Subtle Signs of PTSD: Beyond the Stereotypes
When you think of PTSD, you probably have an image in mind of what someone with PTSD might look like. Popular culture has given us a stylized and even stereotyped version of PTSD. Behaviors like flashbacks and angry outbursts are common notions of what someone with PTSD might experience. And, it’s true, those are potential symptoms a person with PTSD may exhibit. However, PTSD is more complex than that and may not present as clearly as you might think. You might not see what you expect to see. In fact, PTSD often goes undetected or undiagnosed until there is a significant event that demands a closer look. Not what you’d expect given the picture we’re given in movies and TV shows and such. Let’s take a closer look at PTSD and why it may not look like you think.
What Is PTSD?
Post Traumatic Stress Disorder (PTSD) is a clinically-recognized disorder that is directly related to the experience of exceptionally injurious, horrifying, or life-threatening events. This experience of trauma is most often associated with severe abuse or combat-related experiences. However, trauma can be experienced in many ways and in many forms. PTSD can result from trauma experienced by:
- Directly experiencing a traumatic event
- Witnessing a traumatic event that impacted others
- Learning that a close loved one suffered a trauma
- Repeated exposure to aversive details of the event
- A combination of these
It's estimated that as much as 70% of people will experience a potentially traumatic event in their lifetime. About 8% of those who experience trauma will go on to develop PTSD.1The degree of impairment can range from mild to severe, depending on the individual. Clearly, not every person who experiences trauma will develop PTSD. Many people show a tremendous resilience and capacity to recover.
Predicting who will or will not develop PTSD is a challenge because how someone experiences and copes with a traumatic event is highly individual. Whether or not someone develops PTSD or to what degree is not a reflection of someone’s strength or competency. While there is no definitive answer, it appears that a person’s degree of resiliency, the ability to cope with adversity, and the dynamics of the trauma itself all seem to play a key role in the trajectory of post-trauma recovery.2
According to the APA’s Diagnostic and Statistical Manual, (DSM-5), the diagnosis of PTSD requires the presence of certain criteria. 3
These criteria include:
- Exposure to actual or threatened death, serious injury, or sexual violence
- Presence of one (or more) of the following symptoms of intrusion associated with the traumatic event:
- Recurrent, intrusive distressing memories of the traumatic event
- Recurrent distressing dreams about the event
- Flashbacks in which the person feels or acts as if the traumatic event is recurring
- Intense or prolonged psychological distress when exposed to cues that resemble an aspect of the trauma (e.g., a noise, an odor)
- Marked physiological reactions to cues that resemble an aspect of the traumatic event (e.g., panic, heart pounding)
- Persistent avoidance of people, places, or things associated with or are reminders of the traumatic event
- Negative changes in mood or thinking associated with the event (e.g., guilt, shame, fear)
- Negative changes in reactivity and arousal (e.g., increased irritability or volatility, easily startled or hypervigilance)The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning and is not attributable to the physiological effects of substance abuse or a medical condition.
While these criteria are necessary for the diagnosis of PTSD, how these criteria actually present in a person is highly variable. For some, their symptoms may be quite obvious and intense. For others, things aren’t so clear cut.
There’s an old saying, “Still waters run deep” and in the case of PTSD, that is certainly true. Someone may be experiencing intense flashbacks or fears on the inside but not expressing it outwardly. For example, the fear of being judged or misunderstood can be overwhelming. The very nature of PTSD and how symptoms manifest can mask someone’s distress further delaying a diagnosis. With PTSD, you have to look beyond what you “expect” see. PTSD has a more subtle side that is there if you know what to look for.
The Subtle Signs of PTSD
Just because you are not observing the experience of a flashback or a nightmare, or just because the person isn’t telling you about their intense feelings doesn’t mean it isn’t happening. It doesn’t mean the person isn’t in significant distress. It means that they might have developed ways of masking or managing their symptoms in ways that don’t “look like” what you’d expect.
A person’s behavior tells a story. Even the best attempts to mask can reveal clues as to what’s happening. When it comes to trauma, you have to look for the clues.
So what does this side of PTSD look like?
Avoidance - People with PTSD may take extraordinary steps to mask their symptoms and inner turmoil. They often experience intense symptoms and emotions. What they are experiencing may be quite troubling yet they may fear judgment from others. They may worry that disclosure could jeopardize their employment or their relationships. They may fear being labeled or deemed “mentally unfit”, even “dangerous”. As a result, they will often become isolative and aloof. They will actively avoid people, places, and things that may trigger them or risk having others see their distress.
Misplaced Connection - What can complicate matters even further is that symptoms don’t always immediately follow the traumatic event. In some cases, it can be months or years before symptoms emerge or rise to a level requiring attention. The person, and even those around them, may not put 2+2 together. What might look like depression or anxiety, for example, might actually be telltale signs that someone is experiencing traumatic distress.
Refusal of Help – Not unique to those with PTSD, some people believe they can manage their symptoms on their own. They will refuse outside help.
Guilt - People with PTSD sometimes feel guilt related to the trauma. It may be survivor’s guilt or self-blame related to the event. The pain they experience is seen as a “penance” or “punishment”. They may even verbalize feeling deserving of the distress they feel. The result is a reluctance to seek help and often, minimizing or even denying their distress.
Embarrassment – The nature of some types of trauma may be embarrassing for the person to share with others. Sharing such personal details requires a level of vulnerability that the person may be unable or unwilling to cope with. Not disclosing is self-protective.
Changes in Mood or Behavior – Depression is common in people with PTSD. They are also at increased risk to experience anxiety-related disorders such as panic disorder, agoraphobia, obsessive-compulsive disorder, or social anxiety. What confounds the situation is that it can be difficult to know whether these disorders were present before or after the trauma experience and the emergence of PTSD. Either way, symptoms can cloud the clinical picture.
Changes in Substance Use – Using substances to cope is often seen in people with PTSD. The effects of substance use can mask or dampen the effect of symptoms. It can be difficult for others to see or understand what the person is experiencing. What looks like a substance abuse problem on the surface may actually be an attempt to alleviate their trauma symptoms by self-medicating.
How You Can Help Your Loved One with PTSD
Family support is crucial to helping your loved one heal. If your loved one is struggling and you suspect that their pain might be trauma-related, there are things you can do to help.
Don't Try Diagnosing Them - It can be tempting, especially if you know for certain there has been a trauma. However, behavior can be the result of any number of issues and experiences.
Be Supportive - The most important thing that you can do for your loved one is to be supportive and be open when they are ready to talk. Meet them where they are. Not where you think they should be. In other words, don’t pressure them to talk. Your patience and acceptance will help them to feel safe.
Minimize Change - Continue to do things together. Do what you enjoy doing when you can. Know that some days may be hard for your loved one. You might not immediately understand why. They might not either. It’s ok.
Listen – Being a good listener means being open to hearing whatever it is your loved one needs to share without judgment. They may need to talk about something over and over again. What they share may be difficult to hear. Resist the temptation to give advice. Having someone to talk with can be incredibly healing and help them to feel safe and supported.
Help Rebuild Trust – Trauma can rob a person of their sense of safety and security, making the world seem like a dangerous, scary place. They’re always “on guard”. Things like establishing routines and keeping commitments, knowing that things are stable can help to create a sense of security.
When Does Your Loved One With PTSD Need Help?
When symptoms of PTSD become overwhelming or begin to interfere with daily functioning and quality of life, it’s time to start considering treatment options. Every person is unique and will come to that place of decision in their own time.
The first step in treatment is to get a comprehensive assessment by a clinician who is experienced in treating trauma. Sometimes referred to as “trauma-informed” clinicians, they have the expertise and understanding of trauma necessary to appropriately diagnose and treat PTSD and other trauma-related issues. Trauma–integrated care addresses emotional dysregulation, negative beliefs about self, poor relationships with others, and dysfunctional behaviors (including addictions) through the lens of trauma.
What Can You Expect from PTSD Treatment?
Treatment for PTSD generally consists of psychotherapy and sometimes, medications to help with symptom management. Individual therapy can help one address and heal the effects of their trauma. But treatment isn’t just for the individual. Family therapy can help you and your family come together to understand and support your loved one. You will learn ways to be supportive while allowing your loved one to assume responsibility for their healing. If there are other co-occurring issues such as major depression or substance abuse, those issues will need to be addressed as well.
For some people, treatment is best provided on an outpatient basis. That means attending appointments with therapists and doctors on a regular basis. Sometimes, symptoms or issues are significant enough to require a higher level of care, most often inpatient to stabilize symptoms, partial hospitalization, or residential treatment to address issues intensively over time. Depending on one’s needs, treatment may include multiple levels of care as progress is made.
For people who are also dealing with substance abuse, dual-diagnosis programs are designed to treat both a person’s mental health and substance abuse needs. Trauma-integrated residential treatment is particularly effective for people who have co-occurring disorders such as PTSD and substance abuse. Residential programs allow the person in care to gradually address issues and gain the skills needed to function optimally when they return home.
Virtual and In-Person Treatment for PTSD
The program at All Points North Lodge is designed to treat trauma for people with or without substance abuse issues. Nestled in the beautiful Rocky Mountains, APN Lodge offers a luxury rehab experience that offers the perfect environment for healing, personal growth, and recovery. Using evidence-based treatment approaches, our team of clinicians has the expertise to guide you through the process from referral through program completion. To learn about all what the APN Lodge experience offers, reach out to one of our Contact Center team members at 866-525-9107. Let us help you find your way forward.
- Post-traumatic stress disorder (PTSD). (n.d.). Retrieved from https://www.nimh.nih.gov/health/statistics/post-traumatic-stress-disorder-ptsd.shtml
- Benjet, C., Bromet, E., Karam, E. G., Kessler, R. C., McLaughlin, K. A., Ruscio, A. M., Shahly, V., Stein, D. J., Petukhova, M., Hill, E., Alonso, J., Atwoli, L., Bunting, B., Bruffaerts, R., Caldas-de-Almeida, J. M., de Girolamo, G., Florescu, S., Gureje, O., Huang, Y., Lepine, J. P., … Koenen, K. C. (2016). The epidemiology of traumatic event exposure worldwide: results from the World Mental Health Survey Consortium. Psychological medicine, 46(2), 327–343. https://doi.org/10.1017/S0033291715001981
- American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. (2013). Arlington, VA: American Psychiatric Association.
*We cannot understate the importance of working with a doctor and therapist as you recover. None of this content is intended as medical advice.
Speak with your providers to find a plan and strategies that work for you. If you don't have a therapist or provider, give us a call.
Written by Dawn Ferrera. Reviewed and Edited by the team at All Points North Lodge.