through a range ofstrategies to improve relationships.Some of the methods used may includeactive listening (how to really listen toyour partner or children), communicationtraining (how to say effectively whatyou need and feel), and problem solving(how to solve everyday problems withoutfighting). Some of this may occur with theVeteran alone and some with their partner.Separate support and counselling for thepartner is often beneficial. Sometimesfamily therapy is provided, where thewhole family meets to address their issues,with the aim of developing a healthyenvironment for all.www.vac-acc.gc.ca

Exposure Therapy –Confronting Feared SituationsAnxiety frequently causes people to stayaway from the frightening situation. It isquite normal for people to want to escapeor avoid situations, thoughts, memories,or feelings that are painful or distressing.However, this is one of the majorimpediments to recovery.Avoidance and escape providetemporary relief — the anxiety reduces.Unfortunately, the next time the personencounters that situation, he or she islikely to become anxious long beforeit is planned to occur. We call this“anticipatory anxiety.” The more thesituation is avoided, the more the personcontinues to believe that it is dangerous.Further, even if the person does notavoid, the anxiety may continue to buildonce they are in the situation. You mayhave had this experience in a range ofsituations, such as going to a shoppingcentre or watching a movie about war.Very often people believe that if they donot leave the situation they will “losecontrol,” “go crazy,” “have a heart attack,”or have some other dire consequences. Atthe very least, they are likely to believe thatthe unpleasant feelings will be intolerable.Exposure therapy aims to show that thisis not the case by helping the person toconfront the feared situation. This is donein a very controlled and gradual fashion,overseen by therapists who are experiencedwith the procedure, so that discomfort iskept to a minimum. By building uponrepeated successes in facing these fearedsituations, the person is eventually able toconfront them without anxiety and theyare no longer avoided.In many ways, this approach is commonsense. Let’s take an example of a little boywho is standing on the beach when a bigwave knocks him over. He becomes veryfrightened of the sea and refuses to goto the beach the next day. How wouldhis mother or father help? In order toovercome the fear, his parents may takehim for a walk along the beach, stayingaway from the sea, holding his hand andreassuring him. Gradually, they walkcloser and closer to the water’s edge.Eventually, the boy is able to go intothe sea again unaided. This is a simpleexample, but exactly the same processapplies to treating more severe andcomplex fears in adults.In conducting exposure treatment,your therapist will work with you inconstructing a hierarchy — a list of fearedsituations in order of difficulty. Treatmentinvolves tackling each item, one at a time,and moving on to the next only whenyou are confident to do so. More difficultitems may be broken up into several steps.Exposure treatment can be difficult andpainful, but it is the most effective way oftreating many anxieties.23www.vac-acc.gc.ca

24Exposure Therapy –Confronting the MemoriesA form of exposure therapy is also used totreat distressing memories of the trauma.In cases of PTSD, the memories arethe “feared situation.” These memoriesare so frightening, and cause so muchdistress, that the person tries to avoidor escape from them by blocking themout. Often, exposure treatments are usedto assist in confronting the memories.Exposure is only one term used to describethis process. Some people talk about“trauma focus work,” “working throughthe trauma,” “coming to terms with theexperience” or simply “confronting thememories.”Exposure-based treatments are not foreverybody. In some cases, if the memoriesare not causing too much of a problem,it may be best not to drag everythingup again. You may wish to talk to yourtherapist about whether this approachwould be beneficial for you.Cognitive RestructuringFollowing a traumatic experience, peoplemay be left with a range of negativeinterpretations or beliefs about whathappened, as well as about themselves andthe world. For example, they may thinkthat they are bad or evil for acting in theway they did; they may think that whathappened was their fault; they may seethemselves as weak or inadequate; theymay think that the world has become adangerous place and that other people arenasty, cruel, and out to take advantage.Sometimes, there may be elements of truthin these thoughts. Often, however, theyare completely untrue or, at least, grosslyexaggerated. This kind of thinking leadsto all sorts of unpleasant emotions suchas depression and guilt, anxiety, fear andanger. Sometimes therapy will be aimed athelping the person to identify maladaptivethoughts, to challenge and dispute them,and to replace them with a more realisticview of themselves and the world.In a similar vein, people often believe thatcertain events cause specific reactions. Forexample, one may believe that being ina crowded shopping centre causes panic,as if there is some automatic connectionbetween shopping centres and panic.However, the anxiety that people feelis not the result of the event itself. Aninanimate object such as a shopping centrecannot make someone anxious by its owndoing. Instead, it is our interpretationabout the situation that creates the anxiety,and this interpretation is based uponwww.vac-acc.gc.ca

eliefs we hold. In the above example theactive belief may be that one is in dangerof being trapped. Therefore, when theperson is in a shopping centre they mayhave thoughts such as “I’m trapped, I can’tescape, I’m going to lose control.” It isthese thoughts that cause the feelings ofpanic.Cognitive restructuring is a procedurewhereby people’s thoughts, beliefs andinterpretations about past experiences areidentified and mistakes in thinking arehighlighted. (Cognition is just a technicalword for thoughts.) For example, it maybe that the person is thinking in “blackand white terms” — seeing things as allgood or all bad — when in reality theworld holds much that is “grey.” It maynot be perfect, but it’s not all bad either.You may be over-generalizing (e.g., “noone can be trusted”) or over-focussingon the negatives and minimizing thepositives in most situations. They may seeone negative thing as confirmation thatthey are not coping, while ignoring otherevidence that they are, in fact, copingquite well.Once these erroneous thoughts andpatterns are discovered, it is the goal ofcognitive therapy to replace them withmore adaptive, realistic and flexible beliefs.This includes re-evaluating our experiencesand, in particular, the traumatic event.It is a difficult process that can take a lotof hard work, but it can be very effectivein minimizing and managing unpleasantemotions.PsychodynamicPsychotherapyTherapists working with a psychodynamicapproach attempt to integrate the person’straumatic experience with their life as awhole. They do not focus on symptomsalone, but seek to make connectionsbetween the traumatic experience andvulnerabilities in the person’s earlier life.They try to understand how currentsituations evoke traumatic responseseven though the original trauma is past.This approach seeks to understand theway in which the individual continues tointerpret the world in distressing and oftenself-destructive ways.Disruptive and traumatic experienceearlier in life can predispose the individualto more deeply troubled responses totrauma later in life. So, for example,even though he would not have beenresponsible, a young boy may feel thathe caused his parents’ relationship tobreak-up, leading to divorce. Later in life,as a young man, he may feel responsiblefor the death of his comrade in the war,even though in fact he would have beenpowerless to prevent his friend’s death.Psychodynamic psychotherapy canbring to light connections between suchexperiences. By means of this process, itmay free the individual from excessiveand unreasonable guilt (for example),once these experiences have been workedthrough.25www.vac-acc.gc.ca

26However, the focus of the therapy is oncurrent life experience and persistingdifficulties. The past is revisited only tothe extent that it is being replayed inthe present, often in self-defeating ways.Psychodynamic therapy is usually a longerterm therapy and is not suited to allpeople.Relapse PreventionFor some people, even followingtreatment, PTSD can be a chronicdisorder with lapses from time to time.Preventing a recurrence of symptomsis very important for Veterans withPTSD. Times of stress (for example,family or work problems, bereavements,and financial difficulties) may lead to arecurrence of symptoms in some people.When this happens, it is important toremember that it was expected and not tofeel that you are back to square one. Aslong as it is not too severe, and does notlast too long, you can deal with it.As part of treatment, it is common toprovide specific help directed towardmaintaining the gains made duringtherapy and, as far as possible, avoidingrelapse. In order to do this, the copingstrategies listed above are integrated intoall areas of the person’s life in order tominimize causes of stress and its intensity.www.vac-acc.gc.caCoping StrategiesEducation and discussion to identifythe early warning signs of a relapse isimportant - the earlier you recognizethat things are going wrong, the morechance you have of doing somethingabout it. Skills acquired duringtreatment can then be applied to copewith the recurrence of symptoms. Attimes, additional help may be required— do not hesitate to seek professionalassistance if you think you need it.Possible sources of help in case ofrelapse should be identified as part oftreatment so that you know where toseek help quickly if you require it.Alternative andAdjunctive TreatmentsThere are a host of other treatmenttechniques ranging from homeopathyto hypnosis that, while not being “runof the mill,” can help some people. Insome cases, these alternative techniquesare used only when more mainstreammethods have proved ineffective or asan adjunct to those treatments, whenappropriate. Remember: everyone reactsdifferently to therapy and, occasionally,some treatments may do more harmthan good, especially in the hands ofinexperienced practitioners. Beforeembarking upon these treatments, youshould discuss the possibilities with askilled mental health professional who isknowledgeable in all available resourcesfor the treatment of PTSD.

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