A look at the causes and experiences of post traumatic stress disorder, and ways women may experience PTSD.
Women are twice as likely to develop PTSD as compared to men, and are more likely to blame themselves and develop depression afterwards (VA, n.d.).
There are unfortunate reasons for this, which we'll get into below. The good news is that there are effective treatments, and many people can find relief from symptoms. Here’s a closer look at what PTSD is, how it’s diagnosed, how it impacts women specifically, and what treatments may help.
Article Highlights
What is Post-Traumatic Stress Disorder (PTSD)?
PTSD refers to a combination of experiences that some people experience following a trauma. The symptoms may start immediately after the trauma, several weeks later, or in some cases months or years later.
They center around fears that the trauma, or a similar event, is likely to occur again.
Many people who experience a trauma don't develop PTSD. Experts believe PTSD develops when someone has difficulty making sense of a trauma, resulting in them having a hard time feeling safe again. They have trouble adjusting back to everyday life.
The major symptom categories of PTSD (post-traumatic stress disorder) in general include the following:
Intrusive memories of a trauma
Avoiding thoughts and memories about what happened
Feeling on edge
Having strong negative thoughts about yourself and the world
People with PTSD often have unrealistic fears that something similar will happen again (even against all evidence to the contrary), or that they won’t be able to handle any difficult event in the future.
Everyone I’ve worked with who had PTSD either blamed themselves for the trauma itself, or believed that they didn’t protect themselves (or someone else) well enough during the situation. They tended to put the responsibility on themselves, rather than the perpetrator.
This experience of self-blame can interfere with feeling safe in the world again. After all, if I believe I let this happen, how can I be safe in the world at all?
Common examples of a trauma include surviving a car accident, a sexual assault, or active combat. However, any event that leads to a fear of death or to one’s physical or emotional safety may be considered a trauma.
What are Common PTSD Symptoms in Women?
So, how and why might PTSD show up differently for women?
Sexual trauma, such as rape or assault, is one of the most common trauma types that women may experience. This type of trauma is more likely to cause PTSD. (And by the way, people who are transgender may have even higher rates of being assault survivors, according to the Office for Victims of Crime.)
Now, add to that the fact that many cultures shame women for being victims, or doubt their stories entirely. Since shame contributes to developing and maintaining PTSD, it creates the perfect storm for women to develop and continue to suffer from the condition longer.
In general, studies of men and women with PTSD show about the same level of symptoms. However, those who had suffered sexual assault (in both genders studied) had stronger symptoms. And because women have higher incidents of being assaulted, they have higher symptom as a group.
Women are diagnosed with PTSD in the same way as any other gender. For the most part, PTSD is PTSD. The complete list of official symptoms is listed a little later in the article.
Meanwhile, here are some of the most common signs therapists may notice among women in particular (Guina, M.D., 2016). (However, note that this doesn't speak to the experience of all women, or of other genders. Everyone with PTSD will have differing degrees of these symptoms.)
Self-blame. Women may express self-blame following a trauma, especially relating to sexual assault. This may be worsened by cultural issues (such as stigma against assault survivors).
Anxiety and depression. Women may experience more internal symptoms, such as feeling down and anxious, compared to men who sometimes have more struggles with anger or substance abuse (VA, n.d.)
Stronger startle response. Women with PTSD may seem more on edge, being startled more easily or reacting stronger when startled.
More avoidance. Some women may experience more avoidance of reminders of the trauma, which is present to some degree among everyone with PTSD.
Numbness. Women in particular may feel more detached or numb when going through PTSD.
(There's more below about each of these symptoms present in PTSD.)
Stigma Against Women
It's difficult for anyone with PTSD to talk about their trauma. It may be even more difficult if the type of trauma carries a stigma, including a history of blaming the victim.
This is often the case for women who've experienced sexual assault. Women may also be mistreated by authorities or accused of bringing the assault upon themselves. Due to this common occurrence, they may feel more uncomfortable reporting these crimes.
This cycle further reinforces the cultural shame and stigma girls and women often experience.
Another common type of violence women experience is intimate partner violence. Sometimes they may be blamed for bringing abuse upon themselves. This may include ongoing violence over months or years, which makes the trauma even worse.
While these occurrences are most common, women may also go through other types of traumas such as accidents, combat, or an unexpected death of a loved one. Any incident that threatens a person's feeling of ongoing safety could lead to post-traumatic stress disorder.
Screening for PTSD
Let’s look at how anyone, including women, may be diagnosed. As noted above, there are four broad categories of symptoms, and numerous possible experiences under each section.
Mental health professionals commonly use a screen called the PTSD checklist (PCL-5) to measure these. The screen, developed by the VA, breaks things down into 20 experiences someone might have following a trauma.
20 Symptoms of PTSD
You may have heard that there are 17 symptoms of PTSD that experts look for to make this diagnosis. The number comes from the original version of the PCL screen, then called the PCL-C.
These 17 questions were based on a previous version of the DSM, the manual used to make mental health diagnoses. In recent years, the screen has been updated, and is now referred to as the PCL-5. The “5” references the DSM-5, the newest version of the diagnosis manual.
The screen now includes 20 questions. Most of the original questions are included in the new screen, although a few have been updated or removed, and new questions have been added.
DSM-5 Criteria
The more recent screens use are based on today’s understanding of the condition. The infographic above includes a list of the 20 symptoms screened for in the PCL-5, based on, and named after, the DSM-5.
Remember that reviewing this screen doesn’t confirm that you do or don’t have a mental health diagnosis. It should be administered by a professional as part of a larger assessment. And if you do find you have this condition, there are fortunately treatments that can help.
Diagnosing
While the PCL-5 and similar screens are a good start to identifying the disorder, they’re just the beginning. Let’s look further at how clinicians diagnose this condition in women, as well as others, along with the treatment choices available.
Some therapists or doctors may use one screen, several screens, or may simply ask verbal questions about symptoms. This depends on the approach, training, and experience of the clinician.
Simply scoring high on any symptom screen doesn’t necessarily mean someone has a disorder. The therapist will also need to rule out other conditions, such as general anxiety disorder or depression, which have overlapping symptoms.
For example, someone with a past trauma may have high anxiety, and therefore believe they probably have post-traumatic stress disorder.
Someone's previous belief that they do or don't have a condition may affect how they respond to the questions--we all have this type of bias sometimes without realizing it.
Or, the wording of the questions, distractions while completing the screen, or anxiety symptoms may influence the accuracy of their scores.
Because of these factors, the mental health professional will often probe further into what a patient is experiencing. They will likely ask more about thoughts relating to the trauma and how symptoms are experienced in everyday life.
At some point, they may also ask about details of the past trauma as part of the diagnosis, or to determine the best type of treatment.
Most professionals believe it’s important to get as accurate a diagnosis as possible, because this affects the type of treatment provided.
Criteria
Here’s a closer look at how PTSD is diagnosed. Professionals look for specific criteria, or clusters. While screens cover many possible symptoms, each of those questions fall within larger categories (V.A., n.d.).
These clusters include having experienced a trauma, having intrusive symptoms, avoidance, depression-like symptoms, and heightened reactions (such as hypervigilance).
To get a diagnosis, a person must continue to experience the symptoms over time, and it must have a negative impact on their life.
Here’s a look at each of the broader criteria for post-traumatic stress disorder from the DSM-V:
Experiencing a Trauma
Many of these symptoms may be present with other conditions, such as general anxiety disorder.
However, in the case of PTSD, the reactions are obviously based on experiencing trauma.
Mental health professionals look for a connection to the trauma itself. For example, intrusive memories would be related to the specific event.
Hypervigilance symptoms would have started following the trauma. In some cases, symptoms present immediately after, while in others they could come on years and months later.
Intrusive Symptoms
Intrusive symptoms are, as they sound, intrusive. A person may be going about their day, even feeling well, and suddenly thoughts of the trauma pop in.
They might be triggered by a reminder, or it may come up for no apparent reason.
Other intrusive symptoms might include disturbing dreams, or feeling a strong sense of panic or anxiety when reminded of the trauma. These are measured in questions 1 through 5 on the 20-item scale above.
Avoidance
One key difference between PTSD and other anxiety-related disorders relates to avoiding thoughts about the trauma.
Sometimes people go out of their way to avoid conversations, reminders, memories, and any person, place, or thing that reminds them of what happened.
Women in particular may try to avoid these thoughts in order to cope. It may be difficult to explain to people what happened, which plays a role as well.
This avoidance makes sense in the short term, but over time it becomes harder and harder to keep up, and life begins to revolve around the trauma anyway. Questions 6 and 7 above relate to avoidance.
Cognitive Symptoms
Symptoms similar to depression also present with a diagnosis. In fact, many people are also diagnosed with major depression disorder.
However, these symptoms typically clear up as the underlying effects of the trauma get better.
One factor that makes things worse in guilt and self-blame. Because people blame themselves for what happened, they may begin to feel doubt and shame in general.
They may feel they are unworthy to be in the world, or that they’ll continue to put themselves or others in danger.
These constant thoughts may lead to isolation, negative beliefs about the world, and loss of interest in things that used to be important. These symptoms are measured in questions 8 through 14 above.
Arousal Symptoms
One of the most obvious signs is a heightened startle response, or near constant hypervigilance. Experts call these “arousal” symptoms, because they arouse the body’s defensive reactions.
Women with PTSD might feel more jumpy, experience paranoia in public places, or feel easily irritated by others, especially if they feel close or intrusive.
They may also feel ungrounded, or dissociate in the moment.
Often people describe needing to always see an exit door, not being able to stand with people behind them, or feeling on edge even in previously safe places. These symptoms are measured in questions 15 through 20 above.
Life Impact
In the case of most mental health disorders, symptoms must have a negative impact on the person’s life in order to be diagnosed.
With post-traumatic stress, someone with severe symptoms will report that it is interfering with at least some aspect, such as their personal, work, or social life.
Women may be more likely to report that it interferes with dating or intimate relationships.
Timing
To make a diagnosis, symptoms must be present a month or more following the trauma. That’s because having such responses within days to a few weeks after a trauma may be a normal part of adjusting after the event and often clear up on their own.
Adding up the Criteria
A clinician will take these trauma reaction into account along with a patient’s personal history, medical conditions, and other mental health symptoms.
Once it’s determined that all symptoms are present, and not caused by something else, they may make a PTSD diagnosis.
Missing or Misdiagnosing
As mentioned, sometimes PTSD is confused for other conditions, or may be missed by a professional.
Even experienced therapists sometimes miss or confuse mental health signs and symptoms, and may change their diagnoses over time.
For example, if someone reports high anxiety, but not a trauma, a full screen may not be used. They may be avoiding riding in cars, and may be diagnosed with a phobia.
Later, it may come to light that the person stopped riding in cars after they were in an accident. In this case, it may be wise to screen for post-traumatic stress.
This clarification matters, because certain treatments work better for one condition versus another.
In a reverse situation, a doctor or therapist may assume that someone who avoids riding in cars must be doing so because of a previous accident.
However, it may later be apparent that they don’t have intrusive memories of the trauma, and don’t avoid thinking about the accident.
In this case, they still have extreme anxiety when getting near a car. Following this realization, the person may then be diagnosed with another condition, such as a phobia of cars or driving. In that case, a more appropriate treatment can be recommended.
In other cases, medical conditions such as a head injury or dementia could have symptoms that look similar to post-traumatic stress.
This is why it’s important to examine all areas of a person’s life to make a final determination.
Treatments for PTSD
Once a woman is diagnosed, there are few possible next steps. A professional might refer them for therapy, medication, or both. They might suggest that they wait it out, and see if things get better.
They might also recommend ways to manage the symptoms, such as through managing anxiety symptoms.
There are mental health professionals with advanced training who specialize in post-traumatic stress disorder. While any doctor or therapist may treat the condition, many believe these experts are the most appropriate to help with symptoms.
There is a misconception that PTSD is untreatable, and a lifelong condition. Even some mental health clinicians, along with medical professionals, are under this impression.
While it’s true that some people do suffer for years, there are several treatments shown to help a majority of people get better. And, even those who’ve had the condition for decades may benefit from such targeted treatments.
Often, individuals can be entirely free from symptoms, and would report low to zero scores on the 20-question screen included above. These effective treatments typically work within a few months or less.
Here’s a look at the most common, and most effective, treatments currently used.
Cognitive Processing Therapy
Cognitive processing therapy (CPT) is one of the most common and successful treatments for this condition (CPT for PTSD). It was originally developed for female survivors of assault.
CPT involves identifying “stuck points,” or negative beliefs relating to the trauma, and challenging these. Over time, the survivor begins to understand that they were not the cause of the trauma, and that they are able to function safely in the world.
In some cases, this treatment also involves writing a narrative of what happened, to help them further process and stop avoidance techniques that interfere with recovery.
Prolonged Exposure
Prolonged exposure (PE) therapy is also based on countering avoidance patterns. Clients are asked to retell the story of the trauma repeatedly, and listen to recordings of their story.
The therapist then helps them understand their experiences and beliefs that come up during this exposure. Meanwhile, they are desensitized to their memories. Over time, PE clients are also able to work through negative thoughts and guilt relating to the trauma.
EMDR
Once again, this therapy involves remembering the events of the trauma. EMDR stands for Eye Movement Desensitization and Reprocessing.
During this treatment, clients think about the trauma while stimulating both sides of the brain, thought to help them process the memories more easily. EMDR therapists also help clients come to new beliefs and realizations about what happened.
All three of these therapies are focused on desensitizing the individual to the memories of the trauma, and to thinking differently about what happened.
Rather than blaming themselves, or believing they will never be safe again, survivors of trauma reintegrate back to a calmer, more accurate and neutral view of themselves and the world.
This in turn relieves symptoms such as avoidance, intrusive memories, hypervigilance, and depression.
How to Find Support
If you believe you or a loved one is suffering from PTSD, look for a therapist who specializes in trauma and post-traumatic stress. Visit here for some tips, or go to SAMHSA.gov to find a therapist near you.
If you're a therapist or other professional who supports people with PTSD, consider learning more about therapies such as CPT. We offer a set of worksheets focused on anxiety and PTSD, as well as other treatment tools. Visit here to learn more.
-Jennie Lannette, LCSW, is a licensed, practicing therapist in Missouri, specializing in trauma, anxiety, and related mental health issues.
Sources:
Cognitive Processing Therapy for PTSD. About CPT. https://cptforptsd.com/about-cpt/
U.S. Department of Veteran's Affairs (VA), National Center for PTSD (n.d.) How common is PTSD in women? https://www.ptsd.va.gov/understand/common/common_women.asp
U.S. Department of Veteran's Affairs (VA), National Center for PTSD (n.d.). PTSD Treatment Basics. https://www.ptsd.va.gov/understand_tx/tx_basics.asp
Transgender Symptoms of sexual assault. Office for Victims of Crime. (n.d.) https://ovc.ojp.gov/sites/g/files/xyckuh226/files/pubs/forge/sexual_numbers.html