In some exceptional cases, the vivid recollection of a trauma can cause distress many years after the incident. Andy, an ex-fire officer, describes his experience of post-traumatic stress disorder (PTSD) and how the right treatment has helped him to move on.

“The event that caused my trauma happened 20 years ago when I was a fire officer. I was in charge of an appliance at a house fire where three people had died. It was my job to take their remains out of the house.

“A few days later I became distressed and started crying and feeling upset. This strong reaction came as a shock, but I said nothing at the time. I think this was partly because I didn’t want to share my emotions with anybody.

“My feelings and thoughts continued to bother me for a few weeks. After a while I decided that, because of my job, being like this was no good and I had to put these emotions to one side.

“These early responses to the trauma indicated the huge wave of feelings and sensations that would come back 17 years later in a way I couldn’t ignore. 

“I was still a firefighter. I kept remembering that terrible event and the feelings it left me with, but I tried not to think about it. A few days later my colleagues and I were at another house fire. It was similar to the one in which the family had died. Suddenly, I felt as if I wasn’t there. My mind was totally occupied in a flashback of the original incident. One of my colleagues had to step in and take over from me.

“From then on I started to become distressed for no real reason. Everything seemed emotional, and I felt raw and exposed. I got easily frustrated, which made me short-tempered and angry.

“When the distress was at its worst, I had three or four flashbacks a day. I would sweat and become very nervous as I remembered the events 20 years ago. All the smells were there, and I even felt the heat of the fire moving across my face. People who saw me say that I sometimes walked about and mouthed words, but I was completely detached from my surroundings.

“That was when it became obvious that I couldn’t go on. After some time, I had a course of trauma-focused cognitive behavioural therapy with a PTSD charity called ASSIST. They helped me to understand that I had experienced something abnormal, that none of it was my fault, and that there was nothing wrong or crazy about my emotional responses.

“Talking about the fire was uncomfortable at times, but it helped me to process my memories so that they stopped reappearing as flashbacks. They have gone now, and I am able to get on with my life.”

Post-traumatic stress disorder (PTSD) can develop after a very stressful, frightening or distressing event, or after a prolonged traumatic experience.

Types of events that can lead to PTSD include:

• serious road accidents
• violent personal assaults, such as sexual assault, mugging or robbery
• prolonged sexual abuse, violence or severe neglect
• witnessing violent deaths
• military combat
• being held hostage
• terrorist attacks
• natural disasters, such as severe floods, earthquakes or tsunamis

PTSD is not usually related to situations that are simply upsetting, such as divorce, job loss or failing exams.

PTSD develops in about 1 in 3 people who experience severe trauma. It is not fully understood why some people develop the condition while others don’t, but there are factors that appear to make certain people more likely to develop PTSD.

If you’ve had depression or anxiety in the past, or you don’t receive much support from family or friends, you are more susceptible to developing PTSD after a traumatic event.

There may also be a genetic factor involved in PTSD. For example, having a parent with a mental health problem is thought to increase your chances of developing the condition.

Possible causes

Although it is not clear exactly why people develop PTSD, a number of possible reasons have been suggested. These are described below.

Survival mechanism

One suggestion is that the symptoms of PTSD are the result of an instinctive mechanism intended to help you survive further traumatic experiences.

For example, the flashbacks many people with PTSD experience may occur to force you to think about the event in detail so you are better prepared if it happens again, and the feeling of being “on edge” (hyperarousal) may develop to help you react quickly in another crisis.

However, while these responses may be intended to help you survive, they are actually very unhelpful in reality because they mean you can’t process and move on from the traumatic experience.

Adrenaline levels

Studies have shown that people with PTSD have abnormal levels of stress hormones.

When in danger, the body produces these hormones, such as adrenalin, to trigger a reaction in the body. This reaction, often known as the “fight or flight” reaction, helps to deaden the senses and dull pain.

However, people with PTSD have been found to continue to produce high amounts of fight or flight hormones even when there is no danger. It is thought this may be responsible for the numbed emotions and hyperarousal experienced by some people with PTSD.

Changes in the brain

In people with PTSD, parts of the brain involved in emotional processing appear different in brain scans.

One part of the brain responsible for memory and emotions is known as the hippocampus. In people with PTSD, the hippocampus appears smaller in size. It is thought that changes in this part of the brain may be related to fear and anxiety, memory problems and flashbacks.

The malfunctioning hippocampus may prevent flashbacks and nightmares from being properly processed, so the anxiety they generate does not reduce over time.

Treatment of PTSD results in proper processing of the memories so, over time, the flashbacks and nightmares will gradually disappear.

Post-traumatic stress disorder (PTSD) is an anxiety disorder caused by very stressful, frightening or distressing events.

The type of events that can cause PTSD include:

• serious road accidents
• violent personal assaults, such as sexual assault, mugging or robbery
• prolonged sexual abuse, violence or severe neglect
• witnessing violent deaths
• military combat
• being held hostage
• terrorist attacks
• natural disasters, such as severe floods, earthquakes or tsunamis

PTSD can develop immediately after someone experiences a disturbing event or it can occur weeks, months or even years later.

PTSD is estimated to affect about 1 in every 3 people who have a traumatic experience, but it’s not clear exactly why some people develop the condition and others don’t.

Read more about the causes of PTSD.

Signs and symptoms

Someone with PTSD will often relive the traumatic event through nightmares and flashbacks, and may experience feelings of isolation, irritability and guilt.

They may also have problems sleeping, such as insomnia, and find concentrating difficult.

These symptoms are often severe and persistent enough to have a significant impact on the person’s day-to-day life.

Read more about the symptoms of PTSD.

When to seek medical advice

It is normal to experience upsetting and confusing thoughts after a traumatic event, but in most people these will improve naturally over a few weeks.

You should visit your GP if you or your child are still having problems about four weeks after the traumatic experience, or if the symptoms are particularly troublesome.

If necessary, your GP can refer you to mental health specialists for further assessment and treatment.

How PTSD is treated

PTSD can be successfully treated, even when it develops many years after a traumatic event.

Any treatment depends on the severity of symptoms and how soon they occur after the traumatic event. Any of the following treatment options may be recommended:

• watchful waiting – waiting to see whether the symptoms improve without treatment
• psychological treatment – such as trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR)
• antidepressant medication – such as paroxetine or mirtazapine

Read more about treating PTSD.

The Map of Medicine is used by doctors throughout the NHS to determine the best treatment options for their patients. NHS Choices offers everyone in England exclusive and free access to this cutting-edge internet resource, which lets you see exactly what your doctor sees.

The information in the Map has been approved by the UK’s leading clinical experts, is based on the best available clinical evidence, and is continually updated. To take advantage of this unique resource go to:

Map of Medicine: post-traumatic stress disorder

The symptoms of post-traumatic stress disorder (PTSD) can have a significant impact on your day-to-day life.

In most cases, the symptoms develop during the first month after a traumatic event. However, in a minority of cases, there may be a delay of months or even years before symptoms start to appear.

Some people with PTSD experience long periods when their symptoms are less noticeable, followed by periods where they worsen. Other people have severe symptoms that are constant.

The specific symptoms of PTSD can vary widely between individuals, but they generally fall into the categories described below.

Re-experiencing

Re-experiencing is the most typical symptom of PTSD. This is when a person involuntarily and vividly re-lives the traumatic event in the form of flashbacks, nightmares or repetitive and distressing images or sensations. This can even include physical sensations such as pain, sweating and trembling.

Some people will have constant negative thoughts about their experience, repeatedly asking themselves questions that prevent them from coming to terms with the event. For example, they may wonder why the event happened to them and if they could have done anything to stop it, which can lead to feelings of guilt or shame.

Avoidance and emotional numbing

Trying to avoid being reminded of the traumatic event is another key symptom of PTSD. This usually means avoiding certain people or places that remind you of the trauma, or avoiding talking to anyone about your experience.

Many people with PTSD will try to push memories of the event out of their mind, often distracting themselves with work or hobbies.

Some people attempt to deal with their feelings by trying not to feel anything at all. This is known as emotional numbing. This can lead to the person becoming isolated and withdrawn, and they may also give up pursuing the activities that they used to enjoy.

Hyperarousal (feeling ‘on edge’)

Someone with PTSD may be very anxious and find it difficult to relax. They may be constantly aware of threats and easily startled. This state of mind is known as hyperarousal.

Hyperarousal often leads to irritability, angry outbursts, sleeping problems (insomnia) and difficulty concentrating.

Other problems

Many people with PTSD also have a number of other problems, including:

• depression, anxiety and phobias
• drug misuse or alcohol misuse
• headaches, dizziness, chest pains and stomach aches

PTSD sometimes leads to work-related problems and the breakdown of relationships.

PTSD in children

PTSD can affect children as well as adults. Children with the condition can have similar symptoms to adults, such as having trouble sleeping and upsetting nightmares.

Like adults, children with PTSD may also lose interest in activities that they used to enjoy and they may have physical symptoms such as headaches and stomach aches.

However, there are some symptoms that are more specific to children with PTSD, such as:

• bedwetting
• being unusually anxious about being separated from a parent or other adult
• re-enacting the traumatic event(s) through their play

When to seek medical advice

It is normal to experience upsetting and confusing thoughts after a traumatic event, but in most people these will improve naturally over a few weeks.

You should visit your GP if you or your child are still having problems about four weeks after the traumatic experience, or if the symptoms are particularly troublesome.

Your GP will want to discuss your symptoms with you in as much detail as possible. They will ask whether you have experienced a traumatic event, either in the recent or distant past, and whether you have re-experienced the event through flashbacks or nightmares.

Your GP can refer you to mental health specialists if they feel you would benefit from treatment. See treating PTSD for more information.

The main treatments for post-traumatic stress disorder (PTSD) are psychotherapy and medication.

Traumatic events can be very difficult to come to terms with, but confronting your feelings and seeking professional help is often the only way of effectively treating PTSD.

It is possible for PTSD to be successfully treated many years after the traumatic event occurred, which means it is never too late to seek help.

Assessment

Before having treatment for PTSD, a detailed assessment of your symptoms will be carried out to ensure treatment is tailored to your individual needs.

Your GP will often carry out an initial assessment, but you will be referred to a mental health specialist for further assessment and treatment if you have had symptoms of PTSD for more than four weeks or your symptoms are severe.

There are a number of mental health specialists you may see if you have PTSD, such as:

• a psychologist – an expert in how the mind works
• a community psychiatric nurse – a nurse who specialises in mental healthcare
• a psychiatrist – a mental health specialist who diagnoses and treats mental health conditions

Watchful waiting

If you have mild symptoms of PTSD, or you have had symptoms for less than four weeks, an approach called watchful waiting may be recommended.

Watchful waiting involves carefully monitoring your symptoms to see whether they improve or get worse. It is sometimes recommended because 2 in every 3 people who develop problems after a traumatic experience will get better without treatment within a few weeks.

If watchful waiting is recommended, you should have a follow-up appointment within one month.

Psychotherapy

If you have PTSD that requires treatment, psychotherapy is usually recommended first. A combination of psychotherapy and medication may be recommended If you have severe or persistent PTSD.

Psychotherapy is a type of therapy often used to treat emotional problems and mental health conditions such as PTSD, depression, anxiety and obsessive compulsive disorder.

The treatment is carried out by trained mental health professionals who will listen to you and help you come up with effective strategies to resolve your problems.

The two main types of psychotherapy used to treat people with PTSD are described below.

Cognitive behavioural therapy (CBT)

Cognitive behavioural therapy (CBT) is a type of therapy that aims to help you manage your problems by changing how you think and act.

Trauma-focused CBT uses a range of psychological treatment techniques to help you come to terms with the traumatic event.

For example, your therapist may ask you to confront your traumatic memories by thinking about your experience in detail. During this process your therapist will help you cope with any distress you feel, while identifying any unhelpful thoughts or misrepresentations you have about the experience.

By doing this, your therapist can help you gain control of your fear and distress by changing the negative way you think about your experience, such as feeling that you are to blame for what happened or fear that it may happen again.

You may also be encouraged to gradually restart any activities you have avoided since your experience, such as driving a car if you had an accident.

You will usually have 8-12 weekly sessions of trauma-focused CBT, although fewer may be needed if the treatment starts within one month of the traumatic event. Sessions where the trauma is discussed will last for around 90 minutes.

Read more about CBT.

Eye movement desensitisation and reprocessing (EMDR)

Eye movement desensitisation and reprocessing (EMDR) is a relatively new treatment that has been found to reduce the symptoms of PTSD.

EMDR involves making side-to-side eye movements, usually by following the movement of your therapist’s finger, while recalling the traumatic incident.

It is not clear exactly how EMDR works, but it may help the malfunctioning part of the brain (the hippocampus) to process distressing memories and flashbacks so that their influence over your mind is reduced.

Read more about EMDR.

Medication

Antidepressants such as paroxetine, mirtazapine, amitriptyline or phenelzine are sometimes used to treat PTSD in adults.

Of these medications, paroxetine is the only one licensed specifically for the treatment of PTSD. However, mirtazapine, amitriptyline and phenelzine have also been found to be effective and are often recommended as well.

However, these medications will only be used if:

• you choose not to have trauma-focused psychological treatment
• psychological treatment would not be effective because there is an ongoing threat of further trauma (such as domestic violence)
• you have gained little or no benefit from a course of trauma-focused psychological treatment
• you have an underlying medical condition, such as severe depression, that significantly affects your ability to benefit from psychological treatment

Amitriptyline or phenelzine will only be used under the supervision of a mental health specialist.

Antidepressants can also be prescribed to reduce any associated symptoms of depression and anxiety and to help with sleeping problems. However, they are not usually prescribed for people younger than 18 unless recommended by a specialist.

If medication for PTSD is effective, it will usually be continued for a minimum of 12 months before being gradually withdrawn over the course of four weeks or longer. If a medication is ineffective at reducing your symptoms, your dosage may be increased.

Before prescribing a medication, your doctor should inform you about possible side effects that you may have while taking it, along with any possible withdrawal symptoms when the medication is withdrawn.

For example, common side effects of paroxetine include feeling sick, blurred vision, constipation and diarrhoea. Possible withdrawal symptoms associated with paroxetine include sleep disturbances, intense dreams, anxiety and irritability.

See depression medicines information for more information about the medications used to treat PTSD.

Children and young people

For children and young people with PTSD, trauma-focused CBT is usually recommended.

This will normally involve a course of 8-12 sessions that have been adapted to suit the child’s age, circumstances and level of development. Where appropriate, treatment will include consulting with and involving the child’s family.

Treatment with medication is not usually recommended for children and young people with PTSD.