Post-traumatic stress disorder (PTSD) is a mental health condition that some people develop after experiencing or witnessing a traumatic event. PTSD can cause a wide range of symptoms that can vary from person to person. However, hyperarousal is often cited as the most distressing and debilitating symptom of PTSD.
What is PTSD?
PTSD is a mental health disorder that emerges after exposure to a traumatic event. According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), diagnostic criteria for PTSD include:
- Exposure to actual or threatened death, serious injury or sexual violence through direct experience, witnessing an event, learning of an event occurring to a close friend or family member, or repeated extreme exposure to aversive details of traumatic events (e.g. first responders).
- Presence of intrusion symptoms associated with the traumatic event such as distressing memories, dreams, flashbacks, psychological distress and physical reactivity after exposure to traumatic reminders.
- Avoidance of trauma-related stimuli after the event such as trauma-related thoughts or feelings and external reminders such as people, conversations, activities, objects or situations.
- Negative alterations in mood and cognition associated with the event beginning or worsening after the event such as an inability to recall key features of the event, overly negative thoughts and assumptions about oneself or the world, exaggerated blame of self or others, negative affect, decreased interest in activities, feeling isolated and inability to experience positive affect.
- Trauma-related arousal and reactivity that began or worsened after the trauma such as irritability or aggression, risky or destructive behavior, hypervigilance, heightened startle reaction, difficulty concentrating and difficulty sleeping.
- Symptoms lasting for more than 1 month.
- Significant impairment in functioning.
- Symptoms not attributable to medication, substance use or other illnesses.
Prevalence of PTSD
According to the National Center for PTSD, about 8 million adults in the United States have PTSD during a given year, representing about 3.5% of the adult population. The lifetime prevalence of PTSD among US adults is much higher, affecting about 6.8% of people at some point in their lives.
PTSD can occur in people of any age, including children and adolescents, and affects more women than men. Rates of PTSD are higher in certain populations such as military personnel and combat veterans where rates range from 11% to 20% annually. First responders and rescue workers also have higher rates of PTSD.
Symptoms of PTSD
People with PTSD often experience a wide array of symptoms that can be clustered into several categories:
Re-experiencing Symptoms
Re-experiencing symptoms involve the emergence of involuntary and vivid memories of the trauma. This includes:
- Flashbacks or reliving the traumatic event
- Upsetting dreams or nightmares about the trauma
- Severe emotional or physical distress after exposure to traumatic reminders
Avoidance Symptoms
Avoidance symptoms refer to efforts to avoid any reminders associated with the trauma. This includes:
- Avoiding thoughts, feelings or conversations related to the trauma
- Avoiding people, places, activities, objects or situations that bring on trauma-related memories
- Memory loss of aspects of the traumatic event
- Feeling emotionally numb
- Loss of interest in previously enjoyed activities
- Feeling detached or estranged from others
- Sense of a limited future ("foreshortened future")
Arousal and Reactivity Symptoms
This cluster of symptoms involves changes in emotional arousal, reactivity and behavior. This includes:
- Irritability or aggression
- Self-destructive or reckless behavior
- Hypervigilance
- Exaggerated startle response
- Problems with concentration
- Difficulty sleeping
Cognition and Mood Symptoms
PTSD often involves negative changes in mood and thoughts, including:
- Inability to recall key aspects of the trauma
- Negative self-belief or thought distortions
- Blaming oneself or others for the trauma
- Feeling alienated or alone
- Losing interest in activities
- Detachment or estrangement from others
- Distorted sense of blame leading to conflict
- Inability to feel positive emotions
Hyperarousal as Most Severe Symptom
Of all of these symptoms, hyperarousal tends to cause the most functional impairment for those with PTSD. Hyperarousal refers to a cluster of arousal and reactivity symptoms that leave people feeling on edge, jittery, and hypervigilant to threats.
Specifically, hyperarousal involves:
- Feeling constantly “on guard” or like danger is imminent
- A strong startle reflex or very jumpy reactions
- Difficulty concentrating or focusing
- Irritability, agitation or anger outbursts
- Recklessness and destructive behavior
- Insomnia or difficulty sleeping
Hyperarousal stems from changes in the body’s natural fight-or-flight response following trauma. PTSD causes the body’s threat response system to get stuck in overdrive, keeping the brain on constant alert for any potential threats. With hyperarousal, the body overreacts to everyday situations because the brain perceives everything as dangerous. This triggers surges in stress hormones like adrenaline and cortisol.
Problems stemming from hyperarousal include:
Sleep Disturbances
Inability to fall asleep and stay asleep is a hallmark of PTSD hyperarousal. The continuous state of arousal interferes with the body’s ability to relax and transition into restful sleep. Recurring nightmares about the trauma are also common. Chronic sleep deprivation takes a further toll on mental and physical health.
Anger and Irritability
The combination of high stress, insomnia and an overworked threat response system creates a “pressure cooker” situation in the body. As a result, people with PTSD hyperarousal are prone to irritability, anger outbursts, and sudden rages. Relationship conflict and domestic violence are common ripple effects.
Lack of Concentration
The state of hypervigilance makes it incredibly difficult to focus and concentrate. People with PTSD hyperarousal describe feeling perpetually scattered as they try to track all potential sources of danger around them. Poor concentration contributes to problems at home, school or work.
Reckless and Destructive Behavior
In an effort to cope with their constant state of arousal, some individuals turn to reckless behaviors such as substance abuse, thrill seeking, and high risk activities. Addictive behaviors like gambling, sexual compulsivity, and internet addiction can also develop as a way to self-soothe PTSD symptoms.
Withdrawal and Isolation
Faced with the burden of hyperarousal symptoms, many people with PTSD withdraw from family, friends and society in general. Hypervigilance when out in public creates anxiety. Irritability can strain relationships. The combination often leads to increasing isolation and disconnection from others.
Suicidal Thoughts
PTSD doubles the risk of suicidal thinking according to multiple studies. The combination of trauma exposure plus hyperarousal symptoms like insomnia, nightmares, anger, and concentration problems lead to a “psychological pressure cooker” that can make suicide feel like the only option.
Interference with Work/School Functioning
Difficulty sleeping plus inability to concentrate and focus create huge challenges for meeting responsibilities at work or school. People with PTSD hyperarousal often quit jobs or drop out of school because of functional impairment. High risk jobs like first responder roles may have to be abandoned.
How is hyperarousal treated in PTSD?
Since hyperarousal causes so much distress and disruption for those with PTSD, treatment focuses on addressing both psychological and biological components underlying chronic arousal. Common interventions include:
Psychotherapy
Cognitive behavioral therapy (CBT) is the first line treatment for PTSD and hyperarousal symptoms. CBT helps patients challenge distorted threat perceptions, improve coping skills for overcoming avoidance tendencies, and change hypervigilant thought patterns through techniques like cognitive restructuring and exposure therapy. Prolonged exposure therapy that gradually exposes patients to trauma reminders in a safe setting can be particularly helpful.
Medications
Antidepressants such as SSRIs can be used to treat PTSD and hyperarousal symptoms. The SSRI sertraline is FDA-approved specifically for PTSD treatment. SSRIs can help regulate the brain’s neurotransmitters that are involved in the threat perception response. Anti-anxiety medications such as benzodiazepines may also be used short-term to reduce hyperarousal symptoms.
Mind-Body Techniques
Methods that induce relaxation, mindfulness and restoration of healthy sleep patterns are beneficial. This can include meditation, yoga, massage therapy, acupuncture, breathing exercises, and making lifestyle changes to promote sleep hygiene and healthy stress management.
Avoid Stimulants
Since hyperarousal stems from an overworked threat response system, stimuli that further increase arousal like caffeine, energy drinks, and other stimulants should be avoided.
Cut Back on Media Exposure
Graphic media images, violent content and distressing news coverage can act as trauma triggers and feed into hypervigilance. Limiting exposure to overstimulating media content can help reduce hyperarousal symptoms.
Peer Support Groups
Connecting with other survivors can help reduce feelings of isolation. Support groups also provide an understanding environment where hypervigilance and startle responses are normalized. This can help lower shame and validate emotions.
Conclusion
Hyperarousal creates a constant state of tension, panic and dysregulation for those suffering from post-traumatic stress disorder. The chronic feelings of being on edge, inability to sleep, concentration problems, irritability and hypervigilance to threats contribute to severe functional impairment in relationships, work, school and overall quality of life. While many treatments options are available, addressing the biological and psychological underpinnings of hyperarousal remains critical for helping PTSD sufferers regain health and stability in their daily lives. With proper evidence-based treatment, the most distressing symptoms of PTSD like hyperarousal can be overcome.