What is Trauma?

SAMHSA describes individual trauma as an event or circumstance resulting in:

• physical harm
• emotional harm
• and/or life-threatening harm

The event or circumstance has lasting adverse effects on the individual's:

• mental health
• physical health
• emotional health
• social well-being
• and/or spiritual well-being

Who is Affected by Trauma?

Trauma has no boundaries regarding age, gender, socioeconomic status, race, ethnicity, or sexual orientation. Trauma is a common experience for adults and children in American communities, and it is especially common in the lives of people with mental and substance use disorders. For this reason, the need to address trauma is increasingly seen as an important part of effective behavioral health care and an integral part of the healing and recovery process.

Effects of Trauma

The effects of traumatic events place a heavy burden on individuals, families, and communities. Although many people who experience a traumatic event will go on with their lives without lasting negative effects, others will have difficulties and experience traumatic stress reactions. How someone responds to a traumatic experience is personal. If there is a strong support system in place, little or no prior traumatic experiences, and if the individual has many resilient qualities, it may not affect his or her mental health.

Research has shown that traumatic experiences are associated with both behavioral health and chronic physical health conditions, especially those traumatic events that occur during childhood. Substance use, mental health conditions, and other risky behaviors have been linked with traumatic experiences. Because these behavioral health concerns can present challenges in relationships, careers, and other aspects of life, it is important to understand the nature and impact of trauma, and to explore healing.

Alternatives to Seclusion and Restraint

Seclusion and restraint were once perceived as therapeutic practices in the treatment of people with mental and/or substance use disorders. Today, these methods are viewed as traumatizing practices and are only to be used as a last resort when less-restrictive measures have failed and safety is at severe risk.

Seclusion is defined as the involuntary, solitary confinement of an individual. Restraint refers to any method, physical or mechanical device, or material or equipment that immobilizes or reduces an individual’s ability to freely move his or her arms, legs, body, or head. A drug or medication also might be used to restrict behavior or freedom of movement.

Studies have shown that the use of seclusion and restraint can result in psychological harm, physical injuries, and death to both the people subjected to and the staff applying these techniques. Injury rates to staff in mental health settings that use seclusion and restraint have been found to be higher than injuries sustained by workers in high-risk industries. Restraints can be harmful and often re-traumatizing for people, especially those who have trauma histories. Beyond the physical risks of injury and death, it has been found that people who experience seclusion and restraint remain in care longer and are more likely to be readmitted for care.

When you experience a traumatic event, it's common to have an emotional reaction. Such stress reactions are normal and not weakness. Most people recover in time. Learn about stress reactions and problems that occur after trauma.

What Are Common Reactions to Trauma?

All kinds of trauma create stress reactions. People often say that their first feeling is relief to be alive after a traumatic event. This may be followed by stress, fear and anger. Trauma may also lead people to find they are unable to stop thinking about what happened. Traumatic events can create a high level of arousal—or feeling alert or "on guard"—as well, which causes people to react strongly to sounds and sights around them.

If you understand what is happening when you or someone you know reacts to a traumatic event, you may be less fearful and better able to cope. Reactions are common for anyone, even Service members and Veterans, or disaster rescue and relief workers, who have been trained to respond to crises.

Here are some common reactions to trauma:

• Losing hope for the future
• Feeling distant (detached) or losing a sense of concern about others
• Being unable to concentrate or make decisions
• Feeling jumpy and getting startled easily at sudden noises
• Feeling on guard and alert all the time
• Having dreams and memories that upset you
• Having problems at work or school
• Avoiding people, places and things related to the event

You may also experience more physical reactions such as:

• Stomach upset and trouble eating
• Trouble sleeping and feeling very tired
• Pounding heart, rapid breathing, feeling shaky
• Sweating
• Severe headache if thinking of the event
• Not keeping up with exercise, diet, safe sex or—regular health care
• Smoking more, using alcohol or drugs more, or eating too much
• Having your ongoing medical problems get worse

You may have more emotional troubles such as:

• Feeling nervous, helpless, fearful, sad
• Feeling shocked, numb, or not able to feel love or joy
• Being irritable or having angry outbursts
• Getting easily upset or agitated
• Blaming yourself or having negative views of oneself or the world
• Being unable to trust others, getting into fights, or being trying to control everything
• Being withdrawn, feeling rejected, or abandoned
• Feeling detached, not wanting intimacy

Recovery From Stress Reactions

Turn to your family and friends when you are ready to talk. They are your personal support system. Recovery is an ongoing gradual process. Don't look to be "cured" all of a sudden or assume that you will forget what happened. Most people will recover from trauma naturally. If your stress reactions are getting in the way of your relationships, work or other important activities, you may want to talk to a counselor or your doctor. Good treatments are available.

Common Problems That Can Occur After a Trauma

Posttraumatic Stress Disorder (PTSD). PTSD is a condition that can develop after you have gone through a life-threatening event. If you have PTSD, you may have trouble keeping yourself from thinking over and over about what happened to you. You may try to avoid people and places that remind you of the trauma. You may feel numb. Lastly, if you have PTSD, you might find that you have trouble relaxing. You may startle easily, and you may feel on guard most of the time.

Depression. Depression involves feeling down or sad more days than not. If you are depressed, you may lose interest in activities that you used to enjoy or find fun. You may feel low in energy and be overly tired. You may feel hopeless or in despair, and you may think that things will never get better. Depression is more likely when you have had losses such as the death of close friends. If you are depressed, at times you might think about hurting yourself. For this reason, getting help for depression is very important.

Self-blame, guilt and shame. Sometimes in trying to make sense of a traumatic event, you may blame yourself. You may think you are to blame for bad things that happened, or for surviving when others didn't. You may feel guilty for what you did or did not do. Remember, we all tend to be our own worst critics.

Suicidal thoughts. Trauma and loss can lead someone who is depressed to think about self-harm. If you have thoughts of suicide, talk to someone. If you think someone you know may be thinking about suicide, ask them. You will NOT put the idea in their head. If you or someone you care about is thinking about suicide:

• Call the Suicide and Crisis Lifeline at 988 or visit 988lifeline.org.
• If you are a Veteran, or you are concerned about one, call 988 and press 1 to speak with a responder trained to help Veterans. Visit the Veterans Crisis Line.
• You can also call a counselor or doctor; or dial 911 for emergency response services (like police or an ambulance).

Anger or aggressive behavior. Trauma is related to anger in many ways. After a trauma, you might think that what happened to you was unfair or unjust. You might not understand why the event happened and why it happened to you. These thoughts can result in intense anger. Anger is a natural and healthy emotion, but strong feelings of anger and aggressive behavior can cause problems with family, friends or co-workers. If you become violent when angry, it makes the situation worse. Violence can lead to injury, and there may be legal outcomes.

Alcohol or drug abuse. Drinking or "self-medicating" with drugs is a common, and unhealthy, way of coping with upsetting events. You may drink too much or use drugs to numb yourself and to try to deal with difficult thoughts, feelings and memories related to the trauma. While using alcohol or drugs may offer a quick solution, it can lead to more problems. If someone close to you begins to lose control of drinking or drug use, try to get them to see a health care provider about managing their drinking or drug use.

Summing It All Up

Right after a trauma, almost every survivor will find it hard to stop thinking about what happened. Stress reactions—such as fear, anxiety, jumpiness, upsetting memories, and efforts to avoid reminders—will gradually decrease over time for most people.

Use your personal support systems, family and friends, when you are ready to talk. Or, be a support for someone you care about who has been through a trauma. Recovery is an ongoing gradual process that takes time. Don't look for a quick "cure" or assume that you will forget what happened. Most people will recover from trauma on their own. If your emotional reactions are getting in the way of your relationships, work or other important activities, you may want to talk to a counselor or your doctor. Good treatments are available.

Acute Stress Disorder (ASD) is a mental health problem that can occur in the first month after a traumatic event. The symptoms of ASD are like PTSD symptoms, but you must have them for longer than one month to have PTSD. Learn more about ASD and treatment options.

How Common Is ASD?

Studies of ASD vary in terms of the tools used and the rates of ASD found. Overall, within one month of a trauma, survivors show rates of ASD ranging from 6% to 33%. Rates differ for different types of trauma. For example, survivors of accidents or disasters such as typhoons show lower rates of ASD. Survivors of violence such as robbery, assaults, and mass shootings show rates at the higher end of that range.

Who Is at Risk for ASD as a Result of Trauma?

Several factors can place you at higher risk for developing ASD after a trauma:

• Having gone through other traumatic events
• Having had PTSD in the past
• Having had prior mental health problems
• Tending to have symptoms, such as not knowing who or where you are, when confronted with trauma

Does ASD Predict PTSD?

If you have ASD, you are very likely to get PTSD. Research has found that over 80% of people with ASD have PTSD six months later. Not everyone with ASD will get PTSD, though.

Also, those who do not get ASD can still develop PTSD later on. Studies indicate that a small number (4% to 13%) of survivors who do not get ASD in the first month after a trauma will get PTSD in later months or years.

Are There Effective Treatments for ASD?

Yes, a type of treatment called cognitive behavioral therapy (CBT) has been shown to have positive results. Research shows that survivors who get CBT soon after going through a trauma are less likely to get PTSD symptoms later. A mental health care provider trained in treatment for trauma can judge whether CBT may be useful for a trauma survivor.

Another treatment called psychological debriefing (PD) has sometimes been used in the wake of a traumatic event. However, there is little research to back its use for effectively treating ASD or PTSD. It should also be noted that with more severe trauma or reactions such as PTSD, debriefing is not recommended.

Anger is often a large part of a survivor's response to trauma. It is a core piece of the survival response in human beings. Anger helps us cope with life's stresses by giving us energy to keep going in the face of trouble or blocks. Yet anger can create major problems in the personal lives of those who have experienced trauma and those who suffer from PTSD.

Why Is Anger a Common Response to Trauma?

One way of thinking is that high levels of anger are related to a natural survival instinct. When faced with extreme threat, people often respond with anger. Anger can help a person survive by shifting his or her focus. The person focuses all of his or her attention, thought, and action toward survival.

Anger is also a common response to events that seem unfair or in which you have been made a victim. Research shows that anger can be especially common if you have been betrayed by others. This may be most often seen in cases of trauma that involve exploitation or violence.

The trauma and shock of early childhood abuse often affects how well the survivor learns to control his or her emotions. Problems in this area lead to frequent outbursts of extreme emotions, including anger and rage.

How Can Anger After a Trauma Become a Problem?

In people with PTSD, their response to extreme threat can become "stuck." This may lead to responding to all stress in survival mode. If you have PTSD, you may be more likely to react to any stress with "full activation." You may react as if your life or self were threatened.

This automatic response of irritability and anger in those with PTSD can create serious problems in the workplace and in family life. It can also affect your feelings about yourself and your role in society.

Researchers have broken down posttraumatic anger into three key aspects, discussed below. These three factors can lead someone with PTSD to react with anger, even in situations that do not involve extreme threat:

Arousal

Anger is marked by certain reactions in the body. The systems most closely linked to emotion and survival — heart, circulation, glands, brain — are called into action. Anger is also marked by the muscles becoming tense. If you have PTSD, this higher level of tension and arousal can become your normal state. That means the emotional and physical feelings of anger are more intense.

If you have PTSD, you may often feel on edge, keyed up, or irritable. You may be easily provoked. This high level of arousal may cause you to actually seek out situations that require you to stay alert and ward off danger. On the other hand, you may also be tempted to use alcohol or drugs to reduce the level of tension you're feeling.

Behavior

Often the best response to extreme threat is to act aggressively to protect yourself. Many trauma survivors, especially those who went through trauma at a young age, never learn any other way of handling threat. They tend to become stuck in their ways of reacting when they feel threatened. They may be impulsive, acting before they think.

Aggressive behaviors also include complaining, "backstabbing," being late or doing a poor job on purpose, self-blame, or even self-injury. Many people with PTSD only use aggressive responses to threat. They are not able to use other responses that could be more positive.

Thoughts and beliefs

Everyone has thoughts or beliefs that help them understand and make sense of their surroundings. After trauma, a person with PTSD may think or believe that threat is all around, even when this is not true. He or she may not be fully aware of these thoughts and beliefs.

For example, a combat Veteran may become angry when his wife, children, or coworkers don't "follow the rules." He doesn't realize that his strong belief is actually related to how important it was for him to follow rules during the war in order to prevent deaths.

If you have PTSD, you may not be aware of how your thoughts and beliefs have been affected by trauma. For instance, since the trauma you may feel a greater need to control your surroundings. This may lead you to act inflexibly toward others. Your actions then provoke others into becoming hostile towards you. Their hostile behavior then feeds into and reinforces your beliefs about others. Some common thoughts of people with PTSD are:

• "You can't trust anyone."
• "If I got out of control, it would be horrible, life-threatening, or could not be tolerated."
• "After all I've been through, I deserve to be treated better than this."
• "Others are out to get me," or "They won't protect me."

How Can You Get Help with Anger?

In anger management treatment, problems with arousal, behavior, and beliefs are all addressed in different ways. Cognitive-behavioral treatment (CBT), a commonly used therapy, uses many techniques to manage these three anger problem areas:

For increased arousal

The goal of treatment is to help the person learn skills that will reduce overall arousal. He or she may learn how to relax, use self-hypnosis, and use physical exercises that release tension.

For behavior

The goal is first to look at how a person usually behaves when he or she feels threat or stress. The next goal is to help him or her expand the range of possible responses. More adaptive responses include:

• Taking a time out
• Writing thoughts down when angry
• Talking with someone instead of acting
• Changing the pattern "act first, think later" to "think first, act later"

For thoughts/beliefs

Clients are given help in becoming more aware of their own thoughts leading up to becoming angry. They are then asked to come up with more positive thoughts to replace their negative, angry thoughts. For example, they may learn to say to themselves, "Even if I don't have control here, I won't be threatened in this situation."

Another example would be, "Others do not have to be perfect in order for me to survive or be comfortable." Role-play is often used so you can practice recognizing the thoughts that make you angry and applying more positive thoughts instead.

Summary

There are many ways to help people with PTSD deal with the high levels of anger they may feel. Many people have all three of the anger problem areas listed above. Treatment aims to help with all aspects of anger. One important goal of treatment is to improve your sense of flexibility and control. In this way, you do not have to feel as if you're going through trauma again each time you react to a trigger with explosive or excessive anger. Treatment may also have a positive impact on personal and work relationships.

It is common to want to avoid things that remind you of a traumatic event. But avoiding thoughts and feelings can make it hard to recover. Learn about different types of avoidance and why finding ways to cope is helpful.

What Are the Different Types of Avoidance?

Emotional avoidance is when a person avoids thoughts or feelings about a traumatic event. This type of avoidance is internal to the person; others around you may not know what you are avoiding and why. For example:

• Someone who experienced a sexual assault may try to create distance from unpleasant emotions, like fear, when reminded of the trauma. A combat Veteran may try to shut down feelings of sadness about a deployment or war zone.
• A hurricane survivor may drink alcohol or use substances to try to avoid thoughts or memories of the natural disaster.

Avoiding reminders—like places, people, sounds or smells—of a trauma is called behavioral avoidance. For example:

• A combat Veteran may stop watching the news or using social media because of stories or posts about war or current military events.
• Assault survivors might go out of their way to stay away from the scene of their attack or places that remind them of the assault.

What Are the Consequences of Avoidance?

If you go through a trauma, you may have heard advice like, "just try not to think about it" or "time heals all wounds." But if you go out of your way to avoid thoughts, feelings, and reminders related to a traumatic event, your symptoms may get worse. Using avoidance as your main way of coping with traumatic memories can make PTSD symptoms worse and make it harder to move on with your life.

How Can You Learn to Cope with Difficult Thoughts and Feelings?

You may be afraid that if you let yourself feel difficult emotions, they might overwhelm you. You may be afraid that if you start crying, you'll cry forever. Or you may worry that if you experience the anger inside you, you might lose control. There are effective PTSD treatments that can help you learn to cope with your thoughts and feelings about the trauma instead of being afraid of them.

What Is Chronic Pain?

Chronic pain is when a person suffers from pain in a particular area of the body (for example, in the back or the neck) for at least three to six months. It may be as bad as, or even worse than, short-term pain, but it can feel like more of a problem because it lasts a longer time. Chronic pain lasts beyond the normal amount of time that an injury takes to heal.

Chronic pain can come from many things. Some people get chronic pain from normal wear and tear of the body or from aging. Others have chronic pain from various types of cancer, or other chronic medical illnesses. In some cases, the chronic pain may be from an injury that happened during an accident or an assault. Some chronic pain has no explanation.

How Common Is Chronic Pain?

Approximately one in three Americans suffer from some kind of chronic pain in their lifetimes, and about one quarter of them are not able to do day to day activities because of their chronic pain. Between 80% and 90% of Americans experience chronic problems in the neck or lower back.

How Do Health Care Providers Evaluate Pain?

Care providers generally assess chronic pain during a physical exam, but how much pain someone is in is hard to determine. Every person is different and perceives and experiences pain in different ways. There is often very little consistency when different doctors try to measure a patient's pain. Sometimes the care provider may not believe the patient, or might minimize the amount of pain. All of these things can be frustrating for the person in pain. Additionally, this kind of experience often makes patients feel helplessness and hopeless, which in turn increases tension and pain and makes the person more upset. Conversation between the doctor and patient is important, including sharing information about treatment options. If no progress is made, get a second opinion.

What Is the Experience of Chronic Pain Like Physically?

There are many forms of chronic pain, including pain felt in: the low back (most common); the neck; the mouth, face, and jaw (TMJ); the pelvis; or the head (e.g., tension and migraine headaches). Of course, each type of condition results in different experiences of pain.

People with chronic pain are less able to function well in daily life than those who do not suffer from chronic pain. They may have trouble with things such as walking, standing, sitting, lifting light objects, doing paperwork, standing in line at a grocery store, going shopping, or working. Many patients with chronic pain cannot work because of their pain or physical limitations.

What Is the Experience of Chronic Pain Like Psychologically?

Research has shown that many patients who experience chronic pain (up to 100% of these patients) tend to also be diagnosed with depression. Because the pain and disability are always there and that may even become worse over time, many of them think suicide is the only way to end their pain and frustration. They think they have no control over their life. This frustration may also lead the person to use drugs or have unneeded surgery.

Chronic Pain and PTSD

Some people's chronic pain stems from a traumatic event, such as a physical or sexual assault, a motor vehicle accident, or some type of disaster. Under these circumstances the person may experience both chronic pain and PTSD. The person in pain may not even realize the connection between their pain and a traumatic event. Approximately 15% to 35% of patients with chronic pain also have PTSD. Only 2% of people who do not have chronic pain have PTSD. One study found that 51% of patients with chronic low back pain had PTSD symptoms. For people with chronic pain, the pain may actually serve as a reminder of the traumatic event, which will tend to make the PTSD even worse. Survivors of physical, psychological, or sexual abuse tend to be more at risk for developing certain types of chronic pain later in their lives.

Depression is a common problem that can occur following trauma. It involves feelings of sadness or low mood that last more than just a few days. Unlike a blue mood that comes and goes, depression is longer lasting. Depression can get in the way of daily life and make it hard to function. It can affect your eating and sleeping, how you think, and how you feel about yourself.

How Common Is Depression Following Trauma?

In any given year, almost 1 in 10 adult Americans has some type of depression (1). Depression often occurs after trauma. For example, a survey of survivors from the Oklahoma City bombing showed that 23% had depression after the bombing. This was compared to 13% who had depression before the bombing (2). PTSD and depression are often seen together. Results from a large national survey showed that depression is nearly 3 to 5 times more likely in those with PTSD than those without PTSD (3).

What Are the Symptoms of Depression?

Depression is more than just feeling sad. Most people with depression feel down or sad more days than not for at least 2 weeks. Or they find they no longer enjoy or have interest in things anymore. If you have depression, you may notice that you're sleeping and eating a lot more or less than you used to. You may find it hard to stay focused. You may feel down on yourself or hopeless. With more severe depression, you may think about hurting or killing yourself.

How Are Depression and Trauma Related?

Depression can sometimes seem to come from out of the blue. It can also be caused by a stressful event such as a divorce or a trauma. Trouble coping with painful experiences or losses often leads to depression. For example, Veterans returning from a war zone may have painful memories and feelings of guilt or regret about their war experiences. They may have been injured or lost friends. Disaster survivors may have lost a loved one, a home, or have been injured. Survivors of violence or abuse may feel like they can no longer trust other people. These kinds of experiences can lead to both depression and PTSD.

Many symptoms of depression overlap with the symptoms of PTSD. For example, with both depression and PTSD, you may have trouble sleeping or keeping your mind focused. You may not feel pleasure or interest in things you used to enjoy. You may not want to be with other people as much. Both PTSD and depression may involve greater irritability. It is quite possible to have both depression and PTSD at the same time. To find out more about the symptoms of PTSD, see What is PTSD?.

How Is Depression Treated?

There are many treatment options for depression. You should be assessed by a healthcare professional who can decide which type of treatment is best for you. In many cases, milder forms of depression are treated by counseling or therapy. More severe depression is treated with medicines or with both therapy and medicine.

Research has shown that certain types of therapy and medicine are effective for both depression and PTSD. Since the symptoms of PTSD and depression can overlap, treatment that helps with PTSD may also result in improvement of depression. Cognitive behavioral therapy (CBT) is a type of therapy that is proven effective for both problems. CBT can help patients change negative styles of thinking and acting that can lead to both depression and PTSD. A type of medicine that is effective for both depression and PTSD is a selective serotonin reuptake inhibitor (SSRI).

What Can I Do about Feelings of Depression?

Depression can make you feel worn out, worthless, helpless, hopeless, and sad. These feelings can make you feel as though you are never going to feel better. You may even think that you should just give up. Some symptoms of depression, such as being tired or not having the desire to do anything, can also get in the way of your seeking treatment.

It is very important for you to know that these negative thoughts and feelings are part of depression. If you think you might be depressed, you should seek help in spite of these feelings. You can expect them to change as treatment begins working. In the meantime, here is a list of things you can do that may improve your mood:

• Talk with your doctor or healthcare provider.
• Talk with family and friends.
• Spend more time with others and get support from them. Don't close yourself off.
• Take part in activities that might make you feel better. Do the things you used to enjoy before you began feeling depressed. Even if you don't feel like it, try doing some of these things. Chances are you will feel better after you do.
• Engage in mild exercise.
• Set realistic goals for yourself.
• Break up goals and tasks into smaller ones that you can manage.

Conclusions

Depression is common in those who have PTSD. The symptoms of depression can make it hard to function, and may also get in the way of your getting treatment. Be aware that there are effective treatments for both depression and PTSD. If you think you may be depressed, talk to your doctor or see Get Help in a Crisis for more mental health resources.

After loss, there is no specific way to grieve that is right or wrong. There's not a normal length of time to grieve either. Learn about common grief reactions and how to recognize if you would benefit from treatment for grief.

Common Grief Reactions

After loss, there is no specific way of grieving that is right or wrong, and there is not a "normal" length of time to grieve. While everyone experiences grief differently, there are many common grief reactions:

• Physiologically, grief may disrupt sleep patterns, cause changes in stress hormones and health, and lead to physical symptoms such as weakness, trouble breathing, restlessness and immune system changes.
• Emotionally, strong feelings of sadness, loneliness, fear, anxiety or resentment and anger can occur. Some people who are in mourning may feel a sense of guilt when they start to re-engage in activities and relationships, as if they are somehow betraying the person who died.
• Mentally, the bereaved person may have trouble accepting the loss, difficulty concentrating and making decisions, changes to their sense of identity or the belief that their future is disrupted. They may sometimes avoid thinking about the loss, while at other times they may be unable to stop thinking about it. They may find themselves making special efforts to include the person's memory in their life. They may fear forgetting the person who died, or fear losing fond memories of their time with that person.
• Socially, the bereaved person may experience loneliness, boredom, social withdrawal, lack of confidence, emotional sensitivity (or feeling "overemotional"), self-consciousness, as well as difficulties developing new relationships.

While these reactions are common after the loss of someone close, the extent to which they occur depends upon many factors. The nature of the relationship with the deceased, the grieving person's personality style and typical coping strategies and the environment in which the person works or lives can all play a role. Some people do not appear to need to grieve as deeply as others, even for those they most love. In addition, the bereaved can sometimes feel as much relief as sorrow, especially when the person who died had been suffering or in pain.

The Course of Grief

The amount of time a person grieves will depend on many factors, including the circumstances of the death, the nature of their relationship to the deceased and their own personal needs. The popular "stage theory," in which grief passes through five stages—denial, anger, bargaining, depression, and acceptance—may be appealing in that it makes it seem that loss can be controlled. However, research suggests that grief doesn't follow a set of stages. It's a more complicated, ongoing process that comes in waves.

As time goes by, the intensity of grief may lessen, but the person may still have periods when they feel intense emotions. Over time the cycle widens, with a gradual return to a more balanced state. Intense emotions tend to come and go. A 35-year study found that for some, grief fades only gradually, after many years have passed. Reflective thoughts and memories happen less frequently over time, but they may not stop completely, and many bereaved individuals maintain the sense of having an internal ongoing relationship with the person who died.

Prolonged or Complicated Grief

Approximately 10% of the population (or 1 out of every 10 people) experiences a prolonged, impairing reaction when they are grieving. This is called prolonged or complicated grief. This type of grief reaction is sometimes a combination of posttraumatic stress reactions and separation distress. It can include:

• Yearning or longing for the deceased
• A feeling that life is unbearable
• Preoccupation with or difficulty accepting the death
• Intrusive, disturbing images, a sense of hopelessness
• A wish to die to join the deceased
• Avoidance of reminders of the death

The person may feel guilty about their behavior toward the deceased in life, or for living when the deceased person is not. They may feel that they caused or contributed to the death, that they should have prevented the death or that they should have been the one who died.

Complicated grief can be accompanied by:

• Emotional numbness
• Difficulty planning the future
• Loss of identity
• Feeling the future is cut short
• Retreat from others
• Anger and guilt over not having more typical grief reactions

If these reactions linger for months, cause significant distress or interfere with functioning, mental health treatment can help.

Trauma survivors with PTSD may have trouble with their close family relationships or friendships. The symptoms of PTSD can cause problems with trust, closeness, communication, and problem solving. These problems may affect the way the survivor acts with others. In turn, the way a loved one responds to him or her affects the trauma survivor. A circular pattern can develop that may sometimes harm relationships.

How Might Trauma Survivors React?

In the first weeks and months following a trauma, survivors may feel angry, detached, tense or worried in their relationships. In time, most are able to resume their prior level of closeness in relationships. Yet the 5% to 10% of survivors who develop PTSD may have lasting relationship problems.

Survivors with PTSD may feel distant from others and feel numb. They may have less interest in social or sexual activities. Because survivors feel irritable, on guard, jumpy, worried, or nervous, they may not be able to relax or be intimate. They may also feel an increased need to protect their loved ones. They may come across as tense or demanding.

The trauma survivor may often have trauma memories or flashbacks. He or she might go to great lengths to avoid such memories. Survivors may avoid any activity that could trigger a memory. If the survivor has trouble sleeping or has nightmares, both the survivor and partner may not be able to get enough rest. This may make sleeping together harder.

Survivors often struggle with intense anger and impulses. In order to suppress angry feelings and actions, they may avoid closeness. They may push away or find fault with loved ones and friends. Also, drinking and drug problems, which can be an attempt to cope with PTSD, can destroy intimacy and friendships. Verbal or physical violence can occur.

In other cases, survivors may depend too much on their partners, family members, and friends. This could also include support persons such as health care providers or therapists.

Dealing with these symptoms can take up a lot of the survivor's attention. He or she may not be able to focus on the partner. It may be hard to listen carefully and make decisions together with someone else. Partners may come to feel that talking together and working as a team are not possible.

How Might Loved Ones React?

Partners, friends, or family members may feel hurt, cut off, or down because the survivor has not been able to get over the trauma. Loved ones may become angry or distant toward the survivor. They may feel pressured, tense, and controlled. The survivor's symptoms can make a loved one feel like he or she is living in a war zone or in constant threat of danger. Living with someone who has PTSD can sometimes lead the partner to have some of the same feelings of having been through trauma.

In sum, a person who goes through a trauma may have certain common reactions. These reactions affect the people around the survivor. Family, friends, and others then react to how the survivor is behaving. This in turn comes back to affect the person who went through the trauma.

Trauma Types and Relationships

Certain types of "man-made" traumas can have a more severe effect on relationships. These traumas include:

• Childhood sexual and physical abuse
• Rape
• Domestic violence
• Combat
• Terrorism
• Genocide
• Torture
• Kidnapping
• Prisoner of war

Survivors of man-made traumas often feel a lasting sense of terror, horror, endangerment, and betrayal. These feelings affect how they relate to others. They may feel like they are letting down their guard if they get close to someone else and trust them. This is not to say a survivor never feels a strong bond of love or friendship. However, a close relationship can also feel scary or dangerous to a trauma survivor.

Do All Trauma Survivors Have Relationship Problems?

Many trauma survivors do not develop PTSD. Also, many people with PTSD do not have relationship problems. People with PTSD can create and maintain good relationships by:

• Building a personal support network to help cope with PTSD while working on family and friend relationships
• Sharing feelings honestly and openly, with respect and compassion
• Building skills at problem solving and connecting with others
• Including ways to play, be creative, relax, and enjoy others

What Can Be Done to Help Someone Who Has PTSD?

Relations with others are very important for trauma survivors. Social support is one of the best things to protect against getting PTSD. Relationships can offset feelings of being alone. Relationships may also help the survivor's self-esteem. This may help reduce depression and guilt. A relationship can also give the survivor a way to help someone else. Helping others can reduce feelings of failure or feeling cut off from others. Lastly, relationships are a source of support when coping with stress.

If you need to seek professional help, try to find a therapist who has skills in treating PTSD as well as working with couples or families. For resources, please see our Get Help in a Crisis page.

Many treatment approaches may be helpful for dealing with relationship issues. Options include:

• One-to-one and group therapy
• Anger and stress management
• Assertiveness training
• Couples counseling
• Family education classes
• Family therapy

What Is Self-Harm?

Self-harm refers to a person harming his/her own body on purpose. Other terms for self-harm are "self-abuse" or "cutting." Overall, a person who self-harms does not mean to kill himself or herself.

Self-harm tends to begin in teen or early adult years. Some people may engage in self-harm a few times and then stop. Others engage in it more often and have trouble stopping the behavior. Self-harm is related to trauma in that those who self-harm are likely to have been abused in childhood.

How Common Is Self-Harm?

The rates of self-harm vary widely, depending on how researchers pose their questions about it. It is estimated that in the general public, 2% to 6% engage in self-harm at some point in their lives. Among students, the rates are higher, ranging from 13% to 35%.

Rates of self-harm are also higher among those in treatment for mental health problems. Those in treatment who have a diagnosis of PTSD are more likely to engage in self-harm than those without PTSD.

What Are Self-Harmers Like?

Self-harmers, as compared to others, have more frequent and more negative feelings such as fear or worry, depression, and aggressive impulses. Links have also been found between self-harm and feeling numb or feeling as if you're outside your body. Often those who self-harm have low self-esteem, and they do not tend to express their feelings. The research is not clear on whether self-harm is more common in women or men.

Those who self-harm appear to have higher rates of PTSD and other mental health problems. Self-harm is most often related to going through trauma in childhood rather than as an adult. Those who self-harm have high rates of:

• Childhood sexual abuse
• Childhood physical abuse
• Emotional neglect
• Bonds with caregivers that are not stable or secure
• Long separations from caregivers

Those who self-harm very often have a history of childhood sexual abuse. For example, in one group of self-harmers, 93% said they had been sexually abused in childhood. Some research has looked at whether certain aspects of childhood sexual abuse increase the risk that survivors will engage in self-harm as adults. The findings show that more severe, more frequent, or longer-lasting sexual abuse is linked to an increased risk of engaging in self-harm in one's adult years.

Why Do People Engage in Self-Harm?

While many ideas have been offered, the answer to this question may vary from person to person. The reasons that are most often given are "To distract yourself from painful feelings" and "To punish yourself." Research on the reasons for self-harm suggests that people engage in self harm to:

• Decrease symptoms of feeling numb or as if you are outside your body or yourself
• Reduce stress and tension
• Block upsetting memories and flashbacks
• Show a need for help
• Ensure that you will be safe and protected
• Express and release distress
• Reduce anger
• Punish self
• Hurt self instead of others

How Is Self-Harm Treated?

Self-harm is a problem that many people are embarrassed or ashamed to discuss. Often, they try to hide their self-harm behaviors. They may hold back from getting mental health or even medical treatment.

Self-harm is often seen with other mental health problems like PTSD or substance abuse. For this reason, it does not tend to be treated separately from the other mental health problems. Some research suggests, though, that adding in a round of therapy focused just on the self-harming behavior may result in less self-harming.

There have not yet been strong studies on using medicine to treat self-harm behaviors. For this reason, experts have not reached agreement on whether medicines should be used to treat self-harm behaviors.

Almost everyone with PTSD reports sleep problems. In fact, trouble sleeping is the main reason that people first go to a doctor to get help for PTSD. Both insomnia—trouble falling or staying asleep—and nightmares are PTSD symptoms. The good news is there are evidence-based treatments that can help with PTSD and sleep problems. And, these treatments help whether your sleep problems began before a traumatic event or only came about after the trauma.

Why Is Sleep Important?

Both how well (quality) and how much (quantity) a person sleeps are important.

Poor sleep may lead to:

• Slow reaction time
• Trouble with learning and memory
• Feeling irritable and mood problems
• Trouble with thinking and concentration
• Thinking about suicide or acting in ways that self-harm

Also, sleep problems that last a long time are related to medical problems such as heart disease, depression, kidney disease, high blood pressure, diabetes, obesity and stroke.

How Does PTSD Affect Sleep?

Both nightmares and insomnia are symptoms of PTSD. Nightmares are often a replay of the traumatic event; and, if the dreams cause kicking and screaming, bed partners can be affected too. Nightmares can also make it difficult to fall back asleep. Insomnia is when a person has trouble falling or staying asleep at least three nights a week. This lack of sleep continues for a few months or more and is severe enough to cause problems at work and at home.

Because people with PTSD may try to push away trauma memories during the day, it may cause worries to get worse at night and disrupt sleep. Here are some examples:

• Avoidance. People with PTSD may avoid going to sleep. Nightmares and flashbacks—feeling like the trauma is happening again—can create fear or feeling as if going to bed is unsafe.
• Loss of sleep time. Whether or not insomnia is diagnosed, people with PTSD often report less sleep due to problems falling asleep, being restless during the night and waking up earlier than wanted. Even brief periods of sleep loss can affect daily life.
• Increased arm and leg movement. After a trauma, people may have more arm and leg movements during sleep. This can make someone feel restless.
• Talking during sleep. After a trauma, people may talk more in their sleep. Talking during sleep can affect bed partners.
• Feeling "on alert." People with PTSD may feel the need to be on guard, to protect themselves from danger. It is difficult to have restful sleep when you feel the need to be always alert or are startled easily by noise.
• Not liking silence. Some may be uneasy with silence after a trauma. When this happens, a person may keep a television on all night. Changes in light and sound can disrupt the deepest and most needed level of sleep.

What Is the Relationship Between PTSD, Sleep Problems and Substance Use?

Sleep problems may become their own disorders that cause distress. As a result, some will use substances such as alcohol, marijuana, or other drugs to fall asleep. Over time, drug and alcohol use can also have negative effects on sleep quality and on overall health and functioning.

What Is the Best Treatment for Sleep Problems?

The best treatment for insomnia is Cognitive Behavioral Therapy for Insomnia, or CBT-I. This talk therapy is recommended over medication because it is more effective—CBT-I has been shown to work in multiple research studies—and has fewer side effects than medication. CBT-I improves sleep in 7 out of 10 people who complete it. Research also shows that CBT-I reduces how many nightmares people have and the distress related to upsetting dreams.

How does CBT-I work?

CBT-I focuses on a person's beliefs, feelings, and behaviors that affect sleep. A trained CBT-I therapist may offer the treatment in one-on-one appointments or to a group of people with insomnia. It usually lasts six sessions. CBT-I can be delivered in person or through video medical appointments. There are also online programs and a smartphone app—CBT-I Coach—designed to help with the treatment.

What is "sleep hygiene" Is it the same as CBT-I?

Sleep hygiene includes various practices and habits that are important for good sleep. It includes tips to change behaviors that may interfere with sleep. For example, you may limit beverages with caffeine before bedtime to fall asleep more easily. Or, you may find that you need to adjust your sleep environment—such as limiting smartphone use or television viewing in bed—to be more comfortable. CBT-I, on the other hand, is a more focused treatment for chronic insomnia. Sleep hygiene is not the same as CBT-I treatment, but it is often included as a part of CBT-I.

What are the pros and cons of using sleep medication?

Sleep medication is easy to take and usually provides quick, temporary relief. There are many different types of medications used for sleep, from herbal supplements and over-the-counter sleep aids to prescription medications. If you choose to take medication, you should be familiar with the side effects and risks before you take it.

Sleep medication side effects usually include daytime drowsiness, dizziness and confusion. Sleep medication is often recommended for short-term use only (2 to 4 weeks). These medications usually become less helpful over time and don't get to the core cause of sleep problems.

Certain prescription sleep medication can cause serious side effects with long-term use. Examples include:

• Benzodiazepines: such as Xanax, Klonopin, Valium or Ativan
• Nonbenzodiazepines (or "Z-drugs"): such as Ambien, Lunesta and Sonata

Although benzodiazepines—or "benzos"—can make people feel calm, relaxed or sleepy, they can become a problem in the long run and are not recommended for the treatment of PTSD.

Compare Your Treatment Options

What Other Sleep Problems Affect People with PTSD?

Sleep apnea is common among people with PTSD, particularly in Veterans. Sleep apnea is a breathing problem that disrupts normal sleep. People with sleep apnea may wake up not feeling rested and struggle with feeling tired or needing to sleep during the daytime.

Being aware of sleep apnea can be difficult. There are many causes of fatigue or feeling tired during the day. Also, with sleep apnea, breathing pauses (or disruptions) happen during sleep, so a person may be unaware of those symptoms. Often a bed partner notices those breathing changes or snoring first.

To diagnose sleep apnea, a provider may recommend a sleep study. Treatment can include lifestyle changes and use of a breathing device—continuous positive airway pressure, or CPAP machine—at night. Research suggests that for those with PTSD and sleep apnea, using a CPAP device may benefit PTSD treatment.

Final Points About PTSD and Sleep

With PTSD, it can take some time and effort to get good sleep. Using marijuana, alcohol and street drugs to manage PTSD or sleep problems is related to a higher risk of thoughts about suicide and suicide attempts. There are effective treatments available for sleep problems and PTSD. Work with your provider to learn about your treatment options and decide on the best fit for your needs.

People with PTSD are more likely than others to have problems with drugs and alcohol. Substance use can lead to traumatic experiences. At the same time, people may use drugs or alcohol to try to manage PTSD symptoms. Learn about the relationship between substance use problems and PTSD.

• PTSD and Problems with Alcohol Use
  People with PTSD are more likely to have drinking problems. Also, people with drinking problems often have PTSD. Having PTSD and alcohol use problems at the same time can make the symptoms of each worse. Treatment can help you work on both problems at the same time.
• PTSD and Substance Abuse in Veterans
  Studies show PTSD and substance use problems are strongly related in military and civilian groups. Some people try to cope with PTSD symptoms by drinking heavily, using drugs, or smoking too much. People who have problems with drugs or alcohol are also more likely to develop PTSD. The good news is that treatment works, and therapy can target both problems at the same time.

The topics discussed on this page are about the relationship between trauma, PTSD, and suicide. It may help you understand more about suicide, PTSD treatment, and what to do if you are feeling suicidal or know someone who is.

How Common Is Suicide?

No matter how rare it is, suicide is always very tragic. It is hard to say exactly how many suicides occur.

• Often suicides are not reported.
• It can be hard to know whether or not a person meant to die by suicide. For a death to be recorded as suicide, examiners must be able to say that the deceased meant to die.
• The way deaths are recorded (in general) has changed over time.

Overall, men are more likely to die by suicide than women. For example, from 1999-2010, the average suicide rate among U.S. males was 19.4 out of every 100,000, compared to 4.9 out of every 100,000 females. The difference in suicide rates between men and women is also true among Veterans.

Does Trauma Increase a Person's Suicide Risk?

Going through a trauma may increase a person's suicide risk. For example, there is evidence that childhood abuse and sexual trauma may increase a person's suicide risk. Among Veterans, some studies have found that combat trauma is related to suicide, while other studies have not. In this research, combat trauma survivors who were wounded more than once or put in the hospital for a wound had the highest suicide risk. This suggests suicide risk in Veterans may be affected by how intense and how often the combat trauma was. Does PTSD increase a person's suicide risk?

Why is suicide risk higher in trauma survivors? It may be because of the symptoms of PTSD or it may be due to other mental health problems, like depression. Studies show that suicide risk is higher in persons with PTSD. Some studies link suicide risk in those with PTSD to distressing trauma memories, anger, and poor control of impulses. Further, suicide risk is higher for those with PTSD who have certain styles of coping with stress, such as not expressing feelings.

Research suggests that for Veterans with PTSD, the strongest link to both suicide attempts and thinking about suicide is guilt related to combat. Many Veterans have very disturbing thoughts and extreme guilt about actions taken during times of war. These thoughts can often overwhelm the Veteran and make it hard for him or her to deal with the intense feelings.

Can PTSD Treatment Help?

A person can benefit from cognitive behavioral treatments (CBT) for PTSD if suicidal thoughts are able to be managed on an outpatient basis. For example, a study of female rape survivors who received such treatment found that as PTSD symptoms decreased during treatment, suicidal thoughts also became less common. This effect lasted for 5-10 years after treatment ended. More research is needed, but having a good relationship with a mental health provider can help persons with PTSD make the best treatment decisions.

Given the link between PTSD and suicidal thoughts/behaviors, if you have PTSD and are involved in mental health treatment, your suicide risk will likely be regularly assessed. If the provider learns that immediate risk for suicide is high based on his/her assessment, they will make appropriate treatment decisions to ensure safety. If the immediate risk for suicide is not high and suicide risk can be managed safely on an outpatient basis, the provider may suggest treatment for PTSD.

What Can I Do?

I am suicidal

If you are ever thinking about suicide and feel unsafe:

• Call 1-800-273-TALK (1-800-273-8255). The National Suicide Prevention Lifeline is available 24 hours a day.
• Veterans, press "1" after being connected, to be routed to the Veterans Crisis Line.
• Veterans can also chat live online with a crisis counselor to get help at any time of day or night.
• The Veterans Crisis Line also responds to text messages. Send a text to 838255.
• En Español 1-888-628-9454

Everyone feels down from time to time. If you have thoughts about hurting yourself, seek professional help. Many people who have thoughts of suicide also struggle with depression or with drinking or drug problems.

Someone I know is suicidal

You may come in contact with a family member, friend, or coworker who is thinking about suicide. When someone tells you they have these thoughts, you may feel scared and unsure what to do. It is even harder if the person tells you in secret and you feel pressure not to tell others.

If someone you know is thinking about suicide, this is a serious matter. It can be very hard to gauge the level of danger. A mental health professional is the best person to decide how much danger there is.

• You can help the person by staying calm and telling them about mental health options in the area.
• Often the hardest part of getting treatment is making the first call to a mental health provider. It is usually easier if the person who is thinking about suicide has help with this contact.
• Please see the resources listed above for phone numbers you can call for help. While helping someone who is thinking about suicide can be hard, keep in mind that the help you give could save someone's life.

Someone I know has died by suicide

It is very upsetting when someone you know dies by suicide. Getting over the shock and distress will be especially hard if you felt close to them, if you saw the event, or if you have your own mental health issues.

Grieving the loss of a loved one is a natural process. It may take several months to feel "normal" again after someone you know dies by suicide. Due to the traumatic nature of suicide, you may go through what's known as "traumatic grief." If you are feeling intense grief or guilt several months after the suicide, contact a mental health provider for help. Many people feel guilty about not having prevented the suicide. Be aware, though, that suicide is never your fault. Suicide is complex with many factors that contribute.

It can also be difficult to cope when a loved one has made a suicide attempt. You can access education products for family members of Veterans who have made a suicide attempt, including a Family Resource Guide and information about how to talk to a child about a suicide attempt. Some materials are also available in Spanish. Although these products were created with military families in mind, resources and information included in them may be useful for non-military families as well.

TBI occurs from a sudden blow or jolt to the head. Brain injury often occurs during some type of trauma, such as an accident, blast, or a fall. Often when people refer to TBI, they are mistakenly talking about the symptoms that occur following a TBI. Actually, a TBI is the injury, not the symptoms.

How Serious Is My Injury?

A TBI is basically the same thing as a concussion. A TBI can be mild, moderate, or severe. These terms tell you the nature of the injury itself. They do not tell you what symptoms you may have or how severe the symptoms will be.

A TBI can occur even when there is no direct contact to the head. For example, when a person suffers whiplash, the brain may be shaken within the skull. This damage can cause bleeding between the brain and skull. Bruises can form where the brain hits the skull. Like bruises on other parts of the body, for mild injuries these will heal with time.

About 80% of all TBI's in civilians are mild (mTBI). Most people who have a mTBI will be back to normal by three months without any special treatment. Even patients with moderate or severe TBI can make remarkable recoveries.

The length of time that a person is unconscious (knocked out) is one way to measure how severe the injury was. If you weren't knocked out at all or if you were out for less than 30 minutes, your TBI was most likely minor or mild. If you were knocked out for more than 30 minutes but less than six hours, your TBI was most likely moderate.

What Are the Common Symptoms Following a TBI?

Symptoms that result from TBI are known as post-concussion syndrome (PCS). Few people will have all of the symptoms, but even one or two of the symptoms can be unpleasant. PCS makes it hard to work, get along at home, or relax. In the days, weeks, and months following a TBI the most common symptoms are:

Physical

• Headache
• Feeling dizzy
• Being tired
• Trouble sleeping
• Vision problems
• Feeling bothered by noise and light

Cognitive (Mental)

• Memory problems
• Trouble staying focused
• Poor judgment and acting without thinking
• Being slowed down
• Trouble putting thoughts into words

Emotional (Feelings)

• Depression
• Anger outbursts and quick to anger
• Anxiety (fear, worry, or feeling nervous)
• Personality changes

These symptoms are part of the normal process of getting better. They are not signs of lasting brain damage. These symptoms are to be expected and are not a cause for concern or worry. More serious symptoms include severe forms of those listed above, decreased response to standard treatments, and seizures.

Do I Have the Symptoms that Follow a TBI or PTSD - or Both?

You may notice that many of the symptoms that follow a TBI overlap with the common reactions after trauma. Because TBI is caused by trauma and there is symptom overlap, it can be hard to tell what the underlying problem is. In addition, many people who get a TBI also develop PTSD.

It is important to be assessed because:

• People with TBI should not use some medications.
• No matter how mild or severe the injury itself was, the effects could be serious.

Although TBI screens are used, a screen is not used to diagnose TBI. Even if your TBI screen is positive, that does not mean that you have a TBI. It means that you should be assessed further.

Diagnosing a TBI is hard because there may not be any physical signs of injury. Details of the trauma may be hard to pin down. Sometimes right after the injury the effects are so brief that they are not noticed. You may go to the doctor some time later when details of the injury are not as clear. TBI can occur in confused times of crisis, such as combat. In the heat of events the injury may be ignored. Many of the symptoms that can result from a TBI are the same as the symptoms of PTSD. For these reasons, the best way to diagnose a TBI is an interview by a skilled clinician.

Are There Effective Treatments?

Many people recover from TBI without any formal treatment. Problems that linger may clear up in a few weeks. You may notice some problems more as you return to your normal routine. For example, you may not realize that you get tired more quickly until you return to your regular chores, work, or school. Even so, people usually get better after a head injury, not worse. Professional treatment for the symptoms that follow TBI usually involves rehabilitation to improve functioning.

The good news is that effective treatments for PTSD also work well for those who have suffered mTBI. This includes two forms of therapy: Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE).

What Can I Do to Cope?

The best way to deal with symptoms following TBI is to go back slowly to your normal routine, a little at a time. How much time you spend at work, with family, with others, or exercising depends on what feels comfortable. Pace yourself, and be sure to get all the rest you need. Avoiding alcohol and not taking any unnecessary medications is a good idea, to help allow the brain to heal.

If your symptoms get worse, or if you notice new PCS symptoms, this is a sign that you are pushing yourself too hard. Ignoring your symptoms and trying to "tough it out" often make the symptoms worse. Symptoms are your body's way of giving you information. A broken bone or a torn muscle hurts so that you won't use it and it has time to heal. PCS symptoms are your brain's way of telling you that you need to rest it.

Research suggests that one week of relaxing at home and then a week of slowly doing more after leaving the hospital is best for most patients. Most patients who took this advice were back to normal at work or school in 3 to 4 weeks. Most patients who weren't told what to do took 5 to 12 weeks to get back to their normal routine. They also had more PCS symptoms than patients who returned slowly to their routines.

Accept and deal with the stress of the injury

Be aware that having a head injury adds more stress to your life, not just bumps and bruises to your head. The trauma itself, being in the hospital, and going back to work or school and normal routines are all things that add stress to most patients' lives. You may have some trouble with work or school at first, and even though it is normal, this may be stressful and frustrating.

Another main cause of stress after a TBI is worry about the symptoms you have. Thinking and worrying about your symptoms can make them seem worse. Doctors who treat TBI agree that the single most important factor in recovery is that you know what to expect and what to do about the symptoms. You should remember that the symptoms are a normal part of getting better. They will likely go away on their own.

Involve Family

Any level of TBI can disrupt families. Roles and responsibilities change when a family member is hurt. From the start, families needs to be involved and informed about TBI. By supporting the family, patient outcomes can be improved and burnout prevented.

Return to school or work slowly

Returning to school or work is often the biggest challenge after TBI. This is because PCS symptoms can get in the way of meeting your work and school demands. For example, trouble focusing and memory problems may make it harder to learn new things in school. Or fatigue may limit your being able to handle work demands. Keep in mind when trying to return to work or school that the process will be slow. Don't expect yourself to perform right away as you did before your TBI. Instead, you should slowly resume responsibilities as you are able. Slowly increase your workload and hours. Only increase them when you feel fully ready.

TBI and Veterans

The conflicts in Afghanistan and Iraq (OEF/OIF) have resulted in increased numbers of Veterans who have TBI. The main causes of TBI in OEF/OIF Veterans are blasts, motor vehicle accidents, and gunshot wounds. The Department of Defense and the Defense and Veteran's Brain Injury Center estimate that 22% of all OEF/OIF combat wounds are brain injuries. This is compared to TBI in 12% of combat wounds that occurred in Vietnam.

Veterans seem to have symptoms for longer than civilians. Some studies show most will still have symptoms 18-24 months after the TBI. Also, many Veterans have more than one medical problem, including: PTSD, chronic pain, or substance abuse. From 60-80% of Service members who are hurt in other ways by a blast may have a TBI. These other problems make it harder to get better from any single problem. Veterans should remember, though, that their TBI symptoms are likely to last only a limited time. With proper treatment and healthy behaviors, they are likely to improve.

VA is working to make sure that TBI care is easy to access. VA is using a TBI screening tool to begin the assessment process. VA has put in place the Polytrauma System of Care to treat Veterans with TBI who also have other injuries. Veterans with the most severe wounds are being treated at one of the 4 Polytrauma Rehabilitation Centers or one of the 21 Polytrauma Network Sites. Patients with less severe wounds may get treatment at local VA Medical Centers. No matter where a Veteran goes first, there is no "wrong door" for treatment.

People respond to traumatic events in a number of ways. They may feel concern, anger, fear, or helplessness. These are all typical responses to a violent, malicious, or traumatic event. However, research shows that people who have been through trauma, loss, or hardship in the past may be even more likely than others to be affected by new, potentially traumatic events.

Traumatic events can cause a range of reactions. In response to new traumatic events, Veterans may:

• Have general distress or see an increase in his or her PTSD symptoms
• Become quick to anger, sleep poorly, or drink more heavily
• Try to avoid all reminders or media about the incident, or shy away from social situations in general

Recent traumatic events may also trigger old memories among Veterans. When facing a new traumatic event some Veterans expect and/or prepare for the worst based on their past experiences.

For example, Veterans may:

• Become overly protective, vigilant, and guarded
• Become preoccupied by danger
• Feel a need to avoid being shocked by, or unprepared for, what may happen in the future

Research Findings

Research has looked at how Veterans react to terrorism. While some studies report that Veterans react similarly to civilians when acts of mass violence occur, other studies report that their negative reactions may last for a longer length of time than civilians. Some Veterans reported that they had more frequent:

• Military and homecoming memories
• Depressed mood
• General distress
• PTSD symptoms

Veterans with PTSD may be even more likely to see their PTSD symptoms get worse if they are exposed to reminders that are similar to their experiences in the military. For example:

• When Veterans followed news closely they reported that media coverage of war brought back thoughts and feelings of their own military experiences.
• Recent research found that individuals who repeatedly exposed themselves to disturbing images from television reports were at greater risk of developing PTSD over the next two to three years.
• When PTSD symptoms got worse for some Veterans, it may have been related to how closely what they were seeing on the news reflected what they had gone through while serving.
• Veteran gatherings or American symbols with high emotional value also could cause PTSD symptoms to recur or worsen.

How Can Veterans Cope When Current Events Cause Distress?

Below is a list of tips to manage distress for Veterans with or without PTSD. Use them to help you cope when traumatic events affect you.

To help yourself

• Consider limiting your exposure to news on television. While media coverage may draw you in, increased viewing can raise stress levels. Watch yourself for signs of anger, rage, depression, worry, or other negative feelings. Take a time out from the news to let yourself recover from these feelings.
• Keep up with daily schedules and routines. Try to include more pleasant activities in your day, even for brief periods of time.
• Keep up with your body's needs for exercise, food, and sleep.
• Feel what you feel. It is normal to feel a range of emotions. Having these feelings is to be expected. How you deal with them is most important.
• Slow down. Give yourself time and space to deal with what has happened. Remember that people have their own pace for dealing with trauma, including you.
• Count on feeling angry, but balance your actions with wisdom. Try to stay calm. Avoid reacting with sudden anger toward any group or persons.
• Talk with someone close to you who might understand what you are going through.
• If you do not feel like talking, writing in a journal may be helpful for dealing with intense feelings.
• Do not avoid other Veterans even if they remind you of your military past. Seeking support along with other Veterans can be very helpful when stress is high. You can find other Veterans through the VA, Vet Centers, and Veteran's Service Organizations.

If you need help

Get help from your doctor or a mental health provider who is skilled in working with survivors of trauma if:

• You are having any symptoms that are causing high levels of distress, problems in relationships, or problems at work.
• You are abusing alcohol or drugs.
• You cannot get relief using the tips listed above.

To help children in your life

If children hear about acts of violence, they look to adults to help them understand and cope with their feelings. Here are some ways you can help:

• Try to respond when they ask questions.
• Safety is a main concern for them. Comfort them and tell them in an age-appropriate way that adults are working hard to help those involved in the situation, and to make sure children will be safe everywhere.
• Be a positive role model for them.
• Show them how you have ways to deal with difficult events together as a family.

To help your community

• Avoid blame as much as possible. Anger and blame toward others have been shown to increase Veterans' stress symptoms.
• Try to change anger or thoughts of revenge into something positive. You could donate blood, give money to the Red Cross, volunteer, donate to a food bank, or give your support in some other way. Invite others to do the same.
• Try to join together with others, show patience, and help others in times of hardship.

The date of a past traumatic event may bring up feelings, even years later. These "anniversary reactions" could make you upset or create more intense symptoms. Learn about common types of anniversary reactions and how you can cope.

Why Do People Have Anniversary Reactions?

The anniversary date itself may trigger a memory. For example, in a case such as the September 11, 2001 attacks, the date serves as a strong reminder. Since people refer to those attacks with the date on which they occurred, it is hard for anyone who knows about that event to go through that day without being reminded of what happened.

Triggers may also seem to come from out of the blue around the time of an anniversary. They may happen while you are at work, home, or relaxing.

Anniversary reactions may occur because of the way a traumatic experience is saved in memory. Memories of trauma contain information about the danger that the event involved. The memory helps us be aware of when we should be afraid, how we should look at such situations, how to feel in that situation, and what to think. The trauma memory gives information that may help us stay safe.

For example, a memory of a rape might include the information that it's important to beware of strangers at night and to run away if one comes near. The memory might tell survivors to feel fear in this situation and to think that they are in danger and need help. Such memories may produce strong feelings as well as bodily reactions.

What Symptoms Go Along with Anniversary Reactions?

Anniversary reactions usually make symptoms that are common reactions to trauma or part of PTSD get worse.

• Reliving the event (or re-experiencing). Perhaps the most common reaction on the anniversary of a trauma is a repeat of the feelings, bodily responses, and thoughts that occurred at the time of the event. For example, on the anniversary of a rape, a sexual assault survivor might have unusually intense and upsetting memories.
• Avoidance. Another type of PTSD symptom is the avoidance of anything related to the trauma. Sometimes the feelings that are triggered by the anniversary are so strong that people try to avoid events, places, or people that are connected to that event. For example, a combat Veteran may choose to stay home on Veteran's Day to avoid parades, Veterans, and other reminders of military service.
• Negative changes in beliefs and feelings. When the anniversary of an event is near, it can lead to sadness. Some people may find it hard to connect with friends and family. Old thoughts of guilt or shame may come back.
• Feeling keyed up (or hyperarousal). A fourth kind of reaction is to feel nervous and on edge. As the anniversary comes, the trauma memory might be so intense that it is hard to sleep or focus on things you need to do. Some people become more jumpy or quick to anger. Others feel like they have to be more on guard.

Around an anniversary, survivors may have panic attacks, be afraid to go certain places, or find that they worry more about safety for themselves and their loved ones. For example, a car accident survivor may avoid getting in a car on the anniversary for fear they will be hit again. Others may have physical or medical symptoms such as fatigue and pain. They may complain of headaches and stomachaches.

A common type of anniversary reaction is feeling grief and sadness on the anniversary of the death of someone close to you. In fact, this is so common that most major religions have special services to support those who feel increased grief at these times. If the reaction is extreme, the survivor may become depressed or even think about suicide. For most people, though, the feelings of sadness at the anniversary do not last more than a brief time.

What becomes clear is that there is not one classic anniversary reaction. The anniversary reaction will differ among trauma survivors. It may depend on the type of trauma, how much time has passed since the trauma or loss, the qualities of that person, or other factors.

What Can I Do to Feel Better?

Most people will feel better within a week or two after the anniversary. Over time, the stress symptoms will become less frequent and less severe. You may find it helpful to make special plans for the anniversary day. It can help to have other things to occupy your time besides memories of the event. You may choose to take part in a special activity. Some ideas include:

• Visiting a grave
• Donating to charity
• Giving blood
• Helping others
• Spending the day with family

Good help is available if the stress response continues. You should contact your doctor or a mental health provider to seek support. It is common for people who did not seek help when they first went through the trauma to feel ashamed that they are still suffering months or years later. The fact that someone did not seek help may itself be a sign that they are avoiding reminders of the trauma. Such behavior can be viewed as a signal that the survivor needs the help of a professional.

Recovery after a traumatic event is a process that takes time. If you take direct action to cope with your stress reactions it may create a sense of power. Learn how you can use active coping after trauma and for PTSD symptoms.

Active Coping

• Active coping means accepting the impact of trauma on your life and taking direct action to improve things.
• Active coping occurs even when there is no crisis. Active coping is a way of responding to everyday life. It is a habit that must be made stronger.

Know That Recovery Is a Process

Following exposure to a trauma most people experience stress reactions. Understand that recovering from the trauma is a process and takes time. Knowing this will help you feel more in control.

• Having an ongoing response to the trauma is normal.
• Recovery is an ongoing, daily process. It happens little by little. It is not a matter of being cured all of a sudden.
• Healing doesn't mean forgetting traumatic events. It doesn't mean you will have no pain or bad feelings when thinking about them.
• Healing may mean fewer symptoms and symptoms that bother you less.
• Healing means more confidence that you will be able to cope with your memories and symptoms. You will be better able to manage your feelings.

Positive Coping Actions

Certain actions can help to reduce your distressing symptoms and make things better. Plus, these actions can result in changes that last into the future. Here are some positive coping methods:

Learn about trauma and PTSD

It is useful for trauma survivors to learn more about common reactions to trauma and about PTSD. Find out what is normal. Find out what the signs are that you may need assistance from others. When you learn that the symptoms of PTSD are common, you realize that you are not alone, weak, or crazy. It helps to know your problems are shared by hundreds of thousands of others. When you seek treatment and begin to understand your response to trauma, you will be better able to cope with the symptoms of PTSD.

Talk to others for support

When survivors talk about their problems with others, something helpful often results. It is important not to isolate yourself. Instead make efforts to be with others. Of course, you must choose your support people with care. You must also ask them clearly for what you need. With support from others, you may feel less alone and more understood. You may also get concrete help with a problem you have.

Practice relaxation methods

Try some different ways to relax, including:

• Muscle relaxation exercises
• Breathing exercises
• Meditation
• Swimming, stretching, yoga
• Prayer
• Listening to quiet music
• Spending time in nature

While relaxation techniques can be helpful, in a few people they can sometimes increase distress at first. This can happen when you focus attention on disturbing physical sensations and you reduce contact with the outside world. Most often, continuing with relaxation in small amounts that you can handle will help reduce negative reactions. You may want to try mixing relaxation in with music, walking, or other activities.

Distract yourself with positive activities

Pleasant recreational or work activities help distract a person from his or her memories and reactions. For example, art has been a way for many trauma survivors to express their feelings in a positive, creative way. Pleasant activities can improve your mood, limit the harm caused by PTSD, and help you rebuild your life.

Talking to your doctor or a counselor about trauma and PTSD

Part of taking care of yourself means using the helping resources around you. If efforts at coping don't seem to work, you may become fearful or depressed. If your PTSD symptoms don't begin to go away or get worse over time, it is important to reach out and call a counselor who can help turn things around. Your family doctor can also refer you to a specialist who can treat PTSD. Talk to your doctor about your trauma and your PTSD symptoms. That way, he or she can take care of your health better.

Many with PTSD have found treatment with medicines to be helpful for some symptoms. By taking medicines, some survivors of trauma are able to improve their sleep, anxiety, irritability, and anger. It can also reduce urges to drink or use drugs.

Coping with the Symptoms of PTSD

Here are some direct ways to cope with these specific PTSD symptoms:

Unwanted distressing memories, images, or thoughts

• Remind yourself that they are just that, memories.
• Remind yourself that it's natural to have some memories of the trauma(s).
• Talk about them to someone you trust.
• Remember that, although reminders of trauma can feel overwhelming, they often lessen with time.

Sudden feelings of anxiety or panic

Traumatic stress reactions often include feeling your heart pounding and feeling lightheaded or spacey. This is usually caused by rapid breathing. If this happens, remember that:

• These reactions are not dangerous. If you had them while exercising, they most likely would not worry you.
• These feelings often come with scary thoughts that are not true. For example, you may think, "I'm going to die," "I'm having a heart attack," or "I will lose control." It is the scary thoughts that make these reactions so upsetting.
• Slowing down your breathing may help.
• The sensations will pass soon and then you can go on with what you were doing.

Each time you respond in these positive ways to your anxiety or panic, you will be working toward making it happen less often. Practice will make it easier to cope.

Feeling like the trauma is happening again (flashbacks)

• Keep your eyes open. Look around you and notice where you are.
• Talk to yourself. Remind yourself where you are, what year you're in, and that you are safe. The trauma happened in the past, and you are in the present.
• Get up and move around. Have a drink of water and wash your hands.
• Call someone you trust and tell them what is happening.
• Remind yourself that this is a common response after trauma.
• Tell your counselor or doctor about the flashback(s).

Dreams and nightmares related to the trauma

• If you wake up from a nightmare in a panic, remind yourself that you are reacting to a dream. Having the dream is why you are in a panic, not because there is real danger now.
• You may want to get up out of bed, regroup, and orient yourself to the here and now.
• Engage in a pleasant, calming activity. For example, listen to some soothing music.
• Talk to someone if possible.
• Talk to your doctor about your nightmares. Certain medicines can be helpful.

Difficulty falling or staying asleep

• Keep to a regular bedtime schedule.
• Avoid heavy exercise for the few hours just before going to bed.
• Avoid using your sleeping area for anything other than sleeping or sex.
• Avoid alcohol, tobacco, and caffeine. These harm your ability to sleep.
• Do not lie in bed thinking or worrying. Get up and enjoy something soothing or pleasant. Read a calming book, drink a glass of warm milk or herbal tea, or do a quiet hobby.

Irritability, anger, and rage

• Take a time out to cool off or think things over. Walk away from the situation.
• Get in the habit of exercise daily. Exercise reduces body tension and relieves stress.
• Remember that staying angry doesn't work. It actually increases your stress and can cause health problems.
• Talk to your counselor or doctor about your anger. Take classes in how to manage anger.
• If you blow up at family members or friends, find time as soon as you can to talk to them about it. Let them know how you feel and what you are doing to cope with your reactions.

Difficulty concentrating or staying focused

• Slow down. Give yourself time to focus on what it is you need to learn or do.
• Write things down. Making "to do" lists may be helpful.
• Break tasks down into small do-able chunks.
• Plan a realistic number of events or tasks for each day.
• You may be depressed. Many people who are depressed have trouble concentrating. Again, this is something you can discuss with your counselor, doctor, or someone close to you.

Trouble feeling or expressing positive emotions

• Remember that this is a common reaction to trauma. You are not doing this on purpose. You should not feel guilty for something you do not want to happen and cannot control.
• Make sure to keep taking part in activities that you enjoy or used to enjoy. Even if you don't think you will enjoy something, once you get into it, you may well start having feelings of pleasure.
• Take steps to let your loved ones know that you care. You can express your caring in little ways: write a card, leave a small gift, or phone someone and say hello.

A Final Word

Try using all these ways of coping to find which ones are helpful to you. Then practice them. Like other skills, they work better with practice. Be aware that there are also behaviors that DON'T help.