Feeling on edge, being extra-aware and looking out for potential dangers is a core symptom of PTSD. People who have been traumatised are naturally motivated to protect themselves from it happening again, and so may take a wide range of precautions, from checking doors and windows, to scanning around and behind them, to watching other people closely, to monitoring news stories.
Hypervigilance behaviours are usually closely linked to the nature of the person’s trauma and to reminders of it, like repeatedly checking the rear-view mirror after a car accident. Over time hypervigilance can become generalised though, so that people with chronic PTSD can find they focus their attention on all kinds of threats, and not just those reminiscent of their trauma.
Hypervigilance may also be deployed to internal stimuli as well as externally. For example, after a medical trauma, people may internally scan for signs that they are becoming unwell again, such as changes in their heartrate rate, breathing, etc. They may also regularly check the blood pressure, temperature or blood oxygen with medical devices. As you can imagine, the amount of physical and mental effort required for this level of vigilance is exhausting for people, even though it make sense as in ‘investment’ in keeping safe and feeling in control of dangers.
Hypervigilance arises because people with PTSD feel under severe current threat, and this sense of threat comes from poorly processed memories of the trauma, alongside excessively negative or unhelpful trauma-related beliefs (Ehlers, & Clark, 2000). When someone is experiencing frequent vivid flashbacks and nightmares, every new day can feel very much like the trauma has just happened or is about to happen again, and so it becomes hard to distinguish actual threatening stimuli from reminders of the trauma. For this reason, we generally work on trauma memories and beliefs in therapy before directly tackling hypervigilance behaviours, as we find it is really hard for our clients to drop hypervigilance behaviours while they still feel under threat. Reliving and updating trauma memories is therefore important as a first step, as is working on beliefs related to threat e.g. ‘the trauma will happen again’ or ‘if I drop my guard, something bad will happen’.
These steps may result in a spontaneous reduction in hypervigilance as your client begins to feel the trauma is more in the past. You can also make lists of all the main hypervigilance behaviours and support your client in reducing or dropping one at every between-session task. Normally we set this up in the form of a behavioural experiment, to test out what happens in terms of rating the likelihood of a trauma happening again, and also how on edge they will feel – initially and then after some time - if they drop the behaviour.
However, if the trauma happened a long time ago or if vigilance behaviours are an ‘over-learned strategy’ (e.g. in ex-military clients), vigilance behaviours may be so hard-wired and well-rehearsed that they may not reduce easily. There may also be a really complex range of quite subtle behaviours, both overt (e.g. scanning the rooftops for snipers, walking towards oncoming traffic) and covert (going through mental checklists of suspicious behaviours, sideways looks in shop windows) that even your client struggles to identify.
Here a good strategy is to go with your clients into situations in which they usually feel on edge (e.g. a busy place) so you can observe their hypervigilance behaviours in vivo. As you walk or stand, ask your client simply to tell you every threatening thing they notice or want to pay attention to, and every urge they have to make themselves safe. As someone without PTSD in that situation, you can also use yourself as a guide, looking for the things you naturally do or don’t do to maintain your safety, and try to compare their behaviours to yours and the people around you for clues to subtle vigilance – how are they standing or walking, where are they looking or not looking, what are their hands doing etc. The safety behaviours questionnaire (Ehlers et al., unpublished; available for free at www.oxcadatresources.com) is another useful way of identifying and tracking hypervigilance and other trauma-related safety behaviours and you can use that as a discussion tool to prompt for detailed examples before and after an in vivo task.
It’s worth mentioning that often our clients do not see hypervigilance as a problem, or else not something they can risk changing. Indeed, for some, their vigilance behaviours are closely intertwined with important aspects of their role or identity, e.g. “a good soldier is always on guard, whereas civilians are not”. Here we find it helpful to discuss the role of hypervigilance in maintaining PTSD - that the more you look for signs of danger, the more you find signs of danger, and so feel under threat and on edge, making you scan even more. We sketch out a simple ‘vicious circle’ formulation to illustrate this.
We validate and normalise hypervigilance as a strategy everyone uses when they feel unsafe, and reinforce that it is no wonder they have learned to protect themselves like this, given what has happened to them. We then explore the ‘price they pay’ for their hypervigilance, in other words the unintended consequences. Firstly, that scanning for danger can actually make us feel more unsafe and anxious, as it leads us to notice more ambiguous reminders of the trauma (e.g. people who look like the attacker, cars of a similar make and colour to one which hit us, bodily sensations similar to those during the trauma) which further adds to beliefs about unsafety and can trigger trauma memories. Secondly, that it takes a lot of energy and so contributes to tiredness, loss of enjoyment, poor concentration etc. Thirdly, it can contribute to feeling other kinds of threat, for example, feeling self-conscious that others can see them behaving in unusual ways. Fourthly, that when someone is vigilant and nothing then happens, it stops them testing out their beliefs about safety, as they naturally assume their vigilance is what prevented further trauma (rather than it was not going to happen regardless). And finally, that sometimes vigilance might inadvertently increase the risks of other traumas, for example, if someone is constantly checking their rear-view mirror, this might be less likely to quickly spot a danger ahead.
To further develop this understanding, we may use a metaphor to illustrate the effects of selective attention. For example, when we are buying a new car, we may start to notice cars of that type on the road although we had never been aware of them before. Couples who have recently had a baby or are planning to will become more aware of pregnant women, babies and parent-related advertising campaigns.
An experiential exercise can also be helpful. We go with our client to a place where they do not usually feel anxious e.g. a busy road (unless the trauma was a road traffic accident) and take a rating of their anxiety levels and beliefs about the likelihood of witnessing an accident. We then spend a few minutes observing the road, specifically looking out for any signs of danger (e.g. people driving badly, pedestrians crossing the road unsafely, bicycles getting close to cars etc) and then take the ratings again. Usually they have increased, which starts a reflective conversation about the effect of deliberately scanning for danger. These conversations naturally lead into behavioural experiments involving dropping hypervigilance behaviours and testing the effects. Again, these are often best done (at least initially) with your client in session, as they may struggle with them as homework tasks.
Particularly for clients with a long history of trauma, or those still living or working in somewhat threatening environments, it can be difficult to establish what is an appropriate amount of vigilance in different situations. For example, drivers do need to be aware of other vehicles, check mirrors and so on but not to check constantly or drive well below the speed limit. Equally, walking home through an area at night well known for robbery probably does require heightened vigilance and additional precautions, relative to walking around the clinic or hospital in the day. Surveys can be helpful here to establish a consensus on what is a reasonable versus excessive amount of vigilance to danger in different situations, in particular asking those who do not have PTSD who operate in the same environments, and this will still elicit a range of responses amongst people. The client can also be asked to reflect on what precautions they took prior to the trauma, what they have observed in others, and to consult external sources for an objective view, for example, asking the local community police liaison officer what would be reasonable precautions when walking in a given area.
Practice points:
Being excessively vigilant to external and/or internal threat is a core symptom of PTSD and an understandable reaction to trauma.
Hypervigilance is driven by unprocessed trauma memories and beliefs about safety, so these are usually addressed first in therapy.
Go together with your client into an anxiety provoking situation in-session, to help you both identify the range of overt and covert precautions they may be taking.
Normalise, validate and then formulate the role of hypervigilance behaviours in maintaining a sense of current threat, as well as identifying inadvertent costs or consequences. This can help motivate your client to begin reducing them.
Plan behavioural experiments in increasing/decreasing/dropping vigilance behaviours, first in session and then as between-session assignments. Switch up the contexts and combine dropping several at once.
Encourage your client to practice incompatible non-vigilant behaviours, if dropping habitual vigilance behaviours is difficult at first.
Some clients may struggle to know how much vigilance is reasonable or proportional so seek data from other sources, e.g with surveys, to help them consider their behaviours in context.
