PTSD

The memory can push its way in without warning. It might come as upsetting pictures, thoughts, or nightmares. In a flashback, a person can feel as if they are back in the moment, with a pounding heart or sweating.

Reminders, like a word, a smell or a place, can set these off. This is the alarm system firing, not a sign of “dwelling on it”.

Avoidance can be obvious, like no longer driving after a car crash. It can also be quiet, like changing the subject, staying very busy, or pushing feelings away.

Avoiding brings short-term relief, which is why it is so tempting. But it can slowly shrink a person’s world and keep the fear from ever being processed.

Trauma can change how someone sees themselves and the world: “I’m broken.” “Nobody can be trusted.” “It was my fault.” People may lose interest in things they used to enjoy, feel distant from others, or find it hard to feel happy or loving.

Some people can’t remember important parts of what happened. Others carry heavy guilt, including guilt for surviving when others didn’t. The Survivor’s guilt guide goes deeper.

This is called hypervigilance: the body keeps scanning for danger. People may jump at small sounds, sit facing the door, struggle to concentrate, or feel irritable and quick to anger.

Sleep often suffers, because it is hard to switch off when your body thinks it needs to stay on guard. Some people also take more risks than they used to.

You may have upsetting memories that pop up out of nowhere, nightmares, or flashbacks where it feels like it’s happening again. Reminders can bring a rush of fear or distress.

This is your brain trying to make sense of something overwhelming. It doesn’t mean you’re “stuck” or that it will always be this way.

What can help

• Grounding: name 5 things you see, 4 you can touch, 3 you hear
• Slow breathing with a longer out-breath
• Telling yourself: “That was then. I am safe now.”
• Keeping a calm bedtime routine, and getting up for a bit if a nightmare wakes you

Some people feel dazed, as if things aren’t real, or as if they are watching themselves from outside. Some can’t remember important parts of what happened. Many find it hard to feel happy or loving for a while.

This numbness is a protective response. The mind turns the volume down when things are too much. Usually, feelings slowly come back as you feel safer.

It is natural to avoid things that remind you of what happened, like the road where a crash happened, or talking about it. A bit of avoidance can give you breathing room at first.

But if avoidance grows, life can start to shrink. Gently returning to everyday places and routines, at your own pace and with support, can help your brain learn that you are safe now.

Common signs

• Trouble falling or staying asleep
• Being easily startled
• Feeling on guard, scanning for danger
• Irritability or anger outbursts
• Trouble concentrating
• Pounding heart, shaking or sweating
• Stomach upset or headaches

This is the body’s alarm system staying switched on. Movement, regular meals, cutting back on caffeine and alcohol, and calm routines help it settle.

Things that help

• Get to a place where you feel safe, and look after basic needs: food, water, sleep
• Turn to family and friends when you’re ready to talk. You don’t have to share details
• Keep some daily routine, even small things like a morning walk
• Move your body: exercise helps burn off stress
• Be careful with alcohol and drugs. They can make sleep and mood worse
• Expect recovery to be gradual, with good days and hard days
• Join a trauma support group if one is available

Talk therapy is the main treatment if reactions are strong. Trauma-focused CBT is especially helpful. It teaches how the body responds to stress, builds skills to manage symptoms, helps you rethink unhelpful thoughts, and gently helps you face what you’ve been avoiding.

Getting help early matters. Without support, strong early reactions can sometimes turn into longer-lasting PTSD.

Risk factors NIMH lists

• Dealing with more stress afterwards, like losing a loved one, pain and injury, or losing a job or home
• Feeling horror, helplessness or extreme fear
• Getting hurt, or seeing people hurt or killed
• Having a personal or family history of mental illness or substance use
• Having little or no social support after the event
• Living through earlier traumatic experiences, especially in childhood

Resilience factors NIMH lists

• Being prepared and able to respond to upsetting events as they happen, despite feeling fear
• Having a coping strategy for getting through and learning from what happened
• Learning to feel okay with your own actions during the event
• Seeking out and getting support from friends, family or support groups

Many of these can be built at any time, including long after the event. That is part of what therapy and support groups help with.

Having little support after an event is one of the risk factors for PTSD. A 2019 review of 51 studies found that negative reactions when survivors of violence told someone, like blaming them or trying to take control, were linked to worse mental health.

The WHO reports that PTSD rates are more than three times higher among people exposed to war or violent conflict, at about 15.3%. Strong early reactions are also more common after violence, like assault or a mass shooting, than after accidents or natural disasters.

Trauma that is repeated or goes on for a long time, especially in childhood, can lead to complex PTSD. The Complex PTSD guide covers this.

The VA estimates that about 8 in 100 women and 4 in 100 men in the U.S. will have PTSD at some point. One reason is that women are more likely to experience sexual assault, which is linked to high rates of PTSD.

Men are affected too. The VA notes that men more often go through accidents, physical assault, combat, or seeing death or injury. PTSD can affect people of every gender, age and background.

The VA also notes that Veterans are more likely to have PTSD than civilians. The Veterans: PTSD & combat stress guide has much more for those who served.

Signs NIMH describes

• Acting out the scary event during play
• Being unusually clingy with a parent or other adult
• Forgetting how to talk, or being unable to talk
• Wetting the bed after having learned to use the toilet

Young children often don’t have words for big feelings yet. Their behaviour and play are how they show what is going on inside.

NIMH says older children and teens usually show signs more like adults: unwanted memories, avoiding reminders, feeling on edge, and changes in mood.

They may also

• Act in disruptive, disrespectful or destructive ways
• Feel guilty for not stopping what happened
• Have thoughts of revenge

The CDC says the most powerful protection for children is safe, stable, nurturing relationships. Caring adults outside the family, like teachers, coaches and mentors, help too.

Simple things adults can do

• Answer questions honestly, in words that fit their age
• Keep news and graphic images away from young children
• Let them know their feelings make sense, and that it was not their fault
• Spend calm, ordinary time together, like reading, cooking or a walk

If a child’s reactions are getting in the way of school, sleep, friendships or family life, or aren’t easing after a few weeks, talk with their doctor. They can refer you to a therapist who works with young people after trauma.

Talk therapy for PTSD usually lasts 6 to 12 weeks, though it can take longer. It can be one-to-one or in a group. It is fine to ask how you, as a parent or caregiver, can help at home.

Cognitive behavioural therapy (CBT) with a trauma focus helps you understand how trauma affects the body, manage symptoms, change unhelpful thoughts, and slowly face what you’ve been avoiding.

CPT helps you notice and change upsetting thoughts and feelings that started with the trauma, like “It was my fault” or “I can never be safe.” You learn to look at them more fairly and find more balanced ways of thinking.

It often uses short worksheets and practice between sessions. The VA lists it among the therapies with the most support for PTSD.

PE helps you slowly approach trauma memories, feelings and situations you’ve been avoiding, in a planned, step-by-step way with your therapist.

It works because avoidance keeps fear stuck. When you face reminders safely, your brain learns that the memory is not the danger, and the fear slowly drops.

Eye Movement Desensitization and Reprocessing (EMDR) helps you process a traumatic memory while focusing on something that moves back and forth, like a therapist’s hand, sounds, or taps.

The aim is for the memory to become less upsetting and to feel like it is in the past. The WHO, VA and NHS all recommend EMDR for PTSD.

In WET, you do writing assignments during your sessions. They help you find new ways to think about the trauma and what it means to you.

The VA describes it as a brief, 5-session therapy. It is a trauma-focused therapy with less research than CPT, PE and EMDR, but it is an option some people prefer because it is short.

CT-PTSD helps you change thoughts about the trauma. With your therapist, you revisit the memory to make sense of what happened and to challenge harsh thoughts, like “I should have stopped it.”

The VA lists it among trauma-focused therapies with less research support than the top three, but it can still help.

PCT focuses on learning to deal with current life problems that are connected to what happened, in healthier ways. You don’t need to talk about the trauma itself.

It is not trauma-focused, and the VA says it has some research support. It can be a good fit for people who are not ready to work on the memory yet.

Talk therapy can happen in groups as well as one-to-one. Hearing others share similar experiences can make you feel less alone and less “broken”.

Peer support, from people with lived experience, is one of SAMHSA’s six principles of trauma-informed care.

The VA describes several reasons. A body that feels on alert finds it hard to switch off. Some people feel uneasy in silence, so they keep the TV on all night. Pushing memories away during the day can make worries louder at night.

Some people start avoiding bed altogether, staying up late because they fear nightmares or flashbacks. Over time, poor sleep can become its own source of stress.

Nightmares after trauma often replay the event, or carry the same feelings of danger. They can wake you with a pounding heart and make it hard to fall back asleep. If they involve kicking or shouting, they can disturb a bed partner too.

If a nightmare wakes you

1. Remind yourself: “That was a dream. I am in my room. It is [today’s date].”
2. Turn on a soft light and look around at familiar things.
3. Feel your feet on the floor and slow your breathing, with a longer out-breath.
4. If you can’t settle after a while, get up and do something calm in dim light until you feel sleepy.

There is a therapy that works directly on nightmares by rewriting them while awake. The Sleep & mental health guide explains how it works.

The VA recommends Cognitive Behavioral Therapy for Insomnia (CBT-I) as the best treatment for long-term trouble sleeping. It works on the thoughts, feelings and habits that keep poor sleep going, and usually takes about six sessions.

According to the VA, CBT-I improves sleep in 7 out of 10 people who complete it. It can also reduce how often nightmares happen and how upsetting they are. It can be done in person, by video, through online programs, or with the free CBT-I Coach app.

The VA notes that some people use alcohol, marijuana or other drugs to fall asleep after trauma. Over time, this can make sleep worse and harm overall health.

If you’ve come to rely on something to get to sleep, you are not alone, and there is no shame in it. A provider can help you find other ways to rest. The Substance Use guide has more support.

The VA says sleep apnea, where breathing stops and starts during sleep, is common in people with PTSD, especially Veterans. It often goes unnoticed. A bed partner may be the first to notice loud snoring or pauses in breathing.

If you wake up tired no matter how long you sleep, or someone notices you stop breathing at night, tell your clinical provider. Treating sleep apnea can improve energy and mood, and the VA notes research suggesting it may help PTSD treatment too.

The VA describes several links

• If the same event caused both, the pain itself can remind you of what happened
• Being on high alert makes you more aware of body sensations, including pain
• Both disturb sleep, which leaves you more tired and less able to cope
• Avoiding reminders and avoiding pain can both lead to staying home and doing less
• Both can leave you feeling you’ve lost control of your body or your life

Some people notice their pain is worse on days when trauma symptoms are worse, and the other way round.

When something hurts, resting makes sense. But the VA explains that long stretches of rest and avoidance can lead to losing fitness and muscle strength, which can increase pain. Giving up things you enjoy out of fear of pain can also bring loneliness and low mood.

Trauma avoidance works the same way. Both kinds of avoidance bring short-term relief but make life smaller over time.

The VA suggests first checking with your clinical provider that exercise is safe for you, then slowly increasing movement and returning to activities you enjoy. This can help your brain re-engage with life, even while some pain remains.

Ways to start small

• A five-minute walk at the same time each day
• Gentle stretching while the kettle boils
• Returning to one hobby for a short time, like gardening for ten minutes
• Adding a little more each week, not each day

The VA notes that trauma-focused talk therapies are effective for PTSD, and some evidence suggests they may also improve how people function with pain. Pain care often focuses on helping you live well even when pain can’t be fully taken away.

Some programs treat trauma and chronic pain together, with providers working as a team. It helps to tell each of your providers about both, so they can see the whole picture.

Free apps from the VA, such as PTSD Coach and Pain Coach, offer tools for managing symptoms day to day.

Changes the VA describes

• Retirement and fewer activities: more unstructured time can make symptoms more noticeable
• Health problems: pain, illness or limited mobility become more common with age
• Losing people: the deaths of a partner, friends or family can bring grief and shrink a support network
• Looking back: reflecting on life can bring up unwanted memories

For decades, work, raising a family and staying busy may have kept memories at a distance. When life slows down, there is more room for them to surface.

Researchers at the VA’s National Center for PTSD have studied what they first called late-onset stress symptomatology, now described as Later-Adulthood Trauma Reengagement. It describes older combat Veterans who begin re-examining their war experiences later in life.

The VA describes this as a process that can go in different directions. For some it leads to growth, acceptance or a sense of peace. For others it brings distress, low mood, substance use or PTSD. Support can help it go well.

The Veterans: PTSD & combat stress guide has much more on support and programs for those who served.

Older adults may be more likely to mention trouble sleeping, aches or feeling “not themselves” than to talk about memories or fear. The VA notes that a screening tool for older Veterans may help primary care providers uncover underlying concerns in people with physical health complaints.

If you are an older adult, or caring for one, it is okay to bring up past trauma with a primary care provider. They can’t help with what they don’t know about.

The VA is clear: PTSD treatment works at any age, and it is never too late to heal. Evidence-based talk therapy is an option for older adults too, and it can often be done by video if getting to appointments is hard.

Things that support healthy aging

• Staying socially connected with family, friends or neighbors
• Volunteering, which brings purpose and people
• Joining group activities, faith groups or senior centers
• Telling your provider about all your health conditions, so care fits you as a whole person

See the Old age: mental health in later life guide for more on loneliness, purpose and support in later life.

Without knowing that a loved one’s behaviour comes from PTSD, family members may think the person is unhappy with them. The VA says relatives may feel cut off from their loved one, or feel like they are walking on eggshells when that person is irritable.

Feelings family members describe

• Frustration or tiredness
• Helplessness
• Hurt or rejection
• Stress, sometimes from taking on extra jobs at home

Studies the VA describes find that partners of people with PTSD often report less relationship satisfaction, more distress and lower quality of life. Intimacy and sex can become harder too.

The VA is clear that most people with PTSD have never been violent. But conflict, and sometimes violence, is more likely when one or both partners have PTSD.

The VA notes that common parenting challenges may feel harder for a parent with PTSD, and that children may not understand a parent’s PTSD symptoms. When a parent has PTSD, children can be affected.

Ways to help children understand

• Explain in words that fit their age, like “Dad’s brain is still on alert from something scary that happened. It’s not because of you.”
• Keep routines steady, so home feels predictable
• Let them ask questions, and it’s okay to say “I don’t know”
• Make sure they have other caring adults to turn to

Families sometimes change their routines to help, like doing all the shopping so their loved one can avoid crowds. The VA explains that this comes from love, but it can keep the avoidance going.

Avoidance brings short-term relief but keeps fear from being processed. Gently encouraging small steps, ideally with a therapist’s guidance, usually helps more in the long run.

Ideas from the VA

• Agree together what you’ll do if symptoms flare up or there is a crisis
• Ask about couples or family therapy
• Help find a therapist, and be patient: people accept help at their own pace
• Plan activities you both enjoy, and keep them flexible in size and pace
• Set a regular time to talk, and check in often
• Take care of yourself, including getting support or therapy of your own

The VA also offers a free PTSD Family Coach app with tools for family members.