Not Every Trauma Results in PTSD
There's a difference between an intrusive thought and an actual flashback.
Open Minds is a column that explores your most pressing questions about mental health, with the goal of pushing back on stigma and cutting through the confusion. Send your questions to firstname.lastname@example.org.
I recently went through something traumatic and I feel like I'm not recovering. I'm not having flashbacks or anything but do I have PTSD?
The steady creep of psychology lingo into our everyday vocabulary has made for widespread misconception of a bunch of terms. You've heard people casually refer to their lack of focus as "ADD" or say someone's acting "schizo" when they really just mean "being weird." The problem with these words making their way from the psychiatric lexicon into our general one, and into movies and TV, is that their context gets lost along the way. So our perception of what are actually very nuanced and heterogenous conditions is reduced to the most conspicuous two or three symptoms, which excludes all the people with an actual diagnosis, and ones who experience a broader range of symptoms. It also makes it harder for us to recognize symptoms' warning signs when we need to because they don't look the way they did on Law & Order: SVU.
With post-traumatic stress disorder (PTSD), flashbacks are definitely the most well-known—sometimes even stereotypical—symptom in the same way schizophrenia is reduced to paranoia and OCD to counting things and being clean. Flashbacks aren't required for a PTSD diagnosis, says Matthew Robinson, a research psychologist at McLean Hospital's dissociative disorders and trauma research program. And among those who've already been diagnosed, they're still fairly rare. It's also possible, though still uncommon, for people without PTSD to have flashbacks, so the fact that you aren't having them isn't definitive one way or the other. Plus, aside from the drama angle, people tend to think flashbacks play a bigger role than they actually do because they're also factoring in intrusive memories, which are a separate thing.
"Intrusive memories, people tend to call them 'flashbacks,'" Robinson says. "But they're often actually vivid, visual or other types of memories regarding traumatic events. The way to distinguish those from a flashback is when you're having a flashback, you actually believe the event is happening again, and so you lose touch with the present moment. It's typically brief—a few seconds."
Some of the less dramatic but more common symptoms of PTSD are sadness, anger, crying, nausea, strong reactions to triggers, and nightmares. This makes diagnosing the condition difficult, since those things are also common reactions in someone whose brain is just going through the regular, healthy business of processing trauma.
"There's no sharp dividing line between what is and isn't PTSD, so it's kind of tricky," says Joe Bienvenu, associate professor of psychiatry and behavioral sciences at Johns Hopkins. "Definitely having some post-traumatic stress symptoms is very common after a severe stressor. But if those don't pass or are really severe, those are the times when I'd think about going to see someone; not necessarily for medication but to see, would the person benefit from psychotherapy? The thing that concerns me most about PTSD is…when people act like it's supposed to be normal to just have these symptoms go on and on and on."
No one should self-diagnose PTSD based on this because no one should self-diagnose anything, but Robinson and Bienvenu do describe the same two strongest benchmarks: If the symptoms persist at the same intensity for an extended period of time (at least one month in order to formally qualify) and if they inhibit your day-to-day functioning. If, for example, you're too anxious to get in the car to go to work, or you can't stop crying even in professional or otherwise inappropriate situations—this is an indicator of PTSD that you should seek guidance for. Same advice if months are passing and things feel just as visceral as they did on day one.
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You should also examine whether you're engaging in any avoidance behaviors, which Robinson says take one of two forms: avoiding anything external that might remind you of the traumatic event, or avoiding feeling or thinking about it. The first means you isolate, maybe by never leaving your house or by shutting out friends and family. The second often means abusing alcohol or drugs, but it's possible to practice this kind of avoidance behavior in less conspicuous ways, like overeating or overexercising. Robinson says a frequent example of PTSD hiding in plain sight is in the first responder community, where people take on more and more shifts to avoid having to stop and process what they've seen on the job.
Treating PTSD is hardest with patients who've had multiple exposures to trauma, particularly in both childhood and adulthood. But despite what movies and TV might have you believe, it isn't usually chronic. Robinson says the majority of people who engage in treatment—therapy, and sometimes medication—do see a reduction in symptoms. While each case is different, he says that many times, 12 to 14 trauma-focused treatment sessions over the course of three to six months restores sufficient ability to function—especially if the source of the trauma was a one-time event.
Bienvenu, who also works directly with patients, says it's critical not to bottle anything up in the immediate aftermath of whatever your event happened to be. It's cheesy, but the best thing you can do for all the bad feelings is talk to people about them. You can try to avoid the pain, but you'll have to reckon with it eventually; delaying that just delays your whole healing process, and makes the feelings more likely to persist and mutate into PTSD that will be harder to grapple with.
But if you've been confronting what happened, talking about it for weeks with people in your support system, and you still don't feel any better, the next step Bienvenu recommends is talking to a therapist. There are loads who specialize in trauma, and they can help you process what's happened as well as determine whether an antidepressant might help you through it. (Antidepressants aren't only for people with clinical depression—they can also be prescribed for situational depression.)
If you don't have access to a therapist, it's still worth talking everything out. Bienvenu says a useful technique he practices with his patients is to go through what happened in the present tense, as if it's just unfolding now (this, for his patients, has been shown to help in therapy). While he can't make an evidence-based statement about whether this can be applied to talking with friends or family rather than a therapist, he does allow that it might help you heal. At the very least, it won't hurt.
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