TRAUMA | anxietyandstress

Understanding and Managing your Response to Trauma

What is a traumatic event?

Among the many stressful events of living, we can be faced with extraordinary circumstances that leave us feeling terrified, powerless, and/or horrified in the face of threatened or actual injury or death. Examples of traumatic events may include:

natural disaster

catastrophe caused by human error

catastrophe caused by failed equipment

physical or sexual assault; rape

robbery/mugging

serious motor vehicle accident

witnessed violence, injury or death

combat, torture or imprisonment

threats of harm to self or loved ones; stalkings

domestic violence and physical abuse

fire and burn survivors

destruction of one's home

life-threatening illnesses and treatments

How do we usually respond to a traumatic event?

Sometimes immediately, and sometimes after brief or even extended delay, most of us will experience intense feelings and symptoms related to the traumatic event. Not every person experiences the same aftermath to the same trauma. However, you are likely to bounce back and forth between periods during which you relive the trauma and other periods during which you are benumbed of feeling and avoidant of any thought or reminder of the traumatic event. This is entirely normal. This normal, acute response to trauma is not called "post-traumatic stress disorder" unless it is persistent over time and does not gradually heal.

What effects might I experience?

1) Reexperiencing the Trauma

"Flashbacks" or intrusive memories of the trauma: You may experience flashbacks in which you intensely relive the trauma, as if it were really happening again. You may feel all the same emotions and sensory experiences again. You do not lose consciousness during a flashback, but you may have difficulty distinguishing here-and-now reality when a flashback consumes you. This can be a frightening experience, especially since you may see, hear, smell, taste or feel things related to the past traumatic event that are not actually there in your current reality. This does not mean that you are "losing your mind." Such flashbacks are an entirely normal part of the response to trauma as you struggle to rework and integrate the experience. If you had another traumatic experience years before this one, you may even find that sudden flashbacks about that previous experience get mixed up with flashbacks about your more recent traumatic experience.

Nightmares about the trauma or other scary content: You may have nightmares that vividly replay the traumatic event or that just replay fragments of your experience. You may have nightmares that repeatedly replay themes of helplessness, horror, anger, or other feelings related to the trauma. You may awaken very upset and sweating profusely, without remembering any nightmare.

Insomnia: You may often feel "too wired" to sleep. Your nightmares may be so alarming that you become fearful of sleep. You may associate darkness with danger. Being left alone with your own thoughts, without the distractions of your daytime activities, may prompt memories of the trauma which make it difficult to sleep. Coffee or alcohol may interfere with your sleep like never before. Persistent insomnia or awakenings during the night could also be a sign of developing depression which can be treated with medication.

Intense response to reminders or symbols of the trauma: You may experience sudden panic, irritability, anger, grief, horror or vague "sinking" feelings that sometimes seem to come "out of the blue." Sometimes you may recognize at the time, or later, that your feelings are in response to a reminder of the trauma. Such reminders can be obvious or they can be so subtle that you may not easily recognize them as connected with the trauma. You may also experience strong feelings when faced with a monthly or annual anniversary of the traumatic event. You may find that, quite unpredictably, you dissolve under ordinary stress that you would usually take in stride. You might find that music is intolerable, that children's behavior or noise is hard to take, or that you can't watch television because the feelings come.

2) Numbing of Emotions and Avoidance of "Triggers"

Periodic numbing of emotions: Although your emotions may be very intense at some times, at other times they may be so much the opposite that you may feel dull, empty, numb or completely shut down. You may feel emotionally dead or like a robot without feelings. You may feel remarkably detached and estranged from others. You may feel that you can't even generate feelings of love in your most treasured relationships. You may lose interest or feelings of enjoyment for your favorite pastimes, eating or sex. Even though others may think you are doing better at these times compared to periods when you are intensely reliving the trauma, it may alarm you to feel so benumbed and lacking in feeling. Again, this is a part of the normal response to trauma. Just as the iris controls the amount of light entering your eye in order to protect the retina, or, just as the body secretes natural anesthetic after a physical injury, so, too, does your system mobilize to protect you from being overwhelmed after trauma by numbing your feelings.

Avoidance of "triggers" or reminders of the trauma: Given the intensity of your feelings when you are reminded of the trauma, it is only natural that you will often strive to avoid such triggers. You may also find that your memory fails you in recalling certain important aspects of the trauma. Such avoidance or memory lapses can be self-protective in the aftermath of trauma. However, if too persistent or too generalized, such responses may hinder your recovery.

Wishes or attempts to ignore, forget or bury the trauma: You may find that you go through periods during which you strive to keep the trauma out of your thoughts and don't want to discuss it. For example, you might throw yourself into your work so that you're so busy you can't hardly stop to think. This is the opposite extreme from periods during which the trauma consumes your thoughts and you desperately want to talk about it over and over. You may find that the harder you try to keep thoughts of the trauma out of your awareness, the more they intrude in other forms (e.g., nightmares or periodic flashbacks).

Sense of a foreshortened future or of future catastrophe: You may find that you experience either hopelessness or fatalism when you consider the future. You may become preoccupied with ideas that you won't retain your health, that you won't have the love of others, that you will die young, or that you or loved ones will be especially vulnerable to future catastrophe. Once the proverbial one-in-a-million traumatic event has happened to you, it can feel like all other disasters are likely to happen to you, too.

3) Symptoms of Increased Arousal

trouble falling or staying asleep

difficulty deciding anything

irritability

difficulty concentrating

outbursts of anger

spasms of grief

hypervigilance about safety

startle reactions

bodily reactions to triggers (e.g., sweating, nausea, trembling, pain, hyperventilation)

knot in stomach or headache

4) Possible Effects on Beliefs, Attitudes and Sense of Self

Depending on the nature of your experience and how it was caused, you may notice any of the following changes:

the world feels unsafe, unfair, unpredictable and out of control

sense of separation from the rest of humanity

loss of autonomy, mobility or freedom

sense of betrayal, unfairness or mistrust

self-blame and diminished self-respect

sense of degradation, humiliation or personal weakness

indifference, fatalism or cynicism

guilt or shame about surviving, especially if others did not

rage, thoughts of revenge, and aggressive impulses (guilt)

anger at people who have not been affected

sadness over losses

spiritual crisis or loss of faith

How can this all be just "in my head?"

It's not. Researchers have demonstrated that exposure to severe trauma often results in persistent alterations in bodily functions. For example, levels of several neurotransmitters in your brain may be affected by trauma, which can contribute to your symptoms. Trauma can render parts of the brain overactive or underactive, also contributing to your symptoms. Disruption of your sleep cycle after trauma may also contribute to your symptoms. Your baseline level of arousal, as measured by resting heart rate and blood pressure, may be persistently elevated after trauma.

How might my family be affected?

When something traumatic happens to one person in a family, often everyone is affected. Different people's trauma reactions may vary considerably. It may seem that some are "over" or "under" reacting. Often this is because one person is in a period of being benumbed while another may be in a period of over-arousal. Family members often experience changes in their world view or a spiritual crisis of their own. They may also have intense feelings of guilt, anger, or sorrow about what has happened to you, which can sometimes make it difficult for them to be helpful to you.

Why am I so upset about the responses of others?

Unfortunately, the police, the justice system, reporters, medical personnel, the clergy, and others can respond to you in ways that compound your feelings. This is sometimes called "secondary trauma" or "secondary wounding." Ignorant, patronizing, impatient or insensitive responses of others may leave you feeling ignored, blamed, or treated like a child. Even well-intentioned loved ones who care for you and are eager to see you recover may respond to you in ways that compound your feelings. Sometimes your upset about such reactions from others may seem worse than the trauma itself, or you may become very preoccupied by it. Remember that sometimes people may avoid you or even blame you because they don't like to be reminded that bad things can happen unpredictably to good people.

What can I do to help myself?

Learn more about your response to trauma by reading from materials listed below.

You and your loved ones must understand that you may well have a very intense need to discuss the traumatic event repeatedly and in much detail. This can be a natural part of the recovery process as you struggle to integrate the experience. If this proves to be too upsetting for your loved ones, or if you feel you cannot talk to them about parts of the incident or certain feelings that you have, then you may need to find other confidants (e.g., mental health professional, minister or support group), who can understand and tolerate such a need.

Sometimes it is helpful to write down your memories of your traumatic experience, or to keep a journal of what you are going through as you recover. Sometimes it is helpful to look at photographs or other reminders of, or to establish a memorial to, someone or something that is lost. Tears can be healing. Give yourself permission to feel all your feelings, even those that don't make sense or go together.

Strive to identify the "triggers" for your reliving of the trauma so that you can better predict and ready yourself for upset rather than being taken by surprise, which only adds to your sense of alarm. Allow yourself to lean on others a bit when you know something will be difficult.

Be extremely cautious about your use of alcohol. Many people who have experienced trauma try to control or diminish their symptoms with alcohol, only to have their drinking compound their problems.

Strive not to isolate yourself more than briefly. Even if you do not feel like actively relating to others, find ways to be in the vicinity of others. Occasionally, you may need to withdraw for a day or two to "regroup" and come out again.

Remind yourself that your reactions are real and expected reactions to trauma, rather than evidence of personal weakness. Remind yourself that it will take patience and effort to recover, but that you won't stay stuck in your worst feelings. Remember that you can't make yourself recover quickly by sheer force of will. Give yourself the latitude to have good days and bad days. "Trauma" means "wound." Deep wounds take time to heal, even if you do everything you can.

If your intrusive symptoms (e.g., flashbacks, sleep disturbance, nightmares, startle responses) are especially disruptive, or, if you are really struggling with anxiety or depression, consult your family physician or a psychiatrist about whether medication may be useful.

Consider joining a support group if an appropriate choice is available. Your doctor or a mental health agency may be able to direct you to an appropriate group or internet web site. If no group is available, you may find it useful to make individual contact with someone who has survived a similar experience.

At some point in your recovery, it may feel important for you to revisit the scene of the traumatic event or to make contact with certain symbols of the trauma. It may be important for you to seek further information about the event, (e.g., talking with witnesses, reading news stories or police reports, or contacting other authorities for details about the event or its aftermath). Don't rush into this. You may find this easier if you ask a loved one to accompany you.

Others may feel that you are needlessly torturing yourself; but, sometimes details, however terrible, provide relief. If in doubt, seek a consultation before proceeding.

Take time to learn and practice muscle relaxation, imagery and breathing skills to help calm yourself. Consult the references noted below or seek assistance from an expert who can help you develop such skills.

If your symptoms are especially upsetting or especially persistent, you may decide to seek professional help. Do not assume that all mental health professionals understand post-traumatic responses and appropriate treatment. If you need a referral, discuss it with your family physician to see if there are special resources in your community, (e.g., experts in trauma response, rape crisis centers, domestic violence clinics), call the psychology or psychiatry department of the nearest university medical center or contact the Anxiety Disorders Association of America for a referral in your area. If you are unsure about a name you've been given, ask about the nature of the mental health professional's experience in working with people after trauma. Locally, the Anxiety and Stress Disorders Institute of Maryland offers treatment specialized for post-traumatic responses.

Can medication help?

There are several medications that may be helpful in treating post-traumatic symptoms, but there is no single, consensus choice. For example, several of the anti-depressants may diminish your sleep disturbance, nightmares and flashbacks, even if you are not particularly depressed. Some drugs that are ordinarily used to lower blood pressure may help with startle responses and intense reliving experiences. The class of anti-anxiety drugs called the benzodiazepines may also be useful as a short-term means of diminishing your symptoms and helping you sleep. Some of these choices may not be appropriate for you and others may have uncomfortable side effects. More than one drug trial or combinations of drugs may be necessary before you get satisfactory results. A particular drug trial might require many weeks before its effectiveness can be evaluated. The choices should be discussed with your family physician or with a psychiatrist who specializes in treating patients with post-traumatic symptoms. It is especially important to consider medication if you are completely exhausted from lack of sleep or if you are developing significant depression.