A long-term patient of mine (who we’ll call Michael) is a combat medic with multiple combat deployments under his belt. When he started treatment with me, he already carried a Posttraumatic Stress Disorder (PTSD) diagnosis – a diagnosis that was spot-on. After we had been working together for several months, Michael was clearly agitated when he came in for his scheduled follow-up. He explained that he had gone into a well-known big box store to return an item. In comedically colorful language, he explained that another driver almost t-boned him on his way to the store, people were walking uncomfortably close to his car in the store’s parking lot, and he crossed paths with some questionable-looking characters as he walked into the store.
By the time he reached the greeter’s podium, he was perspiring and tight-chested. The greeter apparently blew him off, but when Michael attempted to walk past the greeter, the greeter stopped Michael by grabbing him by the shoulder. At this precise moment, approximately 82 of Michael’s brain cells imploded. He went into a blind rage – screaming in the greeter’s face and threatening to annihilate him.
“I’m losing it, doc,” Michael said to me – not even attempting to hide his fear.
Michael’s story is a common story among my military patients with PTSD. And yet, they all think they’re “crazy” or “losing it.” In psychology, it’s common for providers to say, “It’s a normal response to an abnormal situation,” and unbeknownst to folks with PTSD, it’s their daily reality.
It’s like this: The average person walks around with a subconscious threat-management radar operating at all times. If they’re having a picnic in the forest and a bear approaches them, they immediately spring into action and run (or whatever it is you do if you’re unfortunate enough to come face-to-face with a bear). They don’t sit and think, “Hmm. I wonder if that fury mammal will chew on my head?” This is the basis of fight/flight/freeze. Our radar detects threat, and we respond. It’s the same if we’re walking along a city sidewalk and a car comes careening toward us or if we’re standing in a bank when a masked man with a gun yells for everyone to get on the floor.
The threat-management radar of the average person is set at a specificity level to immediately detect clear and overt threat – like the radar-equivalent of a missile.
A person with PTSD, however, has the sensitivity of their threat-management radar turned up as high as it will go. They’re no longer just detecting missiles. They’re detecting mosquitos.
Why? PTSD is, as its name states, a trauma-based disorder. It is the result of exposure to a trauma event that threatens life or limb, and the research suggests that exposures to multiple traumatic events exponentially potentiates the development of full-blown PTSD. Subsequent to these traumatic events, the person’s thoughts and beliefs about the world, themselves, and others changes. They may come to believe that the world isn’t a safe place or that people can’t be trusted or that if only they had done X, the trauma wouldn’t have occurred.
These changes lead and/or run parallel to hypervigilance (i.e., hyper-awareness of and hyper-sensitivity to one’s surroundings and its changes, and exaggerated reactions designed to manage one’s surroundings and its changes). In other words, the person with PTSD is likely to study people in their environment, notice exits (aka: escape routes), want full visibility of their surroundings, notice and investigate noises of unknown origins, etc. This is their radar operating in the hyper-sensitive mode. They’re detecting mosquitos and interpreting benign stimuli (e.g., noise, movement) as potentially threatening.
And their history tells them that they need to be ready to respond, because nonresponse can be the difference between life and death.
Now, this super-human radar setting may be periodically useful to a law enforcement officer…or a person sitting in a movie theater who hears the sound of a shotgun being cocked. But it can lead to malfunction in daily living – at a big box store, at work, sitting at home. This person’s responses to common situations are often disproportionate to the actual threat probability. People around them might view them as over-reacting or may start tip-toeing around the person’s “temper.”
The tragedy of this is that the individual with PTSD – as well as their friends, family, and colleagues – often have no idea what’s really going on, which results in the individual with PTSD feeling “other”…disenfranchised from society…standing on the outside looking in.
And let me assure you: living a life with a threat-management radar set on high sensitivity is exhausting (and unpleasant). This, unfortunately – but understandably, leads many individuals with PTSD to seek relief from the constant barrage of noise and movement and threat – whether through substance use, ‘leaning into’ threat by engaging in risky, adrenaline-fueled behaviors, or any other behavior that soothes them and allows their mind to escape and rest.
I explained all of this to Michael, and he was dumbfounded that someone could put words to a reality he’s been trapped in for years. I told him that it’s important that he starts taking mental inventories of the various stimuli coming at him at any given time – the radio blaring, the drivers cutting him off, the firetrucks blasting by with their sirens on, his son trying to talk to him, etc. Michael needs to not only take a conscious inventory of incoming stimuli, but he needs to actively manage stimuli (e.g., turn off the radio, tell his son he’ll talk to him when they get home). And on the days that he doesn’t succeed at his stimuli inventory or managing incoming stimuli, he needs to make conscious decisions about what he can and can’t adaptively do at the moment. (For example, by the time Michael walked in the big box store and encountered the greeter, he was already perspiring and tight-chested. It was unlikely that he was going to handle any other hiccups well.)
To be clear, I’m not suggesting outright avoidance, as avoidance can be the death-spiral of PTSD. Rather, what I’m suggesting is that strategic adaptations are not only wise, but can ensure maintained functionality. I’d rather Michael start going to a different, calmer big box store than end up in jail for assault or murder. I’d rather that another of my patients sets limits with his wife on when he can or can’t adaptively have a conversation, as opposed to ending up a divorced alcoholic and absent father.
Today, Michael is working on taking continuous mental inventories of his surroundings, setting limits when feeling overwhelmed, communicating these needs and strategies to his loved ones, and not seeing every situation or person as a threat. Michael is still a work in progress, but ‘progress’ is the operative word. Michael doesn’t spend as much time today perseverating on beliefs that he’s “crazy” or beliefs that he should forever be alone to protect others from his “crazy.” The world may still feel like a threatening place to Michael, but now he understands and can articulate why – which makes him feel a little more in control of his world. At his last appointment, Michael told me that he started opening his blinds every day, that he hung up motivational posters in his home gym, that he got a flower for his house, that he started having light saber wars with his son, and that he started dating a woman – despite nagging (but increasingly quieter) beliefs that she’ll eventually reject his “crazy.” Michael is now living – one little step at a time, but by god, he’s living.
Joye Henrie, PhD