At the other extreme from the low-level continual arousal of generalised anxiety is the constant high arousal generated by post-traumatic stress. If you suffer from this it can be a truly terrifying experience.
Whenever people suddenly find themselves in a life-threatening or extremely dangerous situation, especially one in which they feel helpless, it is natural to experience intense fear and horror. This is also often our reaction if we find ourselves witnessing such an event, rather than being involved in it - or even if just a vivid portrayal or account of it has been seen or heard.
Traumatic events of this kind range from surviving natural disasters, such as earthquakes, tsunamis or avalanches, to ones caused by human error, such as car, train and plane crashes, capsizing boats and sinking ships.
Violent attacks such as being mugged, raped, kidnapped or sexually or physically abused, can all traumatise, as can an event such as a house fire, a complicated childbirth or suffering a heart attack. Surviving a bomb or shooting outrage, or witnessing a massacre in a war zone commonly produces post-traumatic stress symptoms.
Some grandchildren of concentration camp survivors became traumatised after hearing their relatives relive their terrible memories. Imagining the terrible deaths of loved ones who didn't survive a disaster can also induce trauma, as can learning that a relative has been severely injured or that one's child is suffering a life-threatening or terminal illness.
Although it takes time to calm down and to process and cope with whatever terrifying situation has occurred, four out of five people are able to do so without lasting psychological damage.
One in five people, however, goes on to experience persistent post-traumatic stress, in which the memory of the traumatic event, instead of gradually fading or ceasing to take centre stage in their minds, keeps them helplessly and horrifyingly in thrall. The following symptoms associated with post-traumatic stress are deemed severe enough to warrant a diagnosis of post-traumatic stress disorder (PTSD). This symptom description guide is based on the diagnostic criteria for PTSD that appear in the current edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).
The traumatic event is persistently re-experienced in one or more of the following ways:
- Recurrent and intrusive distressing recollections of the event, including images, thoughts or perceptions
- Recurrent distressing dreams of the event
- Acting or feeling as though the event were happening all over again (a sense of re-living it, illusions, hallucinations or flashbacks, in which it feels as though the incident is being re-experienced)
- Intense mental distress when something internal or external triggers associations with the event - even if it is not always consciously recognised as such (for example, significant anniversaries, hearing a particular sound, the sensation of intense bodily heat)
- Being physically responsive, such as experiencing a surge in your heart rate or sweating, to reminders of the traumatic event
Persistent avoidance of anything that could trigger asso-ciations with the trauma and a general numbing of feeling, manifested in three or more of the following ways:
- Efforts to avoid thoughts, feelings or conversation associated with the trauma
- Efforts to avoid activities, places or people that arouse recollections of the trauma
- Amnesia for certain important elements of the trauma
- Marked loss of interest or participation in significant activities
- Feeling detached or estranged from others
- Difficulty in feeling warm emotions (for instance, inability to feel loving or tender)
- Sense of a blighted future (for instance, not expecting a normal career or to marry, have children or live a normal life span)
Persistent symptoms of increased arousal post-trauma, as indicated in two or more of the following ways:
- Difficulty falling or staying asleep
- Irritability or outbursts of anger
- Difficulty in concentrating
- Exaggerated startle response
For a diagnosis of PTSD, these symptoms must have been occurring for at least a month and be causing significant distress to the person or impairment of their social life and/ or work life or other daily functioning.
Looking at the list, it would be surprising if such experiences didn't seriously disrupt one's enjoyment of life and coping abilities. However, some people do manage to soldier on, without realising that their condition can be explained and - more importantly -very quickly resolved so their suffering can stop.
If these miserable, frightening symptoms are familiar to you and you have enough of them to cause you distress, regardless of whether they warrant an actual diagnosis of PTSD - we urge you to seek the very swift and effective help that is available (see Part 3.)
Why some people but not others?
When people have gone through terrifying traumatic experiences, how is it that four out of five people manage to 'walk away' psychologically unharmed? There are three likely explanations.
Some life-or-death situations are more traumatising than others:
If you have no means of escape from the terrifying experience, it is especially likely to become etched in your mind as a traumatic memory.
Post-traumatic stress is cumulative:
The more previous traumatic situations people have found themselves in, the more likely they are to succumb at some point to PTSD. Often a police officer or a fire fighter who suffers PTSD after a particular incident comments, "But why now? Why after this? I've actually been in much worse situations before." The reason is that the stress has mounted up (becoming more than our dreaming brain can deal with) and, at the final occasion, is too much to bear. We would all eventually succumb to PTSD, if we were exposed over our lifetimes to high enough levels of traumatic stress.
How imaginative we are plays a part:
After a traumatic event, it is natural for most people to 'talk' it out of their systems - for instance, talking over the details of a relative's death with different friends help us process the experience mentally and categorise it in a healthy, helpful way. But people with particularly creative temperaments or particularly vivid imaginations may imaginatively re-live and engage in the experience as they describe it to others. In effect, this is like being traumatised all over again. Remember, the amygdala (the brain organ that pattern matches to danger) doesn't know the difference between what's real and what's imagined. So reliving the trauma - whether through imaginative recall or as part of any so-called therapeutic intervention that requires a person to keep going over and re-experiencing it -makes the likelihood of suffering PTSD all the greater.
How trauma affects the brain
This brings us back neatly to the amygdala and its starring role in all this. As we explained earlier, when we are under serious threat, or we perceive ourselves to be under serious threat, our amygdala rushes to raise the alarm ('by setting' i.e. set the fight-or-flight response in motion) before the neo-cortex, the rational thinking part of our brain, even knows what is going on, let alone has a chance to form a judgement about it.
When a situation is highly traumatic, and especially if escape routes are blocked, stress levels rise and stay sky high.
As we have seen, high levels of emotional arousal have the effect of inhibiting any contributions from the neocortex (you can't think straight). In addition, the surge of a stress hor-mone known as cortisol prevents an organ in the brain called the hippocampus from being able to communicate properly with the amygdala. The hippocampus lies adjacent to the amygdala and works in partnership with it. Its normal role is to create the narrative for an event - to give it context and code it in a form that can be stored as a narrative memory in the neocortex. ("The light aircraft in which I was a passenger developed engine failure and we crashed into the trees." "When it was dark and I was walking home alone, a man in a leather jacket wrestled me to the ground, hit me and stole my wallet." ) But, with the neocortex and the hippocampus virtually out of the frame, the amygdala is left to process the emotional experience all by itself, and it is too stupid to do that properly. So the traumatic situation is coded by the amygdala as a terrifying, emotionally intense feeling state -and therefore anything remotely like it must be avoided at all costs.
As we have explained, the amygdala's pattern matching abilities are crude, to say the least. So, when it has had a big fright, it makes matches all over the place. For example, if the smell of fuel was strong when the light aircraft crashed, the smell of petrol at an ordinary petrol station, while filling up the car, could be sufficient to trigger feelings of absolute terror. If a man, or even a woman, passes by in a leather jacket, panic levels may soar. Because the hippocampus has been disabled by stress, no context can be created for the terrible memory. Therefore it is, in effect, an event ever in the present, triggered by any number of sounds, sights or smells that may have only peripheral connections with the original life-threatening trauma. The inexplicable terror experienced, apparently out of the blue, makes the sufferer become hypervigilant, always tense and fearful, and increasingly unwilling to enter situations or engage in activities that might trigger such a reaction. Without context, pattern matches to a traumatic event that happened at the age of 10 can still be triggered at the age of 60, if the memory hasn't been processed properly.
Normally, within a month of a traumatic event, people's stress levels start to fall; this lets the hippocampus communicate with the amygdala again and belatedly create a context for what happened. Then, at last, the neocortex gets to have a look in. It is able to tell the panicky amygdala, "Look, I know we were in a nasty car crash. But we don't have to be frightened of getting in any car ever again. We lost control that night because the road was icy. We will certainly take better care when driving in icy conditions after this but, otherwise, we don't have anything to worry about." And, if the amygdala is calm enough to 'hear' all this, the fear of driving subsides, and things get back to normal.
But, in PTSD, because so many innocent events trigger off terror, the arousal level doesn't ever get down low enough for the hippocampus to create a context and for the neocortex to get a decent conversation going with the amygdala. It's as if the neo-cortex says, "But that's only petrol" or "That's only a man in a leather jacket" or "That's only a car" but the amygdala kicks and bellows and drowns it out, screaming, "I know! But it's going to kill us!"
As panicky ruminations and 're-living' of the event continue, these fresh arousals need to be discharged in the form of dreams - as the expectations aroused cannot be acted on, because the original traumatic event is in the past. And, because the event being dreamed about is so horrific, the dream is likely to be a nightmare and often one that is so vivid that it will wake the dreamer, who then remembers it. Then the nightmares too get added into the fear mix. (The explanation for dreaming is here: How poor sleep can turn worry into depression - in the generalised anxiety section.)
To stop this ongoing cycle, a way has to be found to calm the amygdala down and then reprocess and recodify the event, in its correct context. To do this, the trauma pattern needs to be reactivated briefly, but without allowing the amygdala to get all excited and frightened again. Although this may sound impossible, it is in fact very simple to do. It is what happens in the rewind technique, which has been mentioned a few times already, and in other methods you may have heard of, such as Eye Movement Desensitisation Reprocessing (EMDR), Thought Field Therapy (IFT) and Emotional Freedom Therapy (EFT).
In the rewind technique, the therapist first relaxes the person deeply, to calm them down, and then guides them through the traumatic experience but in a dissociated (distanced) manner, which prevents arousal - they are invited to imagine themselves looking at a video or DVD of the traumatic event, which they are fast-forwarding, and then running backward through it, on fast rewind, as if they are in the event themselves. (The method is described in detail in Part 3). In EFT, the desired dissociation is achieved by asking the person to think about what happened and to re-experience their anxiety but, at the same time, to tap certain parts of their face and body rhythmically in a certain order. In the other methods, something similar happens.
When the trauma is re-experienced in this dissociated, calm way, the hippocampus is no longer inhibited and can record the context as a safe one - the person is aware of sitting in the therapist's office, dealing with a memory. Because the brain is calmly processing the past trauma at the same time as it is processing the current situation of sitting in the room, the experience can be coded by the hippocampus as non-threatening - and the trauma memory is relegated to the past, where it should be. (This is rather like what happens when we wake in panic from a nightmare and realise that we are safe in bed. We immediately stop being fearful because a context has been created. That was a horrible dream, gone and finished. This is real life, now.)
So a new message is put into the person's memory and, while still in this state of low arousal, the therapist can engage the client's neocortex in drawing further distinctions between the traumatic but now non-threatening past event and present-day life. "The smell of petrol is normal at a petrol station, as you fill up your car and spill a little drop. It doesn't signify danger." "A great many people of all shapes and sizes, colours and creeds wear leather jackets. They are not all muggers." Thus a feedback loop is set in place, which allows the pattern in the amygdala to be reprogrammed. The memory of the traumatic event will always be an extremely unpleasant one, but it will no longer induce panic and intense fear or the feeling that it is happening now. The whole procedure can often be completed within 20 minutes, so is easy to do in a normal therapy session. (Of course, it can only work if the trauma is truly in the past. It cannot work, for instance, in cases of abuse that are ongoing.)
Psychologists have suggested that these detraumatisation methods work so simply and quickly not because of magic or special knowledge but because they make use of a simple mechanism with-in the brain - one that brings us back to REM sleep again.
The electrical signal described earlier, which draws our attention to any sudden movements and which fires off repeatedly when we dream, is not only known as the orientation response but also the PGO wave (for complicated reasons not worth bothering with here) and the curiosity reflex. We like the term curiosity reflex, so we'll use that one.
In dreaming, the curiosity reflex fires intensively while the day's emotionally arousing expectations that didn't get acted on, or completed in some way, are cleared out in dreams. As we have seen, we usually forget our dreams for the very good reason that if they became memories we would no longer be able to distinguish between what was real and what was purely metaphorical. So, it seems, the curiosity reflex also triggers us to forget intense emotional memories. Even in waking life, inducing 'forgetting' is often the effect of the curiosity reflex.
Suppose you are chatting on the phone to a friend and there is a loud thud behind you. Instantly you whirl around, curious to identify the source, and see a precariously placed book has fallen off a table or a window blind has suddenly snapped up. When you turn back to your conversation, however, you might well find that you have completely forgotten what you were saying. The curiosity reflex has caused you to momentarily forget whatever was actively on your mind.
In evolutionary terms, this makes sense as a survival mechanism. When life was dangerous for us on a daily basis, we needed a mechanism that instantly drew our attention - and withdrew it completely from whatever we had been doing till that moment. You can't keep putting the finishing touches to your mammoth stew if a live wild boar's hot breath is nearly at your neck.
However, nor would we want to lose track of what we are doing every time something unexpected happens, as that would clearly also be a risk, not an aid, to survival. If we are making dinner or mending a bike or reading, and the distraction turns out to have been unimportant, we can easily get back to what we were doing, as the cooking utensils or the tools or the book remind us what it was.
But it isn't so easy to remember what we were talking about or thinking, as we have nothing to orient ourselves by. That's why so many of us have the experience of setting off to get some item or other, being called or becoming engrossed in another thought, and then forgetting entirely what we had set out to get. This is often referred to in jest as I a senior moment', but it happens to young people too. Any major distraction clears out our working (short-term) memory in case it is needed for something more important. After all, sometimes our survival does depend on a sudden switch of attention and total concentration.
During the rewind technique, a person is in a deeply relaxed state, which, in terms of what is happening in the brain, makes it easy for them to slip into the REM state. It makes sense, therefore, that, during the technique, the curiosity reflex would be triggered by the unfamiliar mental activity of imagining movements being run through backwards, thus causing temporary amnesia and clearing the fear pattern (which the therapist has deliberately aroused) out of consciousness. (In tapping, the curiosity reflex would be triggered by the tapping movements.)
But the therapist has also established an expectation that the trauma will be resolved by this imagination exercise - and the neocortex is curious as to how. So, during the temporary amnesia, a good therapist will also take the opportunity to make suggestions that underline how the present situation is so very different from the trauma situation, and thus complete the neutralisation of the emotion that accompanied the memory.
We hope you are reassured by this explanation of PTSD and how and why it can be so easily and effectively treated by therapists trained in the rewind technique. (This is the method we favour over all others, for reasons we will explain in Part 3.)
Continued in this article: Panic attacks