Recognizing Hyperarousal Symptoms in PTSD

Hyperarousal is a specific cluster of symptoms associated with post-traumatic stress disorder (PTSD). As the name implies, hyperarousal is the abnormally heightened state of anxiety that occurs whenever you think about a traumatic event. Even though the threat may no longer be present, your body will respond as if it were.

PTSD can develop after a recent or past trauma, such as warfare, acts of violence, a life-threatening illness, or abuse. Hyperarousal can persist long after the trauma has passed, leaving you hyper-responsive to anything that reminds you of the event (including sights, smells, sounds, or even specific words of passages of music).

Physiological Causes of Hyperarousal

PTSD does not occur in isolation but rather in response to trauma, either sustained over a long period of time or as a single traumatic event. PTSD symptoms like hyperarousal ultimately develop as a result of the overreaction of the body's stress response. More specifically, due to alterations in the neuroendocrine system, dysregulated neurotransmitters and hormones, and structural and functional changes in the brain.

Neuroendocrine Changes Impact Hyperarousal

PTSD causes biological changes in the brain including dysregulation of the stress response system. This can then be triggered even by simply remembering a traumatic event.

Essentially, the neurological pathways to the hypothalamus-pituitary-adrenal (HPA) axis—which regulates the stress response—become overly sensitized to internal and external stimuli. When confronted with perceived danger, the amygdala will overreact, signaling the HPA axis to release stress hormones including excessive amounts of epinephrine and cortisol.

Epinephrine (adrenaline) is one of two stress hormones that play a role in the body's flight-or-fight response. Epinephrine works in the short term and produces acute stress symptoms, including pupil dilation, increased blood pressure, and a rapid heart rate. The other hormone, cortisol, works over the long term to regulate the body's response to stress.

Unlike chronic stress in which cortisol levels will invariably rise, cortisol levels in people with PTSD tend to be low. Because cortisol is meant to restore balance to the body after a stressful event, if it remains low, the lack of cortisol can potentially prolong and worsen PTSD. Even during a panic attack, epinephrine levels will shoot up in people with PTSD; cortisol levels will not.

Neurochemical Changes that Impact Hyperarousal

There are long-term changes in circulating neurotransmitters in people who have PTSD, including increases in dopamine, norepinephrine, glutamate, and endorphins, and lower levels of serotonin and GABA. Each of these neurochemicals contributes to the symptoms of PTSD in its own way, including emotional dysregulation, heightened arousal levels, impaired fear processing, increased startle response, and acute response to memories.

Structural and Functional Changes in the Brain that Impact Hyperarousal

There are three main brain structures involved in the stress response including the amygdala, hippocampus, and pre-frontal cortex. Changes in the functioning of the areas of the brain following trauma contribute to symptoms of hyperarousal.

An overactive amygdala impairs our ability to discriminate threats from non-threats. This is known as the amygdala hijack. When we perceive danger, the amygdala, the fear center of the brain, sends the alarm and triggers the HPA axis to initiate the stress response.

The low cortisol levels in people with PTSD lead to shrinkage of the hippocampus. The reduced volume and activity in the hippocampus alters the normal stress response and impedes the extinction of the heightened fear response despite being in a safe place.

Low levels of serotonin also disrupt the normal communication between the neighboring limbic system structures, the amygdala and hippocampus, and this new dynamic is linked with the experience of intrusive memories.

The pre-frontal cortex is also found to have decreased volume in people with PTSD. This means executive functions such as attention, focus, perception, and judgment will be impaired.

Common Triggering Events

Among some of the more common events that trigger PTSD:

• Wartime trauma
• Childhood abuse
• Sexual assault or abuse
• Physical violence
• Threats with a weapon
• Vehicle collision
• Airplane crash
• Fire
• Life-threatening illness
• Traumatic injury
• Natural disaster
• Terrorist attack
• Kidnapping

Symptoms

Hyperarousal in PTSD can affect children and adults equally. Symptoms include:

• Chronic anxiety
• Difficulty falling or staying asleep
• Difficulty concentrating
• Irritability
• Anger and angry outbursts
• Panic attacks
• Being constantly on guard for threats (hypervigilance)
• Being easily startled (excessive startle reflex)

Mental Health Complications After Trauma

Many people with PTSD will internalize feelings of shame and guilt and bear an inappropriate sense of responsibility for the trauma they incurred. This can lead to severe bouts of depression. All too often, people with PTSD may turn to unhealthy methods of coping to calm their nerves, numb themselves, and escape their memories.

There is an increased risk of self-destructive behaviors like excessive drinking and substance abuse, risky sex, or reckless driving. There is a higher incidence of alcohol and substance use in people with PTSD. All of these high-risk behaviors exacerbate the challenges of PTSD in the long run.

Eating disorders are not uncommon in people with untreated PTSD.

In extreme cases, PTSD may lead to suicidal thoughts and behaviors. A 2010 study from Denmark, which examined 9,612 suicide cases from 1994 to 2006, reported a 9.8-fold increase in the risk of completed suicide in people diagnosed with PTSD compared to the general population.

Effective Treatments For Hyperarousal Symptoms

As with all symptoms of PTSD, hyperarousal can be difficult to manage. It not only involves managing the underlying anxiety but effectively dealing with sleep problems, panic attacks, impulsive behaviors, self-harm, anger, and substance abuse issues.

Treatment is typically multidisciplinary and may include psychotherapy, medication, and stress management training. Examples include:

• Cognitive behavioral therapy: The aim of cognitive behavioral therapy (CBT), a form of talk therapy, is to change patterns of thinking or behavior that fuel PTSD symptoms.
• Exposure therapy: The aim of exposure therapy is to gradually and safely expose you to the triggers that stimulate stress in order to help you recognize them and alter your response.
• Eye movement desensitization and reprocessing: The goal of eye movement desensitization and reprocessing (EMDR) is to use eye movement to lessen the emotional impact of traumatic memories.
• Mindfulness training: Mindfulness aims to focus your attention on the present, instead of thinking about the past, or worrying about the future. You are encouraged to focus on current sensations, breathing, body position, and your surroundings. As stressful thoughts arrive, you try to observe them in a non-judgmental way and move on to more neutral thoughts or expressing compassion toward yourself.
• Medications: PTSD may be treated with one or several medications, including antidepressants, beta-blockers, and anti-anxiety drugs. The antidepressants such as Zoloft (sertraline), Prozac (fluoxetine), Paxil (paroxetine), and Effexor (venlafaxine) are considered the first-line drugs of choice.

Some doctors will also prescribe medical marijuana, where legal, to help alleviate anxiety and aid in sleep (although there is no clear clinical evidence of its benefit in improving PTSD over the long term).

Coping with Symptoms of Hyperarousal

Hyperarousal symptoms are part and parcel of the PTSD experience. There is rarely a straight road to recovery, and there may be setbacks and complications along the route. But, even when faced with these challenges, it is important to remember that you are as much a factor in your recovery as are your doctors and medications.

To this end, there are things you can do to better cope as you take the steps to recognize and overcome PTSD. Among them:

• Improve your sleep hygiene. People with PTSD often fear sleep and will do anything to avoid it. This can lead to sleep deprivation and the worsening of your symptoms. While your doctor may recommend a sleep aid, you can do your part by improving your sleep hygiene, including keeping to the same sleep schedule every night.
• Avoid alcohol and caffeine. Alcohol is a depressant that can amplify feelings of depression and the side effects of your drugs. Caffeine is a stimulant that can increase feelings of edginess and anxiety.
• Exercise regularly. Exercise stimulates the production of endorphins, the hormone that can ease pain and elevate moods and potentially temper the stress response. Exercise also makes you feel stronger and more in control.
• Take time to relax. People with PTSD often avoid silence because they fear it will bring up negative thoughts. But without taking the time to relax, you cannot effectively manage stress. To this end, it helps to set aside time for relaxing mind-body therapies, such as breathing exercises, stretching, or progressive muscle relaxation (PMR).
• Improve your eating habits. Stress-related eating is a common problem in people with PTSD. To avoid this, remove junk food from your pantry and stock your fridge with healthy fruits, nuts, and vegetables. Always eat your meals at a table with a plate and utensils rather than eating out of a bag or fast food container. Use cooking as a means to decompress after a long day.
• Build a support network. Don't suffer in silence. Find friends and family in whom you can confide, ideally people who don't panic or try to "make things right." You can also speak to your therapist about PTSD support groups to share your thoughts with others who understand what you are going through.