"Debbie" escaped the daily beatings, insults and threats of an abusive relationship more than 10 years ago, but when her 3-year-old son hits her sometimes, the emotions come flooding back.
Debbie, who asked that her name not be used because her abuser still stalks her, understands intellectually that her son means no harm — but because she suffers from post-traumatic stress disorder, her nerves and emotions can be hard to control.
"I was beaten every day for four years of my life, and it was years ago, but it still seems to affect everything I do," she said. "My son, I know he's just rambunctious, but when he hits, sometimes I feel my PTSD coming out."
Debbie, who lives in Vancouver, was diagnosed with the illness in 2000 and has done some psychotherapy and group therapy; but because of the prolonged situation that caused her PTSD, it will be difficult for her to completely heal, her psychologist has told her.
As a civilian suffering from PTSD, she's far from alone.
According to the National Center for PTSD, which is run by the Department of Veterans Affairs, between 7 percent and 8 percent of the general population — not just veterans — will experience PTSD at some point in their lives.
Women are more likely to develop it than men, with about 10 percent developing the disorder, compared with 5 percent of men.
"PTSD is a much bigger public health issue than just affecting veterans," said Matt Friedman, director of the center, which was founded in 1984 and opened in 1989.
The agency's goal is to lead research and education about the disorder for both the military and the general public.
About 5.2 million adults in the United States suffer from PTSD at any given time, but there are a lot of misconceptions about what the illness is and what segments of the population are afflicted with it, Friedman said.
"I think we need to do a lot more in the civilian sector," Friedman said. "The first order of business is to educate the public."
PTSD became an officially recognized condition in 1980, but it's been around as long as there have been humans. In the Civil War, it was called "soldier's heart"; in World War I, "combat fatigue"; in World War II, "gross stress reaction."
It's also been called "post-Vietnam syndrome," "battle fatigue," "accident neurosis" and "shell shock." But it all comes down to a similar set of symptoms triggered by a traumatic event or events that threaten a person's survival or integrity.
For those who have it, stress from the incident continues long after and is re-experienced in a variety of ways.
Cycles and patterns
In general, symptoms of PTSD include recurring nightmares, panic attacks or flashbacks where a person feels like they're reliving the traumatic situation. Sometimes, the person shuts down emotionally or goes to great lengths to avoid situations similar to the original trauma. And many PTSD sufferers feel jumpy or startle easily and end up in a heightened state of alert called hyperarousal.
"I feel like I'm constantly paranoid," Debbie said. "I've been married for three years, but it's affected my relationship. It's hard."
When the phone rings, or there's a loud noise, or sometimes even just a knock at the door, Debbie gets a jolt of adrenaline and feels her heart start to pound. Some part of her feels that her abuser could come back at any moment.
In essence, the disease triggers a fight-or-flight response in the nervous system.
Even when Debbie tries to intellectualize her way out of it, the fearful thoughts are hard to stop. Her mind cycles obsessively through what might come next, as she considers the best hiding spots and what can she do to defend herself.
That's part of the destructive power of the disorder. It leaves the sufferer in constant survival mode, said David B. Harris, a Vancouver licensed clinical social worker.
"The trauma that they experienced in the past is not in the past for people with PTSD," Harris said. "They experience it today the same as they may have 20 years ago."
Sometimes, a familiar-looking place or unusual smell will trigger a memory of the trauma and cause symptoms, he said.
"Frequently, they're not at all aware even of what it was that set them off," Harris said.
And all of that makes it hard for sufferers to create normal lives without help, he said.
"PTSD can wreak havoc in things in life that are very common, like relationships," Harris said. "They can have a very difficult time sustaining long-term relationships, which isn't surprising if you consider things like numbing, hyperarousal and other things they may do to protect themselves."
The severity of symptoms also varies. Some sufferers may only have a few problems, like jumping at strange sounds or avoiding something that triggers the trauma, like a darkened hallway. Others may have full-blown flashbacks to the traumatic event and abuse substances to make themselves feel more numb.
"A variety of factors could be behind it, if there's no early intervention, if the trauma goes on for a long time it can become more complicated," Harris said. "And part of (why PTSD occurs) can be biology. It's not always a weakness. People who tend to be more compassionate than most tend to be at risk, and I'm not sure anybody would consider that a weakness."
Searching for a cause
The illness can develop from a wide range of trauma experienced at any phase of life. Combat exposure is just one trigger. Things like disaster situations, car wrecks, physical abuse, emotional abuse or neglect can also lead to PTSD.
"In female clients, I tend to see it much more from sexual abuse, although it can also be from sexual assault," Harris said. "With males, it tends to be more from physical violence."
As part of its mission, the National Center for PTSD has been compiling information and learning more about how the disease works and why some people suffer from it while others who went through similar experiences do not, Friedman said.
More than half of all adults have been exposed to trauma at some point in their lives, yet only about 7 or 8 percent develop PTSD.
There aren't many statistics available on PTSD in children. One 2003 study, using data from the National Survey of Adolescents, estimated that the PTSD rate was 3.7 percent for boys and 6.3 percent for girls in any six-month span, which is a much lower percentage than those who experience sexual, physical or other trauma.
It's still unclear why some people are more prone than others. It could be physiological, biological, psychological or even genetic — or a combination of those factors, he said.
"The research has gotten into very basic issues of stress," Friedman said. "The human stress response is altered in people with PTSD."
Rates for PTSD are higher for certain types of trauma survivors. Almost 100 percent of kids who see a parent killed or witness a sexual assault will develop PTSD. The rates are about 90 percent for sexually abused children, 77 percent for those who see a school shooting and 35 percent who see violence where they live, according to the National Center for PTSD.
Having strong social support, good personal coping mechanisms and being an optimist are all factors that seem to make people more resistant to developing the illness.
"Most people who are exposed to a traumatic event don't develop PTSD," Friedman said. "There's a lot to learn, but there are many things that contribute to resilience."
On the flip side, past trauma, poor family support and other factors can make people more susceptible, Friedman said.
Of course, severity of symptoms varies from person to person, and treatment isn't one size fits all, either.
"There's a lot of treatment research going on right now," Friedman said. "If both you and I have PTSD, might one treatment help you more than me?"
Combinations of treatments and better drugs have made fighting the disorder more effective. But there are still a lot of misconceptions about it in the public eye.
One thing to keep in mind, especially, is that it is reversible with psychotherapy and/or medication in most patients, he said.
And the center has several online tools and even a few iPhone applications to help people self-diagnose and determine if they need more help.
Still, PTSD, like most mental illnesses, is poorly understood by the public, which can stop people from looking for help.
"We know there's a stigma about psychiatric problems in general, not just PTSD," Friedman said. "We've been very concerned in VA and DOD (The Department of Defense) about whether having a mental health label is going to be a barrier to people seeking help."
Sufferers may fear that employers, friends or family will have a negative view of them if they are diagnosed. That image is further complicated when only severe cases of military PTSD are reported in the news, because people end up associating the disorder with violence.
"Some people think that people are dangerous that have it," Harris said. "In the proper settings, people can have flashbacks, but I don't think people with PTSD are any more or less dangerous than anybody else."
Insurance companies won't always pay for treatment for less severe cases, either. If a patient doesn't meet the full criteria, companies can use that as an excuse to deny treatment, Harris said.
And even if treatment is covered by insurance, the co-payments can add up fast — especially considering treatment is most effective when it's done on a regular, at least weekly, basis.
"Last year on our insurance, it was $20 a week to see a psychologist — but the co-pay went up," Debbie said. "This year, it's $40 a week. I was supposed to go every week, but I had to cut back to every two, because it got too expensive. And really, it's hard to afford it at all."
The expense can further complicate things for patients who already have a problem with avoiding help, Harris added.
"In one of the symptom clusters, there's a factor of numbing, which also includes avoidance and avoiding talking about the incident," Harris said. "So one of the symptoms is to avoid getting help."
That could be an indication that post-traumatic stress is even more widespread than some studies suggest, he said.
"We only know people that in some way get assessed," Harris said. "I'd say as a whole, it's underreported because of that symptom of avoidance."
There are also probably a lot of people wandering around who don't realize they're experiencing symptoms of PTSD, he said.
"What they would probably subjectively report is that they knew something was wrong but they didn't know quite what it was," Harris said. "As far as they know, everybody might be on guard all the time like they feel."
Addiction rates are also high in people who have PTSD.
Substance abuse tends to fall in two categories for sufferers. One category is stimulants, like meth and cocaine, which recreate the physical jolt of the stress of the original trauma.
"They're addicted to the trauma, in a way," Harris said. "The brain gets juiced up from the neurotransmitters and they get addicted to the norepinephrine. It's also part of a compulsive self-destructive element."
The other category is opiates and alcohol, which tend to go with the desire for numbing emotional connections to the event, he said.
Despite that knowledge, though, drug treatment and community health centers often don't screen for PTSD as a co-occurring disorder, Harris said.
"I wish they'd get in and do more screening for it — if you get help early on you can get through it more easily and get back to a normal range of life," Harris said.