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1. Understanding the impact of trauma. Center for Substance Abuse Treatment. Trauma-Informed Care in Behavioral Health Services. https://www.ncbi.nlm.nih.gov/books/NBK207191/. Published 2014. Accessed November 23, 2022. 

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1. Veterans & Active Duty. NAMI. https://www.nami.org/Your-Journey/Veterans-Active-Duty  Accessed October 23, 2022. 
2. Kessler RC, Heeringa SG, Stein MB, et al. Thirty-day prevalence ofDSM-ivmental disorders among nondeployed soldiers in the US army. JAMA Psychiatry. 2014;71(5):504. doi:10.1001/jamapsychiatry.2014.28. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/1835338. Accessed October 23, 2022.
3. Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the national comorbidity survey replication. Archives of General Psychiatry. 2005;62(6):617. doi:10.1001/archpsyc.62.6.617. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/208671. Accessed October 23, 2022.
4. Wisco BE, Marx BP, Wolf EJ, Miller MW, Southwick SM, Pietrzak RH. Posttraumatic stress disorder in the US veteran population. The Journal of Clinical Psychiatry. 2014;75(12):1338-1346. doi:10.4088/jcp.14m09328. https://pubmed.ncbi.nlm.nih.gov/25551234/. Accessed October 23, 2022.
5. Moradi Y, Dowran B, Sepandi M. The global prevalence of depression, suicide ideation, and attempts in the military forces: A systematic review and meta-analysis of Cross Sectional Studies. BMC Psychiatry. 2021;21(1). doi:10.1186/s12888-021-03526-2. https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-021-03526-2. Accessed October 23, 2022.
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9. Lin L(A, Peltzman T, McCarthy JF, Oliva EM, Trafton JA, Bohnert ASB. Changing trends in opioid overdose deaths and prescription opioid receipt among veterans. American Journal of Preventive Medicine. 2019;57(1):106-110. doi:10.1016/j.amepre.2019.01.016. https://www.ajpmonline.org/article/S0749-3797(19)30076-5/fulltext. Accessed October 23, 2022.
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11. Stein MB, Jain S, Giacino JT, et al. Risk of posttraumatic stress disorder and major depression in civilian patients after mild traumatic brain injury. JAMA Psychiatry. 2019;76(3):249. doi:10.1001/jamapsychiatry.2018.4288. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2722564. Accessed October 23, 2022.
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13. Kline AC, Panza KE, Nichter B, et al. Mental health care use among U.S. military veterans: Results from the 2019–2020 national health and resilience in veterans study. Psychiatric Services. 2022;73(6):628-635. doi:10.1176/appi.ps.202100112. https://ps.psychiatryonline.org/doi/10.1176/appi.ps.202100112. Accessed October 23, 2022.
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Cited Sources:

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Q: Can PTSD and social anxiety relapse randomly for no particular reason? I had therapy for months last year, and I was normal for months after. Now I can barely function and do basic things at work like speak up in meetings. I’m seriously considering handing in my notice, as I feel like I’m failing at my job so they’ll fire me anyway.

Dear Ayah,

To answer your question, YES — PTSD and anxiety symptoms can pop back up months,  even years later. It’s typical for them to resurface without any clear reason, which can feel really frustrating and confusing. But here’s the thing, 2020 is far from a typical year, and there has been a LOT to be anxious over these days. Even if you are not directly impacted by the physical effects of COVID-19, social and racial unrest, or the ongoing election stress, you cannot avoid all of the news and social media coverage which can have a devastating impact. Being constantly exposed to so much news of trauma can create something called vicarious trauma and can be incredibly harmful to our mental health.  Research is finding that the bombardment of traumatic materials in the media can lead observers to  anxiety, difficulties in coping, feelings of fear and helplessness, and in rare cases PTSD. Because of your history you’re more vulnerable to the effects of news and media in your environment. 

What you’re experiencing is a relapse of your symptoms. I highly recommend jumping back into therapy with your therapist! In all of the years that I have been providing trauma therapy, my clients often come back months or even  years later for a few “maintenance” sessions. This is completely normal, and in some trauma protocols like Cognitive Processing Therapy it’s strongly recommended as a standard part of the process. Therapists plan for these recurrences of symptoms. 

Of course this must feel extremely distressing. Does it make sense though, that despite the overwhelm and frustration, that this isn’t the best time to quit your job? Avoidance is a really common symptom of PTSD (and anxiety), but avoidance of the things that scare us does little to calm our fears. This is a decision that can create a lot more stress as opposed to relieving it. We lose perspective when our mental health is compromised.You’re in pain Ayah. You’re not working up to your capacity because your mental health needs care, not because you’re incapable. Reach out to your manager and communicate what’s going on.  My guess is that this isn’t going to come as a surprise. Most employers will follow a planned protocol. If they didn’t have one before 2020, they probably do now.

I applaud the courage it took to engage in therapy last year. Therapy is vulnerable and requires  dedication — especially when dealing with trauma. It’s not a singular event though, and your ongoing dedication to your mental wellbeing will require tune-ups throughout your life. You have the advantage this time around. You already have some tools and a blueprint for what your mental health feels like. You have control over how you manage this and an already established lifeline to grab onto. Reach for it. I can’t say it enough — this is a normal part of the process. You will feel better again. And when you do, reach out and let us know. You’re not alone Ayah.

-Ashley

Ask a Therapist is for informational purposes only, does not constitute medical advice, and is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your mental-health professional, or other qualified health provider with any questions you may have regarding a medical or mental health condition. By submitting a question you are agreeing to let Talkspace use it. Full names will not be used. *In case of urgent issues, do not ask a question, call 1-800-273-8255 or go to https://suicidepreventionlifeline.org/

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Anxiety is your body’s “fight or flight” response to danger. The bodily sensations of heart palpitations, sweating, decreased appetite, and increased blood pressure are nature’s way of helping you escape from a harmful situation. After stages of shock and denial, many people begin to feel sadness, anger, helplessness, and other emotions that help them make sense of their new reality. For those who develop post-traumatic stress disorder, the symptoms of anxiety will persist and their brains will not be able to accept that they’re now safe.

How Do I Know I’m Experiencing Prolonged PTSD, Not Anxiety?

Signs that you’re experiencing PTSD and not a normal range of anxiety include vivid flashbacks or dreams about the traumatic event that cause high levels of distress, changing behaviours to avoid being triggered, feeling numb, and staying alert or hypervigilant to potential threats. These symptoms are intrusive and will interrupt daily activities. They can also affect relationships with family, friends, and colleagues. Getting support from a therapist and connecting with other survivors can help to lessen the pain.

There can be some overlap between anxiety disorders and PTSD. Anxiety symptoms include restlessness, being on edge, easily tired or frustrated, having a hard time focusing, and feelings of intense worry. Some people with posttraumatic stress disorder also experience generalized anxiety disorder, where they feel intense anxiety symptoms all the time. At times it can be difficult to differentiate between anxiety disorder symptoms and PTSD, but people with anxiety don’t have to experience a traumatic event to develop anxiety and can experience anxiety symptoms without triggers. The largest difference between PTSD and anxiety, is that people experiencing PTSD mainly have symptoms in response to a traumatic event or series of events. 

Whether you’re experiencing PTSD or anxiety, it’s important to remember that you’re not alone. In the course of an entire human lifetime, traumatic events are largely unavoidable and most of us do not go through the world unscathed by moments of intense stress. It’s estimated that 60% of men and 50% of women in the U.S. will encounter at least one traumatic event. However, not everyone who experiences trauma will develop PTSD. In fact, only 4% of men and 10% of women will have a disordered response to stress caused by trauma.

How long does PTSD last?

In research on prolonged PTSD, the statistics get smaller. A study on rape survivors found that 94% had symptoms of PTSD after a week of the assault and by nine months that number declined less than 25%. It’s generally believed that the average duration for posttraumatic stress disorder is three years if the proper treatment is received and five years without treatment. Failure to receive psychiatric support for this mental health condition within six years will likely result in a more challenging recovery. This is why we shouldn’t hesitate to reach out to licensed mental health professionals after trauma. We deserve to be assessed for PTSD and adequately cared for there are no awards for sticking it out alone or suffering in silence.

There are several factors that are linked to prolonged PTSD. For example, alcohol and drug abuse will both exacerbate the symptoms and mask their severity. Getting into a pattern of self-medicating to push away distress, rather than deal with it, only makes things worse in the long run. A therapist can help you discover healthy coping skills that actually do what you’re hoping substances will do and help improve your quality of life. If you have resistance or difficulties in adjusting your coping skills, your therapist will be there to support you without judgement. It can be hard just to breathe when you’d rather drink, but all of the science shows us that the former leads to better long-term mental health.

Comorbidity and PTSD

Other factors that can influence the severity and length of response to a traumatic event include repeated experiences with trauma and other coexisting conditions such as depression phobias obsessive-compulsive disorder (OCD) . Prolonged PTSD can reveal that other issues need to be addressed in treatment and finding a therapist with knowledge about comorbidity (i.e. simultaneous presence of two or more conditions) will be important for recovery. For instance, you may need to spend time working on your depressive symptoms before addressing PTSD. Treatment is usually layered and non-linear. We heal in our own time, in our own way. The bigger threats to our mental health should usually be addressed first, however. For example, if we’re managing suicidal ideation due to severe depression, that will take precedence over PTSD-related fear of public spaces.

Seeking Help is Crucial

Understanding the difference between anxiety, PTSD, and prolonged PTSD is a crucial first step in educating ourselves about the effects of trauma. However, identifying symptoms can be easier said than done.

Research has found that a major blocker to getting support involves individuals who believe they don’t have a problem. Other obstacles are treatment cost, lack of knowledge that resources exist, stigma, fear of forced hospitalization, language barriers, and poor experiences with facilities or quality of care. This is why it’s especially important and helpful to share information with our community and take action when a loved one is suffering. Once anxiety has crossed over into the threshold of PTSD, the data is clear that treatment makes all the difference.

We don’t have to suffer alone and hope that things get better. We deserve the support to get through PTSD and come out stronger on the other side.

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Breen’s case brought attention to the ongoing trauma faced by healthcare workers during a prolonged public health crisis. Studies already show high rates of PTSD in medical workers who have been braving the pandemic. In Italy, almost 50% of surveyed medical workers have demonstrated PTSD symptoms related to the pandemic. A full 70% of Chinese medical workers exhibited serious distress.

In the United States, where cases continue to surge and PPE and staffing shortages remain, many medical workers are showing signs of depression, panic, and paranoia. “This isn’t posttraumatic yet, because the trauma piece is still ongoing,” Laura S. Brown, a clinical psychologist, told the American Psychological Association.

While the pandemic is placing unprecedented strain on the American healthcare system, some medical workers say that these problems aren’t new. Just as the coronavirus has revealed the glaring gaps in the United State’s mental health and housing safety nets, it has also brought the challenging conditions medical workers face into sharp relief.

“The pandemic arrived to a healthcare system that’s already deeply in crisis,” said Wendy Dean, a psychiatrist and president of Moral Injury of Healthcare, a group that advocates for more sustainable medical workplaces. “All of the challenges that clinicians are facing prior to the pandemic are just highlighted, exacerbated, and added to.”

Medical Professionals Are Facing “Moral Injury”

Dean’s critique of the American healthcare system began long before the pandemic. She began her medical career as a surgeon, switched to emergency room medicine, and eventually settled on psychiatry. Some called Dean’s career “eclectic.” But she was simply searching for a specialty that would allow her to provide the best care for her patients.

“I was trying to find a way to take care of patients in the way I knew they needed to be taken care of, that was also sustainable for me,” Dean said.

But the profit-driven model of our medical system was coming in the way of that. Administrators urged doctors to schedule as many patients as possible, meaning they weren’t all getting the attention they needed. Meanwhile, the need to constantly tend to electronic medical records took away from face-to-face time with patients, and encouraged doctors to bring their work home.

Dean left practice after ten years. The more medical workers Dean talked to, the more she realized that she was far from the only one who felt deeply conflicted. Doctors she spoke to reported a tension between the care they wanted to give their patients, and the constraints of the system. “They were breaking a covenant to their patients,” she said.

There’s a word for this feeling: moral injury. The term refers to the intense dissonance people experience when a system compels us to do something out of line with our deepest-held values. Psychiatrist Jonathan Shay first coined the term in relation to the trauma faced by Vietnam veterans, many of whom were haunted by memories of times they committed atrocities at odds with their moral beliefs.

Dean defines moral injury as “perpetrating acts that transgress deeply held moral beliefs.” She said the trauma medical workers are experiencing during the pandemic isn’t just because of the sheer horror of the virus, though that’s traumatic, too. It’s also a form of moral injury, resulting from deep-seated problems that prevented the American healthcare system from responding appropriately to the virus.

COVID-19 Revealed Long-Term Problems

As the pandemic was approaching, many doctors asked hospitals to shut down elective procedures immediately, in order to conserve resources and stop the spread of the virus. But at some hospitals, there was hesitation: after all, elective procedures form the financial lifeblood of most American hospitals. When government mandates forced elective procedures to shut down, the loss of revenue meant layoffs even at a time when medical workers were urgently needed.

This profit-based model, said Dean, is one of the many ways in which the health care system was not adequately prepared for the pandemic — and one of the many factors leading to moral injury to health care workers.

Other barriers added to the harm. During the darkest days of March and April, when medical workers were treating patients with a dangerous lack of PPE, many tried to organize for greater protections. But some were met with reprisal, causing the physical injury of COVID-19 exposure to mingle with the moral injury of retaliation.

“We were telling our organizations what they needed, and weren’t being heard, or were being dismissed,” Dean said. “That’s a different type of trauma. That’s the trauma of betrayal.”

What’s more, even when medical workers want to seek psychological support for their experience, they are often hampered by restrictive licensing regulations that scrutinize all records of psychiatric care. Even if medical workers don’t have serious ongoing symptoms, licensing boards can require them to participate in restrictive and expensive inpatient programs in order to obtain licensing. This discourages medical professionals who wish to seek mental health support.

How Medical Workers Can Practice Self-Care

While Dean believes systemic change is needed to truly get at the root cause of moral injury, there are ways medical professionals can care for themselves during the pandemic. First, she said, it’s important to simply prioritize basic needs: food, water, shelter, PPE, the safety of professionals’ families, and adequate sleep.

This is easier said than done when supplies of protective equipment are short, and sleep, even shorter. But the American Medical Association advises some ways medical workers can still practice self-care. These include:

• Feel your feelings. It’s not weak to acknowledge feeling overwhelmed, depressed, or exhausted. Feelings always have a way of making themselves known; ignoring them now means they will come back stronger later. Wendy Dean recommends using mindfulness as a way to continue to check in on what you are experiencing and what you need.

• Employ coping strategies. Most medical professionals have a toolbox of coping strategies they’ve already employed to get through their laborious training and the daily strains of working in healthcare. Draw upon this toolbox now. Connect with family and friends remotely or in a socially distanced way, practice a hobby, or get out and enjoy a form of exercise you love.

• Take a break from the news. Choose one or two reputable news sources and stick with them. You’re living the pandemic; you don’t need to know every pundit’s take on it.

• Get good sleep. Prioritize getting enough sleep, if you can. Even if you don’t have time to get enough sleep, you can still make sure it’s good-quality sleep.

Dean adds that it’s important for employers and support networks not to stigmatize or label medical workers for experiencing distress. “Recognize this as an expected reaction to an extraordinary event that most people will recover from just fine,” said Dean.

Finally, said Dean, we all need to accept that it will likely take a while for the full extent of the trauma to unfurl — and even longer to heal. She advises organizations to maintain needed mental health services for medical workers for up to three years.

Above All, Medical Workers Need Support

The trauma from the pandemic is profound, and collective, affecting not just medical workers and their families, but all of us. It will take time for society to witness the pandemic’s full effects. “It has changed people,” said Dean.

In the meantime, however, we can support medical workers by providing immediate care, and advocating for long-term mental health support and for a medical system that values patients and workers over profit. “As difficult as this pandemic has been, the silver lining is that it has shown everybody what the gaps and vulnerabilities in the healthcare system are,” said Dean.

And even though she’s spent her career examining the way that healthcare causes moral injury to its practitioners, Dean holds out hope in our collective resilience. “I am a determined optimist.”

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When the trauma seems to live on beyond the event itself, when you find yourself having constant flashbacks of what happened, or when you find these recurring feelings difficult to cope with, you may have developed a case of post-traumatic stress disorder, or PTSD.

What Is PTSD?

The American Psychiatric Association (APA), describes PTSD as: “a psychiatric disorder that can occur in people who have experienced or witnessed a traumatic event such as a natural disaster, a serious accident, a terrorist act, war or combat, rape or other violent personal assault.”

However, it’s important to note that you don’t necessarily need to experience or witness a major event such as war or a natural disaster to be diagnosed with PTSD. Losing your job, breaking up with someone, childhood traumas, and other difficult experiences can cause PTSD for some people.

“PTSD can occur in all people, in people of any ethnicity, nationality or culture, and any age,” writes the APA. PTSD is more widespread than most people realize. As the APA reports, “PTSD affects approximately 3.5 percent of U.S. adults, and an estimated one in 11 people will be diagnosed [with] PTSD in their lifetime.”

Another important detail is that PTSD symptoms can manifest years after the traumatic event or experience. The Anxiety and Depression Association of America (ADAA) notes that PTSD symptoms can appear within months of that trauma, but sometimes it takes years for symptoms to develop.

According to the ADAA, PTSD symptoms usually have to be present for a month for you to be diagnosed with the disorder.

Symptoms Of PTSD

The experience of PTSD includes many of the symptoms you might classically associate with PTSD, such as nightmares and flashbacks. But there are some symptoms of PTSD that are a little harder to immediately recognize — emotional numbness and insomnia, for example — which sometimes makes it difficult for people to seek help for the disorder.

Emotional Symptoms of PTSD

There are many emotional reactions and mood changes that happen as a result of PTSD. You may experience only one of these symptoms, or you may experience several — sometimes even within the same day.

Some of the most common emotional symptoms of PTSD include:

• Feelings of hopelessness and desperation
• Feeling numb or distant
• Dissociation (disconnecting from thoughts, feelings, memories, or sense of identity)
• Wanting to detach from friends and family
• Difficulty remembering, including the memories of the traumatic event
• No longer enjoying activities that you used to enjoy
• General feelings of negativity and depression
• Feeling on edge, agitated, and angry
• Feelings of guilt and shame
• Suicidal ideation (if you are experiencing this symptom, seek emergency help immediately)

Physical Symptoms of PTSD

PTSD, however, isn’t only an emotional state, in fact, many of the symptoms of PTSD are physical in nature. PTSD causes your body to release stress hormones such as adrenaline. You may experience the symptoms of “fight-or-flight,” anxiety, and panic attacks, all of which are physical, as well as emotional in nature.

Some of the common physical symptoms of PTSD include:

• You may become easily startled, agitated, or “jumpy”
• You may feel “on guard,” as though danger is lurking behind every corner
• You may experience a rapid heartbeat, tight breathing, or digestive upset
• You may have trouble falling asleep or staying asleep
• You may have trouble remembering things or concentrating
• You may lose your appetite
• You may be more prone to substance abuse issues

“Re-Experiencing” As A Symptom of PTSD

Besides the emotional and physical symptoms of PTSD, another defining characteristic is “re-experiencing” the traumatic event.

The most common manifestations of this include:

• Recurrent memories of the traumatic event
• Experiencing flashbacks of the event
• Bad dreams or nightmares about the event
• Feeling easily “triggered” by things that remind you of the trauma

How Can I Feel Better?

PTSD can make you feel trapped. You might think there is no way for you to be released from these scary thoughts — a full-body feeling of traum, and the constant, recurring memories.

You should know that you aren’t alone. PTSD is quite common and treatable. Your first step in getting help will be to find a therapist or psychiatrist you like and trust. Try to find someone who specializes in PTSD and has treated it before. Therapy treatments commonly used to treat PTSD include cognitive behavioral therapy (CBT), exposure therapy, and eye movement desensitization and reprocessing (EMDR).

When it comes to therapy, today you have more options than ever. You can schedule an appointment with an in-person therapist. Online therapy and online psychiatry are other possibilities, and are especially helpful for someone who may not have time to travel to a therapist, may not have many therapists to choose from locally, or who is looking for a more budget-friendly option.

The bottom line is that, as awful and debilitating as the symptoms of PTSD can be, they are not something you have to live with forever. Help — and hope — is out there.

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