Post-traumatic Stress Disorder

Post-traumatic stress disorder ("PTSD"), Complex PTSD and Acute Stress Reaction are stress-induced psychological conditions that can occur after traumatic experiences; They are natural emotional reactions to a deeply shocking and disturbing experiences. They are normal reactions to an abnormal situation. The main difference between the two conditions is that in Acute Stress Reaction, the reactive symptoms are more immediate and less enduring than they are for PTSD.

Definition of PTSD

Post-traumatic Stress Disorder is the name given to a range of symptoms a person may develop in response to a deeply shocking, disturbing experience outside the normal range of human experience. The condition is classified in the American Psychiatric Association's Diagnostic and Statistical Manual, DSM-5, and in the international equivalent manual, the World Health Organization's ICD-10. For a clinical diagnosis, a patient must meet the diagnostic criteria in the DSM or ICD manuals. In both manuals, the basic requirement for diagnosis is that the patient must have been exposed to a stressor, and must then display certain psychological and behavioural symptoms relating to the trauma.

Post-traumatic Stress Disorder is within a spectrum of trauma and stress-related disorders. Another condition in the spectrum is "Acute Stress Reaction", a condition that usually begins very soon after exposure to a exceptional physical or mental stress and which subsides within hours or days.

Making a Diagnosis

For a doctor or mental health professional to make a diagnosis of ptsd or any other condition, the patient's experiences and symptoms must meet criteria set out in manuals. The American Psychiatric Association currently uses the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as its classification and diagnostic tool. Europe and the rest of the world rely on the World Health Organisation's International Statistical Classification of Diseases and Related Health Problems (ICD), currently at revision 10, with revision 11 due in 2018. So far as PTSD is concerned, these manuals set out the symptoms of PTSD along with a description of the trauma a patient would need to have experienced, to obtain a diagnosis of PTSD.

The less pervasive condition of Acute Stress Reaction (in ICD) or Acute Stress Disorder (in DSM) has its diagnostic criteria set out in the same manuals.

ICD-10 Diagnostic Criteria for Post Traumatic Stress Disorder (PTSD)

"Arises as a delayed or protracted response to a stressful event or situation (of either brief or long duration) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone. Predisposing factors, such as personality traits (e.g. compulsive, asthenic) or previous history of neurotic illness, may lower the threshold for the development of the syndrome or aggravate its course, but they are neither necessary nor sufficient to explain its occurrence. Typical features include episodes of repeated reliving of the trauma in intrusive memories ("flashbacks"), dreams or nightmares, occurring against the persisting background of a sense of "numbness" and emotional blunting, detachment from other people, unresponsiveness to surroundings, anhedonia, and avoidance of activities and situations reminiscent of the trauma. There is usually a state of autonomic hyperarousal with hypervigilance, an enhanced startle reaction, and insomnia. Anxiety and depression are commonly associated with the above symptoms and signs, and suicidal ideation is not infrequent. The onset follows the trauma with a latency period that may range from a few weeks to months. The course is fluctuating but recovery can be expected in the majority of cases. In a small proportion of cases the condition may follow a chronic course over many years, with eventual transition to an enduring personality change (F62.0). Diagnostic Criteria

A. Exposure to a stressful event or situation (either short or long lasting) of exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone.

B. Persistent remembering or "reliving" the stressor by intrusive flash backs, vivid memories, recurring dreams, or by experiencing distress when exposed to circumstances resembling or associated with the stressor.

C. Actual or preferred avoidance of circumstances resembling or associated with the stressor (not present before exposure to the stressor).

D. Either (1) or (2):

(1) Inability to recall, either partially or completely, some important aspects of the period of exposure to the stressor

(2) Persistent symptoms of increased psychological sensitivity and arousal (not present before exposure to the stressor) shown by any two of the following:

a) difficulty in falling or staying asleep;

b) irritability or outbursts of anger;

c) difficulty in concentrating;

d) hyper-vigilance;

e) exaggerated startle response

E. Criteria B, C (For some purposes, onset delayed more than six months may be included but this should be clearly specified separately.)

(source https://www.estss.org/learn-about-trauma/icd10/)

Developmental History

In earlier revisions of DSM and ICD, the nature of the trauma for PTSD had to be a single, major, life threatening event. Tim Field wrote that this was because (a) most of the research on PTSD had been undertaken with people who had suffered a threat to life (eg combat veterans, especially from Vietnam, victims of accident, disaster, and acts of violence), and (b) it was thought that PTSD could not be a result of "normal" events such as bereavement, business failure, interpersonal conflict, bullying, harassment, stalking, marital disharmony, working for the emergency services, etc.

In DSM-IV the requirement was eased although most mental health practitioners continued to interpret diagnostic criterion A1 as applying only to a single major life-threatening event. The current revision, DSM-V, holds that the patient must either:-

  • Directly experience the traumatic event(s)
  • Witness, in person, the event(s) as it occurred to others
  • Learn that the traumatic event(s) occurred to a close family member or friend
  • Experience repeated or extreme exposure to aversive details of the traumatic event(s); albeit that exposure through tv, radio, movies or images is not counted.

A further change in DSM-V is the reclassification of PTSD to a new chapter, "Trauma- and Stressor-Related Disorders".

ICD-10 defines the stressor as "Exposure to a stressful event or situation (either short or long lasting) of exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone."

It is possible for a patient to have the symptoms of PTSD, but to have experienced a trauma that falls outside the criteria set out in either manual. In such a case, strictly spealing, a psychiatrist would not be able to make a complete PTSD diagnosis. However, for years, it has been argued that "complex PTSD" is a valid term for a condition where the trauma has not been a single event. It appears that ICD-11 will finally address this anomaly.

ICD-11 (due for publication in 2018), has proposed two related diagnoses, posttraumatic stress disorder (PTSD) and complex PTSD within the spectrum of trauma and stress-related disorders. This is an important development, showing recognition by the profession that PTSD symptoms (which this article has not yet touched upon) can arise from "sustained exposure to repeat or multiple types of traumatic stressors (e.g., childhood abuse, domestic violence, genocide campaigns, torture)." [Evidence for proposed ICD-11 PTSD and complex PTSD: a latent profile analysis]

The ICD-10 diagnostic criteria for Acute Stress Reaction is in the professional reference area of patient.info, as is this excellent article on PTSD which includes information on predisposing factors and treatments. Patient.info also provides a less technical article on Acute Stress Reaction and one on PTSD, by the Royal College of Psychiatrists. Each article links to further, professional references on the conditions.

Causes of PTSD

PTSD resulting from accident, disaster, war, terrorism, torture, kidnap, etc has been extensively studied and literature is available elsewhere. The first written reference to PTSD symptoms comes from the sixth century BC; Post Traumatic Stress Disorder is nothing new.

This section of Bully OnLine focuses on PTSD and Complex PTSD resulting from bullying, primarily in the workplace, however anyone interested in PTSD (however caused) may find this page enlightening.

Most of the information on this page and web site is relevant to other types of bullying, eg at school, in relationships (including domestic violence), by families, by neighbours or landlords, in the care of elderly, young or disadvantaged people, in the armed services, etc. Bullying is behind harassment, discrimination, prejudice and persecution, therefore targets of repeated sexual harassment or racial discrimination or religious or ethnic persecution will also identify with the symptoms. The insight about bullying on this web site is therefore also relevant to more serious issues including physical abuse, repeated verbal abuse, sexual abuse, violent crime, kidnap, abduction, rape, war, terrorism, torture, and denial and abuse of human rights. Those exploring Contact Experience may also find this page helpful.

CAUTION: Some medical practitioners would agree with the information on this page, others would not. Beware of self diagnosis!

PTSD and bullying

ICD-10 demonstrates recognition by the WHO that PTSD can result from an accumulation of many incidents which, in isolation are not life-threatening, but which as a whole creates a trauma that is similar in severity to a more serious single trauma that threatens life, serious injury and so on. ICD-11 is expected to further broaden the criteria for the trauma and, from that, classify conditions as PTSD and complex PTSD

PTSD can potentially arise from any prolonged period of negative stress in which certain factors are present, which may include any of captivity, lack of means of escape, entrapment, repeated violation of boundaries, betrayal, rejection, bewilderment, confusion, and - crucially - lack of control, loss of control and disempowerment. It is the overwhelming nature of the events and the inability (helplessness, lack of knowledge, lack of support etc) of the person trying to deal with those events that collectively form the trauma that can lead to PTSD. Situations that can create these stresses include bullying, harassment, abuse, domestic violence, stalking, long-term caring for a disabled relative, unresolved grief, mounting debt, contact experience, etc. Those working in regular traumatic situations, eg the emergency services and armed services, through repeated exposure to horrific scenes, are also prone to developing PTSD. The ever present risk to armed services personnel working in war zones, of being killed or seriously injured, is a readily understandable source of extreme stress.

A key stressor is the aspect of captivity, i.e. a perceived or actual inability to escape the situation. Despite some people's assertions to the contrary, situations of domestic abuse and workplace abuse can be extremely difficult to get out of. In the latter case there are several reasons, including the financial effect of losing the present job along with the unavailability of replacement jobs with comparable income and status. A very real concern to the target is the likely inability to get a job reference, given their bully's influence, as well as the prospect of having a previously untarnished disciplinary and/or attendance record ruined by the effects of being bullied. All these things, along with the hope that the bullying will stop before things get really silly, tend to prevent the target from following friends' advice to "just leave".

Society's Attitude to PTSD

In World War One, armed forces personnel faced threats of being labelled with "cowardice" and "lack of moral fibre" (LMF) if they gave in to the symptoms of PTSD. Then, 306 British and Commonwealth soldiers were shot as "cowards" and "deserters" on the orders of General Haig in an act which today would be treated as a war crime - see a separate page on this injustice.

Even now, 40 years after the introduction of the UK's Health and Safety at Work Act, many employers pay little or no attention to the harm caused by bullying and harassment occurring in their workplaces. Uninformed adages still abound: "It's something you have to put up with" or "Bullying toughens you up" or "He's gone mad".

Thankfully, one does not hear the same being openly said to targets of repeated sexual abuse or domestic violence, even though they are all forms of bullying.

Employers that use bullying as a substitute for leadership and management, and therefore not only tolerate but rely upon bullying for their existence, typically pounce upon any stress related illness in a bullied employee as a sign of mental weakness, discrediting any allegation they may have made, blaming the victim for their situation and, according to their records, absolving the bully and employer of any responsibility.

Mapping the health effects of bullying onto PTSD

Workplace Bullying can result in symptoms of Post Traumatic Stress Disorder. How does a typical workplace bullying experience and its effects relate to the ICD-10 criteria for diagnosing PTSD?

A. The prolonged (chronic) negative stress resulting from bullying has lead to threat of loss of job, career, health, livelihood, often also resulting in threat to marriage and family life. The family are the unseen victims of bullying.
A.1.One of the key symptoms of prolonged negative stress is reactive depression; this causes the balance of the mind to be disturbed, leading first to thoughts of, then attempts at, and ultimately, suicide.
A.2.The target of bullying may be unaware that they are being bullied, and even when they do realise (there's usually a moment of enlightenment as the person realises that the criticisms and tactics of control etc are invalid), they often cannot bring themselves to believe they are dealing with a disordered personality who lacks a conscience and does not share the same moral values as themselves. Naivety is the great enemy. The target of bullying is bewildered, confused, frightened, angry - and after enlightenment, very angry. For an answer to the question Why me? click here.

B.1. The target of bullying experiences regular intrusive violent visualisations and replays of events and conversations; often, the endings of these replays are altered in favour of the target.
B.2. Sleeplessness, nightmares and replays are a common feature of being bullied.
B.3. The events are constantly relived; night-time and sleep do not bring relief as it becomes impossible to switch the brain off. Such sleep as is achieved is non-restorative and people wake up as tired, and often more tired, than when they went to bed.
B.4. Fear, horror, chronic anxiety, and panic attacks are triggered by any reminder of the experience, eg receiving threatening letters from the bully, the employer, or personnel about disciplinary hearings etc.
B.5. Panic attacks, palpitations, sweating, trembling, ditto. Criteria B4 and B5 manifest themselves as immediate physical and mental paralysis in response to any reminder of the bullying or prospect of having to take action against the bully.

C. Physical numbness (toes, fingertips, lips) is common, as is emotional numbness (especially inability to feel joy). Sufferers report that their spark has gone out and, even years later, find they just cannot get motivated about anything.
C.1. The target of bullying tries harder and harder to avoid saying or doing anything which reminds them of the horror of the bullying.
C.2. Work, especially in the person's chosen field becomes difficult, often impossible, to undertake; the place of work holds such horrific memories that it becomes impossible to set foot on the premises; many targets of bullying avoid the street where the workplace is located.
C.3. Almost all callers to the UK National Workplace Bullying Advice Line report impaired memory; this may be partly due to suppressing horrific memories, and partly due to damage to the hippocampus, an area of the brain linked to learning and memory (see John O'Brien's paper below)
C.4. the person becomes obsessed with resolving the bullying experience which takes over their life, eclipsing and excluding almost every other interest.
C.5. Feelings of withdrawal and isolation are common; the person just wants to be on their own and solitude is sought.
C.6. Emotional numbness, including inability to feel joy (anhedonia) and deadening of loving feelings towards others are commonly reported. One fears never being able to feel love again.
C.7. The target of bullying becomes very gloomy and senses a foreshortened career - usually with justification. Many targets of bullying ultimately give up their career; in the professions, severe psychiatric injury, severely impaired health, refusal by the bully and the employer to give a satisfactory reference, and many other reasons, conspire to bar the person from continuance in their chosen career.

D.1. Sleep becomes almost impossible, despite the constant fatigue; such sleep as is obtained tends to be unsatisfying, unrefreshing and non-restorative. On waking, the person often feels more tired than when they went to bed. Depressive feelings are worst early in the morning. Feelings of vulnerability may be heightened overnight.
D.2. The person has an extremely short fuse and is often permanently irritated, especially by small insignificant events. The person frequently visualises a violent solution, eg arranging an accident for, or murdering the bully; the resultant feelings of guilt tend to hinder progress in recovery.
D.3. Concentration is impaired to the point of precluding preparation for legal action, study, work, or search for work.
D.4. The person is on constant alert because their fight or flight mechanism has become permanently activated.
D.5. The person has become hypersensitized and now unwittingly and inappropriately perceives almost any remark as critical.

E. Recovery from a bullying experience is measured in years. Some people never fully recover.

F. For many, social life ceases and work becomes impossible; the overwhelming need to earn a living combined with the inability to work deepens the trauma.

Common symptoms of PTSD and Complex PTSD that sufferers report experiencing

  • hypervigilance (feels like but is not paranoia)
  • exaggerated startle response
  • irritability
  • sudden angry or violent outbursts
  • flashbacks, nightmares, intrusive recollections, replays, violent visualisations
  • triggers
  • sleep disturbance
  • exhaustion and chronic fatigue
  • reactive depression
  • guilt
  • feelings of detachment
  • avoidance behaviours
  • nervousness, anxiety
  • phobias about specific daily routines, events or objects
  • irrational or impulsive behaviour
  • loss of interest
  • loss of ambition
  • anhedonia (inability to feel joy and pleasure)
  • poor concentration
  • impaired memory
  • joint pains, muscle pains
  • emotional numbness
  • physical numbness
  • low self-esteem
  • an overwhelming sense of injustice and a strong desire to do something about it

Associated symptoms of Complex PTSD

Survivor guilt: survivors of disasters often experience abnormally high levels of guilt for having survived, especially when others - including family, friends or fellow passengers - have died. Survivor guilt manifests itself in a feeling of "I should have died too". In bullying, levels of guilt are also abnormally raised. The survivor of workplace bullying may have develop an intense albeit unrealistic desire to work with their employer (or, by now, their former employer) to eliminate bullying from their workplace. Many survivors of bullying cannot gain further employment and are thus forced into self-employment; excessive guilt may then preclude the individual from negotiating fair rates of remuneration, or asking for money for services rendered. The person may also find themselves being abnormally and inappropriately generous and giving in business and other situations.

Shame, embarrassment, guilt, and fear are encouraged by the bully, for this is how all abusers - including child sex abusers - control and silence their victims.

Marital disharmony: the target of bullying becomes obsessed with understanding and resolving what is happening and the experience takes over their life; partners become confused, irritated, bewildered, frightened and angry; separation and divorce are common outcomes.

Breakdown

The word "breakdown" is often used to describe the mental collapse of someone who has been under intolerable strain. There is usually an (inappropriate) inference of "mental illness". All these are lay terms and mean different things to different people. I define two types of breakdown:

  • Nervous breakdown or mental breakdown is a consequence of mental illness
  • Stress breakdown is a psychiatric injury, which is a normal reaction to an abnormal situation

The two types of breakdown are distinct and should not be confused. A stress breakdown is a natural and normal conclusion to a period of prolonged negative stress; the body is saying "I'm not designed to operate under these conditions of prolonged negative stress so I am going to do something dramatic to ensure that you reduce or eliminate the stress otherwise your body may suffer irreparable damage; you must take action now". A stress breakdown is often predictable days - sometimes weeks - in advance as the person's fear, fragility, obsessiveness, hypervigilance and hypersensitivity combine to evolve into paranoia (as evidenced by increasingly bizarre talk of conspiracy or MI6). If this happens, a stress breakdown is only days or even hours away and the person needs urgent medical help. The risk of suicide at this point is heightened.

Often the cause of negative stress in an organisation can be traced to the behaviour of one individual. The profile of this individual is on the serial bully page. I believe bullying is the main - but least recognised - cause of negative stress in the workplace today. To see the effects of prolonged negative stress on the body click here.

The person who suffers a stress breakdown is often treated as if they have had a mental breakdown; they are sent to a psychiatrist, prescribed drugs used to treat mental illness, and may be encouraged - sometimes coerced or sectioned - into becoming a patient in a psychiatric hospital. The sudden transition from professional working environment to a ward containing schizophrenics, drug addicts and other people with genuine long-term mental health problems adds to rather than alleviates the trauma. Words like "psychiatrist", "psychiatric unit" etc are often translated by work colleagues, friends, and sometimes family into "nutcase", "shrink", "funny farm", "loony" and other inappropriate epithets. The bully encourages this, often ensuring that the employee's personnel record contains a reference to the person's "mental health problems". Sometimes, the bully produces their own amateur diagnosis of mental illness - but this is more likely to be a projection of the bully's own state of mind and should be regarded as such.

During the First World War, British soldiers suffering PTSD and stress breakdown were labelled as "cowards" and "deserters". During the Second World War, soldiers suffering PTSD and stress breakdowns were again vilified with these labels; Royal Air Force personnel were labelled as "lacking moral fibre" and their papers stamped "LMF". It's noticeable that those administrators and top brass enforcing this labelling were themselves always situated a safe distance from the fighting; see the section on projection.

The person who is being bullied often thinks they are going mad, and may be encouraged in this belief by those who do not have that person's best interests at heart. They are not going mad; PTSD is an injury, not an illness.

Sometimes, the term "psychosis" is applied to mental illness, and the term "neurosis" to psychiatric injury. The main difference is that a psychotic person is unaware they have a mental problem, whereas the neurotic person is aware - often acutely. The serial bully's lack of insight into their behaviour and its effect on others has the hallmarks of a psychosis, although this obliviousness would appear to be a choice rather than a condition. With targets of bullying, I prefer to avoid the words "neurosis" and "neurotic", which for non-medical people have derogatory connotations. Hypersensitivity and hypervigilance are likely to cause the person suffering PTSD to react unfavourably to the use of these words, possibly perceiving that they, the target, are being blamed for their circumstances.

A frequent diagnosis of stress breakdown is "brief reactive psychosis", especially if paranoia and suicidal thoughts predominate. However, a key difference between mental breakdown and stress breakdown is that a person undergoing a stress breakdown will be intermittently lucid, often alternating seamlessly between paranoia and seeking information about their paranoia and other symptoms. The person is also likely to be talking about resolving their work situation (which is the cause of their problems), planning legal action against the bully and the employer, wanting to talk to their union rep and solicitor, etc.

Transformation

A stress breakdown is a transformational experience which, with the right support, can ultimately enrich the experiencer's life. However, completing the transformation can be a long and sometimes painful process. The Western response - to hospitalise and medicalize the experience, thus hindering the process - may be well-intentioned, but may lessen the value and effectiveness of the transformation. How would you feel if, rather than a breakdown, you viewed it as a breakthrough? How would you feel if it was suggested to you that the reason for a stress breakdown is to awaken you to your mission in life and to enable you to discover the reason why you have incarnated on this planet? How would it change your view of things if it was also suggested to you that a stress breakdown reconfigures your brain to enable you to embark on the path that will culminate in the achievement of your mission? [More | More]

Differences between mental illness and psychiatric injury

The person who is being bullied will eventually say something like "I think I'm being paranoid..."; however they are correctly identifying hypervigilance, a symptom of PTSD, but using the popular but misunderstood word paranoia. The differences between hypervigilance and paranoia make a good starting point for identifying the differences between mental illness and psychiatric injury.

Paranoia

Hypervigilance

paranoia is an aspect of a mental illness, where the cause is thought to be internal, eg a minor variation in the balance of brain chemistry is a response to an external event (violence, accident, disaster, violation, intrusion, bullying, etc) and therefore an injury
paranoia tends to endure and to not get better of its own accord wears off (gets better), albeit slowly, when the person is out of and away from the situation which was the cause
the paranoiac will not admit to feeling paranoid, as they cannot see their paranoia the hypervigilant person is acutely aware of their hypervigilance, and will easily articulate their fear, albeit using the incorrect but popularised word "paranoia"
sometimes responds to drug treatment drugs are not viewed favourably by hypervigilant people, except in extreme circumstances, and then only briefly; often drugs have no effect, or can make things worse, sometimes interfering with the body's own healing process
There is no objectively rational, plausible explanation or evidence of the cause of paranoid fears of  
The paranoid person's fears are based on something that does not exist, and therefore cannot be supported by evidence. The beliefs may be clearly irrational or implausible, although a sincere listener may be convinced initially that there is a cause for concern. The paranoid person will likely have an unswerving belief that what they are saying is irrefutably true, but will resist inquiries for evidence to demonstrate the truth of their beliefs, and shun the person making such inquiries. There is an objectively rational, plausible explanation and/or evidence to justify a hypervigilant person's concerns, even if those concerns may seem exaggerated to someone who has not been through/is not going through the same experience.
paranoia is often seen in conjunction with other symptoms of mental illness, but not in conjunction with symptoms of PTSD hypervigilance is seen in conjunction with other symptoms of PTSD, but not in conjunction with symptoms of mental illness
the paranoiac is convinced of their plausibility the hypervigilant person is aware of how implausible their experience sounds and often doesn't want to believe it themselves (disbelief and denial)
the paranoiac feels persecuted by a person or persons unknown (eg "they're out to get me") the hypervigilant person is hypersensitized but is often aware of the inappropriateness of their heightened sensitivity, and can identify the person responsible for their psychiatric injury
sense of persecution heightened sense of vulnerability to victimisation
the sense of persecution felt by the paranoiac is a delusion, for usually no-one is out to get them the hypervigilant person's sense of threat is well-founded, for the serial bully is out to get rid of them and has often coerced others into assisting, eg through mobbing; the hypervigilant person often cannot (and refuses to) see that the serial bully is doing everything possible to get rid of them
the paranoiac is on constant alert because they know someone is out to get them the hypervigilant person is on alert in case there is danger
the paranoiac is certain of their belief and their behaviour and expects others to share that certainty the hypervigilant person cannot bring themselves to believe that the bully cannot and will not see the effect their behaviour is having; they cling naively to the mistaken belief that the bully will recognise their wrongdoing and apologise

 

Other differences between mental illness and psychiatric injury include:

Mental illness

Psychiatric injury

the cause often cannot be identified the cause is easily identifiable and verifiable, but denied by those who are accountable
the person may be incoherent or what they say doesn't make sense the person is often articulate but prevented from articulation by being traumatised
the person may appear to be obsessed the person is obsessive, especially in relation to identifying the cause of their injury and both dealing with the cause and effecting their recovery
the person is oblivious to their behaviour and the effect it has on others the person is in a state of acute self-awareness and aware of their state, but often unable to explain it
the depression is a clinical or endogenous depression the depression is reactive; the chemistry is different to endogenous depression
there may be a history of depression in the family there is very often no history of depression in the individual or their family
the person has usually exhibited mental health problems before often there is no history of mental health problems
may respond inappropriately to the needs and concerns of others responds empathically to the needs and concerns of others, despite their own injury
displays a certitude about themselves, their circumstances and their actions is often highly sceptical about their condition and circumstances and is in a state of disbelief and bewilderment which they will easily and often articulate ("I can't believe this is happening to me" and "Why me?" )
may suffer a persecution complex may experience an unusually heightened sense of vulnerability to possible victimisation (ie hypervigilance)
suicidal thoughts are the result of despair, dejection and hopelessness suicidal thoughts are often a logical and carefully thought-out solution or conclusion
exhibits despair is driven by the anger of injustice
often doesn't look forward to each new day looks forward to each new day as an opportunity to fight for justice
is often ready to give in or admit defeat refuses to be beaten, refuses to give up

Common features of Complex PTSD from bullying

People suffering Complex PTSD as a result of bullying report consistent symptoms which further help to characterise psychiatric injury and differentiate it from mental illness. These include:

  • Fatigue with symptoms of or similar to Chronic Fatigue Syndrome (formerly ME) An anger of injustice stimulated to an excessive degree (sometimes but improperly attracting the words "manic" instead of motivated, "obsessive" instead of focused, and "angry" instead of "passionate", especially from those with something to fear)
  • An overwhelming desire for acknowledgement, understanding, recognition and validation of their experience
  • A simultaneous and paradoxical unwillingness to talk about the bullying or abuse
  • A lack of desire for revenge, but a strong motivation for justice
  • A tendency to oscillate between conciliation (forgiveness) and anger (revenge) with objectivity being the main casualty
  • Extreme fragility, where formerly the person was of a strong, stable character
  • Numbness, both physical (toes, fingertips, and lips) and emotional (inability to feel love and joy)
  • Clumsiness
  • Forgetfulness
  • Hyperawareness and an acute sense of time passing, seasons changing, and distances travelled
  • An enhanced environmental awareness, often on a planetary scale
  • An appreciation of the need to adopt a healthier diet, possibly reducing or eliminating meat - especially red meat
  • Willingness to try complementary medicine and alternative, holistic therapies, etc
  • A constant feeling that one has to justify everything one says and does
  • A constant need to prove oneself, even when surrounded by good, positive people
  • An unusually strong sense of vulnerability, victimisation or possible victimisation, often wrongly diagnosed as "persecution"
  • Occasional violent intrusive visualisations
  • Feelings of worthlessness, rejection, a sense of being unwanted, unlikeable and unlovable
  • A feeling of being small, insignificant, and invisible
  • An overwhelming sense of betrayal, and a consequent inability and unwillingness to trust anyone, even those close to you
  • In contrast to the chronic fatigue, depression etc, occasional false dawns with sudden bursts of energy accompanied by a feeling of "I'm better!", only to be followed by a full resurgence of symptoms a day or two later
  • Excessive guilt - when the cause of PTSD is bullying, the guilt expresses itself in forms distinct from "survivor guilt"; it comes out as:
    • an initial reluctance to take action against the bully and report him/her knowing that he/she could lose his/her job
    • later, this reluctance gives way to a strong urge to take action against the bully so that others, especially successors, don't have to suffer a similar fate
    • reluctance to feel happiness and joy because one's sense of other people's suffering throughout the world is heightened
    • a proneness to identifying with other people's suffering
    • a heightened sense of unworthiness, undeservingness and non-entitlement (some might call this shame)
    • a heightened sense of indebtedness, beholdenness and undue obligation
    • a reluctance to earn or accept money because one's sense of poverty and injustice throughout the world is heightened
    • an unwillingness to take ill-health retirement because the person doesn't want to believe they are sufficiently unwell to merit it
    • an unwillingness to draw sickness, incapacity or unemployment benefit to which the person is entitled
    • an unusually strong desire to educate the employer and help the employer introduce an anti-bullying ethos, usually proportional to the employer's lack of interest in anti-bullying measures
    • a desire to help others, often overwhelming and bordering on obsession, and to be available for others at any time regardless of the cost to oneself
    • an unusually high inclination to feel sorry for other people who are under stress, including those in a position of authority, even those who are not fulfilling the duties and obligations of their position (which may include the bully) but who are continuing to enjoy salary for remaining in post [hint: to overcome this tendency, every time you start to feel sorry for someone, say to yourself "sometimes, when you jump in and rescue someone, you deny them the opportunity to learn and grow"]

Fatigue

The fatigue is understandable when you realise that in bullying, the target's fight or flight mechanism eventually becomes activated from Sunday evening (at the thought of facing the bully at work on Monday morning) through to the following Saturday morning (phew - weekend at last!). The fight or flight mechanism is designed to be operational only briefly and intermittently; in the heightened state of alert, the body consumes abnormally high levels of energy. If this state becomes semi-permanent, the body's physical, mental and emotional batteries are drained dry. Whilst the weekend theoretically is a time for the batteries to recharge, this doesn't happen, because:

  • the person is by now obsessed with the situation (or rather, resolving the situation), cannot switch off, may be unable to sleep, and probably has nightmares, flashbacks and replays;
  • sleep is non-restorative and unrefreshing - one goes to sleep tired and wakes up tired
  • this type of experience plays havoc with the immune system; when the fight or flight system is eventually switched off, the immune system is impaired such that the person is open to viruses which they would under normal circumstances fight off; the person then spends each weekend with a cold, cough, flu, glandular fever, laryngitis, ear infection etc so the body's batteries never have an opportunity to recharge.

When activated, the body's fight or flight response results in the digestive, immune and reproductive systems being placed on standby. It's no coincidence that people experiencing constant abuse, harassment and bullying report malfunctions related to these systems (loss of appetite, constant infections, flatulence, irritable bowel syndrome, loss of libido, impotence, etc). The body becomes awash with cortisol which in high prolonged doses is toxic to brain cells. Cortisol kills off neuroreceptors in the hippocampus, an area of the brain linked with learning and memory. The hippocampus is also the control centre for the fight or flight response, thus the ability to control the fight or flight mechanism itself becomes impaired.

Most survivors of bullying experience symptoms of Chronic Fatigue Syndrome - see health page for details.

Legal

In law, gaining compensation for psychiatric injury is a long arduous process which can take years. As years have passed, legal precedents have been made and then reversed with case after life-changing case. The Tim Field Foundation is not in a position to maintain up-to-date information on bullying as it relates to personal injury law. Please contact a personal injury specialist for advice or, if you believe you have been subjected to criminal abuse, report it to the Police.

One of the factors that make it so difficult to win a compensation claim for pyschiatric injury is that the respondent to the claim can, and is highly likely to have the claimant examined by a psychiatrist of their choosing, who will dismiss the notion of post-traumatic stress disorder and claim, instead, testify that the claimant has some other underlying mental illness.

Incidence of PTSD and Complex PTSD

The number of people suffering PTSD is unknown but David Kinchin estimates in his book Post Traumatic Stress Disorder: the invisible injury that at any time around 1% of the population are experiencing PTSD. This figure is only for PTSD resulting from traditional causes such as accident, violence or disaster.

The incidence of Complex PTSD is unknown; with estimates of the number of people being bullied at work in the UK ranging from 1 in 8 (IPD, November 1996) to 1 in 2 (Staffordshire University Business School, 1994).

Useful Books

Post Traumatic Stress Disorder: the invisible injury, 2005 edition, David Kinchin

Supporting Children with Post-traumatic Stress Disorder: a practical guide for teachers and professionals, David Kinchin and Erica Brown

Stress and employer liability, Earnshaw & Cooper, IPD, 1996

Why zebras don't get ulcers: an updated guide to stress, stress-related diseases, and coping, Robert M Sapolsky

The Body Bears the Burden: Trauma, Dissociation and Disease, Robert C Scaer, MD

Recovering damages for psychiatric injury, M Napier & K Wheat

Understanding stress breakdown, Dr William Wilkie, Millennium Books, 1995

Understanding stress, V Sutherland & C Cooper, Chapman and Hall

Trauma and transformation: growing in the aftermath of suffering, R Tedeschi & L Calhoun, Sage, 1996

The Railway Man, Eric Lomax (a poignant story of undiagnosed PTSD from World War II)

Articles

US soldiers return from Iraq with PTSD

Untreated PTSD may mean a lifetime of impoverished physical health including heart disease and cancer

Bullied workers suffer 'battle stress' and show the same symptoms of armed forces personnel who have been engaged in war:

National Center for PTSD articles:

National Center for PTSD factsheet

Lifestyle Changes Recommended for PTSD Patients

Anger and trauma

NICE guidelines for PTSD:

Dave Baldwin's trauma information pages contain comprehensive links.

Pre-action protocol for disease/illness claims

Post-Traumatic Stress Disorder is covered on the Mental Health Network

The Healing Centre Online

Information on Falsification of Type (Dr Carl Gustav Jung's description for an individual whose most developed and/or used skills were outside one’s area of greatest natural preference) and PASS (Prolonged Adaption Stress Syndrome) is at http://www.benziger.org/articles/physfalsoftype.php

Rebecca Coffey's PTSD bibliography

PTSD Association of Canada

Gillian Kelly, barrister at law, looks at the development of Post Traumatic Stress Disorder and the legal recognition thereof on her web site

The Highly Sensitive Person (HSP)

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