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CHAPTER TWO

MENTAL, EMOTIONAL, AND PHYSICAL EFFECTS OF PTSD

“It isn’t in my past, it’s in my every day.”

— Helen Wilson

Regardless of how you may appear on the outside, if you have PTSD, you are dealing with a lot on the inside. The unwanted thoughts, emotions, and physical effects of PTSD can be extremely debilitating and can cause significant impairments in your ability to function in several areas of life — mentally, emotionally, physically, spiritually, socially, sexually, financially, professionally, and in relationships. Even when you’re smiling or laughing, you may be overwhelmed by the erratic, agonizing, persistent, and devastating symptoms of PTSD. Therefore, this chapter is aimed at helping you recognize and understand your symptoms. Since it is impossible to cover everything you may experience, I will cover the symptoms listed in the DSM-5, as well as some other common effects of PTSD.

INTRUSIVE SYMPTOMS

The reexperiencing of trauma is a hallmark feature and diagnostic marker of PTSD. Intrusive symptoms such as flashbacks, nightmares, and disturbing memories are common in the weeks and months following a traumatic event, even for those who do not develop PTSD. For most people who experience trauma, these flashbacks and other intrusions become less frequent and less intense as time goes on. However, for those with PTSD, the distressing intrusive reexperiencing of trauma does not subside with time.

Flashbacks consist mostly of vivid sensory perceptions (images, sounds, smells, tastes, textures) that were experienced during the actual event. Here are some examples:

I can feel his weight against my body, his breath against my ear.

I smell smoke. I could swear it’s real. I panic every time, even though I should know by now that it’s just a flashback.

I hear the car skidding out of control, the sound of the transport truck downshifting, the loud, crunching sound of metal. I can’t explain how real it feels, but it’s like I’m actually there in that moment again.

I see the look on his face right before it happened. It’s like he’s right here in front of me.

For the person experiencing a flashback, it’s almost like there is a warp in the space-time continuum and they are back in the past reexperiencing the event. Flashbacks are not the only types of disturbing scenes and imagery you may experience. You may also have disturbing memories or nightmares, as well as intrusive thoughts. These consist of horrible, violent, repulsive, disgusting, threatening, and deeply disturbing thoughts that may or may not be related to your trauma. It can be images of despicable things happening to you or to your loved ones, or even scenes of you doing horrific things that you would never do in reality (attacking someone, hurting a child, sexually inappropriate or illegal behaviour, public displays of aggression, etc.). These involuntary thoughts bring guilt and can make the person fearful that they may lose control and actually do something terrible. They may believe they’re a horrible person for having such thoughts and that if they’re capable of thinking these thoughts, it must mean they are capable of doing these things. But this is not the case. The fact is, everyone has seen or heard these aggressive and disturbing types of things on TV, on the news, or somewhere else, and everyone has forbidden thoughts. Before developing PTSD, you had the ability to filter these things out of your awareness and block them with little effort. After PTSD, due to changes in brain structures and functioning which will be explained in the next chapter, you have a significantly diminished ability to suppress these intrusive thoughts. Here is what one woman said about this:

Intrusive thoughts pop out of nowhere. It’s completely involuntary. I often can’t relate it to anything that has happened in the past or to anything that is bothering me in real life. I am fully aware of it, don’t like it, and do my best to block it. But sometimes I can’t. It scares me, so I try to switch my thoughts to something else, but I get pulled right back into the intrusive imagery. Trying to control these thoughts is exhausting.

It is important to recognize intrusive thoughts as part of PTSD and to separate them from who you are. When you have intrusive thoughts, turn your awareness to the picture of PTSD that you drew in the last chapter and call it by its name (the name you gave your PTSD in Chapter 1). Recognize these thoughts as a PTSD episode and not as you.

“Hallucinations” can be another intrusive symptom of PTSD. We tend to associate hallucinations with psychosis, and as much as these experiences make you feel paranoid, in the case of PTSD, it is not a psychotic phenomenon, but rather a dissociative experience. This may happen because the amygdala is so primed for something bad to happen that it projects things externally and creates the sense perceptions to match the perceived or imagined threat. Sometimes these “hallucinations” are referred to as pseudohallucinations, nonpsychotic hallucinations, or parahallucinations to distinguish them from standard hallucinations where the person believes their hallucination to be real. In those with PTSD, although it feels very real, they know it is not actually happening in their objective reality and can usually recognize that their mind is playing tricks on them.

It is quite common in PTSD to have brief moments of vivid sensory perceptions that are not directly related to the traumatic event. Here are some examples:

• Hearing footsteps, creaking doors, buzzing, breathing, someone saying your name, or other strange sounds that no one else can hear

• Seeing a shadow, reflection in a mirror, or a person that’s not there

• Feeling someone’s presence or touch

You may have noticed that your intrusive symptoms can come and go and tend to increase when you’re stressed or when you come across reminders of your trauma. For example, you may hear sirens going by and be flooded with memories of your car accident, or perhaps you see fireworks and are brought back in time to the war. You may see, smell, hear, taste, or feel something that you don’t consciously associate with your trauma, and the next thing you know, you’re in full-blown fight-or-flight mode. For example, one paramedic said he had a flashback immediately after noticing an almost-dead turtle on the side of the road. Unable to catch his breath, he stopped on the side of the road to vomit. He couldn’t understand why roadkill — which he’d seen many times in the years since his traumatic event — would suddenly have such an effect on him. When asked to provide more detail about the event, he explained that the turtle’s body was completely crushed and that it was still gasping for air. Then it dawned on him: “That’s just like the boy,” he said, referring to his precipitating trauma where he’d been called to the scene of a motor-vehicle accident involving a four-year-old child whose body was completely crushed, but he was still breathing reflexively. Although he hadn’t made the conscious connection on the spot, he could easily see how the two were subconsciously associated and why he was triggered by the turtle.

Here’s another example: a woman who was assaulted in a park by a tall, dark-haired man with a beard wearing jeans and brown shoes. Although she only consciously remembers these specific details, there were also several things in the background that were not consciously noticed but that were nonetheless picked up by her senses. In this case, tall men, beards, parks, jeans, and brown shoes can become identifiable triggers, but there may be other more generalized triggers that are less easy to identify. Perhaps the smell of grass, the colours blue or brown, or other less obvious things like pavement or something in the distance that was barely noticed that became unconsciously associated with the trauma. All of these subconscious details can become triggers for her intrusive symptoms. These “triggers” will be further explained in chapter six, but for now, it is important to know that trauma can be stored deep in the unconscious mind, hidden even from ourselves, just waiting for a trigger to resurface. Sometimes these intrusive symptoms seem random, as though they are coming out of nowhere, but other times there is an identifiable trigger. Here is an example of a clear trigger:

My husband took his life in our bedroom while I was in the house. Now any loud sounds trigger a visceral reaction in me. Fireworks, sirens, car backfiring, anything loud will cause an intense emotional reaction. I start shaking, bawling, and completely losing emotional control.

Here is an example of intrusive symptoms that don’t have such a clear trigger:

I started having flashbacks several years after an abusive relationship. I don’t know exactly what triggered them, but I started having these flashbacks of specific moments — the worst parts — things I had totally forgotten about. They just sort of came out of the blue. It’s like they were suppressed memories. When a flashback comes on, I can feel the emotions and sometimes even the physical sensations. I really don’t know what causes them.

Although there isn’t always a clear trigger, sometimes a traumatic experience that has been completely blocked is reactivated years later when something happens to bring it back into awareness. This can also happen when under extreme stress, even when the person thinks they have moved past their trauma and believe it is no longer affecting them. Then intrusive thoughts, memories, flashes, and nightmares started plaguing them.

PRACTICAL EXERCISE — IDENTIFY YOUR TRIGGERS

See if you can determine which of your senses trigger your intrusive symptoms most: sight, smell, touch, taste, or hearing. For the next few days, notice what, if anything, has come in through your senses just before you experience intrusive symptoms. Note them in your workbook or journal.

REFLECTIVE QUESTIONS

• What are the sounds, smells, sights, tastes, and sensations that trigger flashbacks or intrusive memories?

• What are the internal things (thoughts, emotional states) that trigger intrusive symptoms?

• What external things (people, places, situations) trigger intrusive symptoms?

AVOIDANCE

Avoiding pain or other unpleasant emotions is a natural human response. Avoidance includes all actions aimed at avoiding thoughts, emotions, situations and reminders associated with trauma. This can include physical, mental, and/or emotional avoidance. Physical avoidance is avoiding people, places, and situations, while emotional avoidance is the avoidance of feelings, and mental avoidance is the avoidance of thoughts and memories associated with the traumatic event. Here are some examples of physical, mental, and emotional avoidance:

Physical Avoidance: Now that I have PTSD, I avoid social situations like the plague. I’m not comfortable in crowds or even in places where there will be other people (i.e., the grocery store). I was much more social before being sexually abused, but now I make excuses as to why I can’t go places, even if I really want to. Part of it is not knowing when I will be triggered, and not knowing whether I will be able to handle myself in those situations. Another part is a fear of human beings. When someone you know and trust traumatizes you in such a personal and intentional way, you lose almost all faith in humanity.

Mental Avoidance: When I start having bad thoughts, I often start sorting, cleaning, spending, and doing anything I can to keep me busy and distracted from my own thoughts. I just try to push it away instead of facing it. Why? I guess I’m afraid of thinking about it. I’m afraid to “go there” because it brings about negative thoughts and feelings that I can’t handle.

Emotional Avoidance: I started drinking to ease the pain. At first, a little shot of brandy did the trick. It calmed me down, allowed me to sleep, and eased my fears. In time, I drank more and more. When I’m drinking, I’m not feeling, and I guess I just don’t want to feel any of it because I’m afraid I might totally lose control and never be able to pull myself back together again.

In many ways, avoidance is adaptive. It is a self-protection mechanism that temporarily shields us from the full extent of the intense emotions associated with trauma, such as fear. Although not always conscious or intentional, there is good reason for this protective shield. It’s what allows us to function during times of crisis. When we experience thoughts and sensations that make us anxious or uncomfortable, we will try to withdraw by whatever means available. If these avoidance behaviours cause a lessening of anxiety, we are being rewarded through a process known as negative reinforcement (the removal of something we don’t like). Over time, these “rewards” cause us to become more and more avoidant of anything that causes anxiety, fear, or other difficult emotions. At first, avoidance behaviours can provide temporary relief, but they also cause long-term problems by increasing fears, worsening symptom severity, and interfering with healing, as well as creating new problems such as addiction, debt, or relationship problems. It is instinctual to try to escape from pain or to fight against it, but trying to avoid your dark thoughts and painful emotions actually makes them worse. Trying to ignore and push it all down causes it to grow. Now, this doesn’t mean we should discard all of our avoidance behaviours, but we should at least start alternating between avoiding and slowly allowing ourselves to face what it is we need to deal with.

PRACTICAL EXERCISE — IDENTIFY AND VALIDATE

Think about some of the ways you avoid the thoughts, emotions, situations, and reminders of your trauma. Make a list of everything you uncover and then validate your reasons for using avoidance to cope with what you’re going through. No matter how many problems these avoidance behaviours may be causing now, there was a time when they allowed you to temporarily escape pain, gain pleasure, or simply get through a painful moment. Acknowledge that you had good reasons for avoiding, but also recognize that alcohol, isolation, or whatever other strategies you are using are only prolonging and worsening your agony. Since you already know fighting your thoughts and emotions doesn’t work, try to slowly start acknowledging them. This will give you more psychological flexibility and allow you to stay connected to the present moment, despite unpleasant thoughts or emotions. So, the next time you notice a distressing thought or emotion, set a timer for three minutes and objectively observe it, the same way you would watch a movie on television. Try to remain objective, nonjudgmental, and unattached to your thoughts and emotions and see if you can let them pass through you without getting attached, fighting, fuelling, or avoiding them. Don’t try to figure out why they are there, where they came from, or how to get rid of them. Just let them be.

REFLECTIVE QUESTIONS

• What avoidance behaviours do you use to get through challenging moments? Make a list.

• How are these avoidance behaviour strategies working for you in those moments? How are they working long-term?

• What are you afraid might happen if you slowly start facing your trauma instead of avoiding it?

NEGATIVE ALTERATIONS IN COGNITION AND MOOD

The mental and emotional effects of PTSD can seem endless, like a bottomless pit. You may feel completely defeated and find yourself questioning whether life is still worth living, even though there are people in your life that you love dearly. You may start to lose hope and think you are cursed to a life of not being able to work or contribute to your relationships or to society. You may ask yourself things like:

• Am I always going to be like this?

• Will I always have to take medication?

• Am I ever going to be successful again?

• Will I ever feel happy or be at peace?

• Will I be able to live a productive life or have fulfilling relationships?

• What is the purpose of life? Why am I here?

PTSD alters your worldview in negative, distrusting, and pessimistic ways. It can also negatively affect your views and beliefs about yourself. You may go from blaming others to blaming yourself for the trauma or for other things. You may feel mostly distressing moods — irritability, anger, fear, sadness, guilt — and have difficulty accessing positive emotional states. You may feel unlovable, insecure, unworthy, and unsafe, and this may come out in disturbing ways. The ways trauma can affect us emotionally can include:

• Anger, irritability, cynicism, rage, control

• Sadness, depression, isolation, loneliness, hopelessness, and despair

• Anxiety, fear, and doubt

• Guilt, shame, worthlessness

• Dissociation, detachment, derealization, shock, numbness, indifference

Example Statements (emotional):

• I feel overwhelmed by every little thing. Something really small can feel like the end of the world to me.

• I wake up in the middle of the night with panic attacks and can’t get back in bed for hours.

• I feel nothing; it’s like I’m just a zombie going through the motions.

• I’m always acting like an asshole and getting mad for every little thing.

• I cry and cry. I just break down, my body just shakes, and I can’t pull myself together.

• I’m afraid of everything, things that never even used to cross my mind.

• I’m irritable and angry, lashing out at my kids for no real reason. Sometimes I scream at them or even hit them. I feel ashamed and know I need help.

• I can’t get out of bed, I have no motivation, I feel down. Just getting through the day is exhausting.

• I’m always on edge, worried about what’s coming next. I always have the feeling that something bad is about to happen.

Trauma can affect our cognitive abilities in several ways, including:

• Diminished ability to think or concentrate/low attention span

• Difficulty processing and organizing information

• Forgetting/memory issues

• Difficulty making decisions or making rash decisions

• Thoughts of death and/or suicide

• Ruminating and dwelling on things (related or unrelated to trauma)

• Inability to suppress unwanted thoughts and memories

• Inability to remember certain aspects of the trauma

Example Statements (cognitive):

• I can only remember about thirty seconds of the crisis, but that thirty seconds is imprinted on my brain and plays repeatedly like a jumbled slideshow of graphic, violent images.

• I’m in a brain fog. I can’t concentrate long enough to watch a movie or read a book.

• Things that used to be easy for me are impossible now because I forget everything and have zero attention span.

• I’m forgetting the simplest things and making stupid mistakes.

• Sometimes I get lost. Literally. I can be driving, and suddenly I don’t know where I am or where I’m going.

• I’m hard to live with because I’m always thinking the worst about people and expecting worst-case scenarios.

• There are times when I can’t make any decisions; it’s like I’m paralyzed. Other times I’m impulsive and spend money I don’t have, even though I used to be very decisive and rational about my finances.

• People might say I’m paranoid, but the world is a dangerous place; they just don’t know it yet because nothing really bad has happened to them.

• Sometimes it’s like my brain just shuts down, and I can’t think straight. I can be in the middle of a conversation, and I stop mid-sentence and don’t know what I was talking about.

You may not relate to all of these examples, and your personal experiences may be different, but this small list and set of examples show the many ways PTSD can negatively affect cognition and mood.

PRACTICAL EXERCISE — ALLOW YOUR UNPLEASANT THOUGHTS AND EMOTIONS

If you always try to suppress your disturbing thoughts and unwanted emotions, those suppressed thoughts and emotions will become more and more difficult to manage. So instead, give yourself permission for short periods of time to start allowing yourself to think, feel, and process whatever you’ve been blocking and avoiding.

• Sit in a comfortable position, close your eyes, put your hands on your lap with your fingers intertwined (try not to move your hands), and then let your thoughts flow.

• If an upsetting thought or emotion arises, just let it be, reminding yourself that you are safe and that none of these thoughts or emotions have power over you, unless you give them power.

• Do nothing. Do not try to think or not think anything. Try to allow your mind to handle itself for a few minutes, the way your lungs handle your breathing without any help from you.

• If you feel an unpleasant thought or emotion arising, see if you can observe it and follow it from a detached perspective and let it pass through you. Sometimes putting your focus on it causes it to dissipate. Notice what you are feeling in your body. Describe it out loud.

• Do this two or three times a day. Once you are done the exercise, you can consciously go back to your usual coping strategies, if needed.

REFLECTIVE QUESTIONS

• What repetitive thoughts are playing over and over in your mind?

• In what ways do you fight or fuel your distressing thoughts?

• In what ways do you fight or fuel your distressing emotions?

AROUSAL

When we think of PTSD, we usually think of the hyperarousal aspect of it — fear, anxiety, panic, hypervigilance, heightened startle response, inability to relax, low access to cognitive functions, and little ability to regulate emotions — which is characterized by excessive activation of the fight-or-flight response. When hyperarousal exceeds the threshold that we are able to tolerate, or when the threat is too powerful to fight or outrun it, the defensive freeze response is the only survival response left. In this case, the sympathetic nervous system turns things over to the parasympathetic nervous system, and you go from a state of hyperarousal to a state of hypoarousal (freeze). Here’s how these survival states work:

1. Hyperarousal

Most of us want to feel like we are in control and that life is predictable. We want to think we know what’s going to happen next, yet when we experience trauma, we realize we are not in control. That anything can happen at any time. Life can get turned upside down at the drop of a hat. Instantly, what once seemed certain no longer is. A traumatic experience can deconstruct all of your notions about how the world works. Things you believed about human nature are no longer certainties, and your assumptions about the world being safe and predictable have been shattered. You’ve learned that terrible things can happen to you and your loved ones at any given moment, and this has launched you into a state of fear. Your fears after a traumatic event can include things like fear of change, fear of judgement, fear of the unknown, fear of dying or of losing someone, fear of remembering details of the trauma, fear of facing your own difficult emotions, and all kinds of other fears that you never used to think about. Now you’re on guard, anxious, easily startled, and unable to relax. This may leave you trying to control all aspects of your environment, including the people in your life. Here is what one person with PTSD had to say about the fear and lack of predictability she felt following the death of both her parents in a double homicide: