What is PTSD?
Posttraumatic stress disorder (PTSD) is an anxiety disorder that a person may develop after experiencing or witnessing an extreme, overwhelming traumatic event during which they felt intense fear, helplessness, or horror.
The dominant features of posttraumatic stress disorder are emotional numbing (i.e., emotional nonresponsiveness), hyperarousal (e.g., irritability, on constant alert for danger), and reexperiencing of the trauma (e.g., flashbacks, intrusive emotions).
Posttraumatic stress disorder is also referred to as shell shock or battle fatigue (when describing the disorder in combat veterans) and as postrape syndrome.
Trauma
A trauma is an intensely stressful event during which a person suffers serious harm or the threat of serious harm or death or witnesses an event during which another person (or persons) is killed, seriously injured, or threatened. Traumatic events are commonly classified as follows:
Abuse
Mental
Physical
Sexual
Verbal (i.e., sexual and/or violent content)
Catastrophe
Harmful and fatal accidents
Natural disasters
Terrorism
Violent attack
Animal attack
Assault
Battery and domestic violence
Rape
War, battle, and combat
Death
Explosion
Gunfire
Types of PTSD
There are three types of PTSD: acute, chronic, and delayed onset. In acute PTSD, symptoms last less than 3 months. In chronic PTSD, symptoms last 3 months or more. In delayed onset PTSD, symptoms first appear at least 6 months after the traumatic event.
Symptoms of PTSD
Post-Traumatic Stress Disorder (PTSD) is a debilitating condition that follows a terrifying event. Often, people with PTSD have persistent frightening thoughts and memories of their ordeal and feel emotionally numb, especially with people they were once close to. PTSD, once referred to as shell shock or battle fatigue, was first brought to public attention by war veterans, but it can result from any number of traumatic incidents. These include kidnapping, serious accidents such as car or train wrecks, natural disasters such as floods or earthquakes, violent attacks such as a mugging, rape, or torture, or being held captive. The event that triggers it may be something that threatened the person's life or the life of someone close to him or her. Or it could be something witnessed, such as mass destruction after a plane crash.
Whatever the source of the problem, some people with PTSD repeatedly relive the trauma in the form of nightmares and disturbing recollections during the day. They may also experience sleep problems, depression, feeling detached or numb, or being easily startled. They may lose interest in things they used to enjoy and have trouble feeling affectionate. They may feel irritable, more aggressive than before, or even violent. Seeing things that remind them of the incident may be very distressing, which could lead them to avoid certain places or situations that bring back those memories. Anniversaries of the event are often very difficult.
PTSD can occur at any age, including childhood. The disorder can be accompanied by depression, substance abuse, or anxiety. Symptoms may be mild or severe--people may become easily irritated or have violent outbursts. In severe cases they may have trouble working or socializing. In general, the symptoms seem to be worse if the event that triggered them was initiated by a person--such as a rape, as opposed to a flood.
Ordinary events can serve as reminders of the trauma and trigger flashbacks or intrusive images. A flashback may make the person lose touch with reality and reenact the event for a period of seconds or hours or, very rarely, days. A person having a flashback, which can come in the form of images, sounds, smells, or feelings, usually believes that the traumatic event is happening all over again.
Not every traumatized person gets full-blown PTSD, or experiences PTSD at all. PTSD is diagnosed only if the symptoms last more than a month. In those who do have PTSD, symptoms usually begin within 3 months of the trauma, and the course of the illness varies. Some people recover within 6 months, others have symptoms that last much longer. In some cases, the condition may be chronic. Occasionally, the illness doesn't show up until years after the traumatic event.
Specific Symptoms of this Disorder:
The person has been exposed to a traumatic event in which the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others and the person's response involved intense fear, helplessness, or horror.
The traumatic event is persistently reexperienced in one (or more) of the following ways:
recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions.
recurrent distressing dreams of the event.
acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated).
intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
The individual also has persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:
efforts to avoid thoughts, feelings, or conversations associated with the trauma
efforts to avoid activities, places, or people that arouse recollections of the trauma
inability to recall an important aspect of the trauma
markedly diminished interest or participation in significant activities
feeling of detachment or estrangement from others
restricted range of affect (e.g., unable to have loving feelings)
sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)
Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
The disturbance, which has lasted for at least a month, causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Conditioned Memory
This is something that I learned in therapy when dealing with PTSD and foud it very helpful with understanding it.
Conditioned Memory
A class of implicit memory includes behavior learned through classical conditioning (CC) or operant conditioning (OC).
Either or both of them can be involved in the learned trauma responses of those with PTS and PTSD.
Classical conditioning
The easiest place to start is with a little example. Consider a hungry dog who sees a bowl of food. Something like this might happen:
Food ---> Salivation
The dog is hungry, the dog sees the food, the dog salivates. This is a natural sequence of events, an unconscious, uncontrolled, and unlearned relationship. See the food, then salivate.
Now, because we are humans who have an insatiable curiosity, we experiment. When we present the food to the hungry dog (and before the dog salivates), we ring a bell. Thus,
Bell
with
Food ---> Salivation
We repeat this action (food and bell given simultaneously) at several meals. Every time the dog sees the food, the dog also hears the bell. Ding-dong, Alpo.
Now, because we are humans who like to play tricks on our pets, we do another experiment. We ring the bell (Ding-dong), but we don't show any food. What does the dog do? Right,
Bell ---> Salivate
The bell elicits the same response the sight of the food gets. Over repeated trials, the dog has learned to associate the bell with the food and now the bell has the power to produce the same response as the food. (And, of course, after you've tricked your dog into drooling and acting even more stupidly than usual, you must give it a special treat.)
This is the essence of Classical Conditioning. It really is that simple. You start with two things that are already connected with each other (food and salivation). Then you add a third thing (bell) for several trials. Eventually, this third thing may become so strongly associated that it has the power to produce the old behavior.
Now, where do we get the term, "Conditioning" from all this? Let me draw up the diagrams with the official terminology.
Food ---------------------> Salivation
Unconditioned Stimulus ---> Unconditioned Response
"Unconditioned" simply means that the stimulus and the response are naturally connected. They just came that way, hard wired together like a horse and carriage and love and marriage as the song goes. "Unconditioned" means that this connection was already present before we got there and started messing around with the dog or the child or the spouse.
"Stimulus" simply means the thing that starts it while "response" means the thing that ends it. A stimulus elicits and a response is elicited. (This is circular reasoning, true, but hang in there.) Another diagram,
Conditioning Stimulus
Bell
with
Food -----------------------> Salivation
Unconditioned Stimulus------> Unconditioned Response
We already know that "Unconditioned" means unlearned, untaught, preexisting, already-present-before-we-got-there. "Conditioning" just means the opposite. It means that we are trying to associate, connect, bond, link something new with the old relationship. And we want this new thing to elicit (rather than be elicited) so it will be a stimulus and not a response. Finally, after many trials we hope for,
Bell ---------------------> Salivation
Conditioned Stimulus ---> Conditioned Response
Operant Conditioning
Operant conditioning has been widely applied in clinical settings (i.e., behavior modification) as well as teaching (i.e., classroom management) and instructional development (e.g., programmed instruction). Parenthetically, it should be noted that Skinner rejected the idea of theories of learning.
1. Practice should take the form of question (stimulus) - answer (response) frames which expose the student to the subject in gradual steps
2. Require that the learner make a response for every frame and receive immediate feedback
3. Try to arrange the difficulty of the questions so the response is always correct and hence a positive reinforcement
4. Ensure that good performance in the lesson is paired with secondary reinforcers such as verbal praise, prizes and good grades.
1. Behavior that is positively reinforced will reoccur; intermittent reinforcement is particularly effective
2. Information should be presented in small amounts so that responses can be reinforced ("shaping")
3. Reinforcements will generalize across similar stimuli ("stimulus generalization") producing secondary conditioning
Complex PTSD
The diagnosis of PTSD accurately describes the symptoms that result when a person experiences a short-lived trauma. For example, car accidents, natural disasters, and rape are considered traumatic events of time-limited duration. However, chronic traumas continue for months or years at a time. Clinicians and researchers have found that the current PTSD diagnosis often does not capture the severe psychological harm that occurs with such prolonged, repeated trauma. For example, ordinary, healthy people who experience chronic trauma can experience changes in their self-concept and the way they adapt to stressful events. Dr. Judith Herman of Harvard University suggests that a new diagnosis, called Complex PTSD, is needed to describe the symptoms of long-term trauma.
What are examples of captivity that are associated with chronic trauma?
Judith Herman notes that during long-term traumas, the victim is generally held in a state of captivity. In these situations the victim is under the control of the perpetrator and unable to flee.
Examples of captivity include:
Concentration camps
Prisoner of War camps
Prostitution brothels
Long-term domestic violence
Long-term, severe physical abuse
Child sexual abuse
Organized child exploitation rings
What are the symptoms of Complex PTSD?
The first requirement for the diagnosis is that the individual experienced a prolonged period (months to years) of total control by another. The other criteria are symptoms that tend to result from chronic victimization. Those symptoms include:
* Alterations in emotional regulation, which may include symptoms such as persistent sadness, suicidal thoughts, explosive anger, or inhibited anger
* Alterations in consciousness, such as forgetting traumatic events, reliving traumatic events, or having episodes in which one feels detached from one's mental processes or body
* Alterations in self-perception, which may include a sense of helplessness, shame, guilt, stigma, and a sense of being completely different than other human beings
* Alterations in the perception of the perpetrator, such as attributing total power to the perpetrator or becoming preoccupied with the relationship to the perpetrator, including a preoccupation with revenge
* Alterations in relations with others, including isolation, distrust, or a repeated search for a rescuer
* Alterations in one's system of meanings, which may include a loss of sustaining faith or a sense of hopelessness and despair
What other difficulties do those with Complex PTSD tend to experience?
Survivors may avoid thinking and talking about trauma-related topics because the feelings associated with the trauma are often overwhelming.
Survivors may use alcohol and substance abuse as a way to avoid and numb feelings and thoughts related to the trauma.
Survivors may also engage in self-mutilation and other forms of self-harm.
There is a tendency to blame the victim.
A person who has been abused repeatedly is sometimes mistaken as someone who has a "weak character."
Because of their chronic victimization, in the past, survivors have been misdiagnosed by mental-health providers as having Borderline, Dependent, or Masochistic Personality Disorder. When survivors are faulted for the symptoms they experience as a result of victimization, they are being unjustly blamed.
Researchers hope that a new diagnosis will prevent clinicians, the public, and those who suffer from trauma from mistakenly blaming survivors for their symptoms.
Summary
The current PTSD diagnosis often does not capture the severe psychological harm that occurs with prolonged, repeated trauma. For example, long-term trauma may impact a healthy person's self-concept and adaptation. The symptoms of such prolonged trauma have been mistaken for character weakness. Research is currently underway to determine if the Complex PTSD diagnosis is the best way to categorize the symptoms of patients who have suffered prolonged trauma.
Rape Trauma Syndrome
Many people experience physical, psychological and behavioural problems after suffering a serious trauma like losing someone they love or being disabled in a car accident. These problems have been called Post Traumatic Stress Disorder. This condition is a normal reaction to abnormal stress. People who have not previously had a mental illness or psychological problems can suffer Post Traumatic Stress Disorder.
Different kinds of traumas can produce different reactions. Take rape for example: Rape is not just unwanted sex, it is a highly traumatic experience and like other serious traumas, it has negative effects on those who survive it. Rape is usually experienced as life threatening and as an extreme violation of a person. It is not surprising then, that many rape survivors suffer from a particular kind of Post Traumatic Stress Disorder, known as Rape Trauma Syndrome:
PHYSICAL SYMPTOMS OF RAPE TRAUMA SYNDROME
Immediately after a rape, survivors often experience shock: they are likely to feel cold, faint, become mentally confused (disoriented), tremble, feel nauseous and sometimes vomit.
Pregnancy.
Gynaecological problems like: irregular, heavier and/or painful periods, vaginal discharges, bladder infections, sexually transmitted diseases like syphilis, gonorrhoea and/or AIDS.
Bleeding and/or infections from tears or cuts in the vagina or rectum, depending on what happened during the rape.
A soreness of the body. There may also be bruising, grazes, cuts etc, depending on the kind of force used during a rape.
Nausea and/or vomiting.
Throat irritations and/or soreness due to forced oral sex.
Tension headaches.
Pain in the lower back and/or in the stomach.
Sleep disturbances like: difficulty falling asleep, waking up during the night, being woken by nightmares about the rape, getting less sleep than usual; or on the other hand feeling exhausted and needing to sleep more than usual.
Eating disturbances such as: not feeling like eating, eating less than usual and so losing weight; or on the other hand eating more than usual and so putting on weight.
BEHAVIOURAL SYMPTOMS OF RAPE TRAUMA SYNDROME
Crying more than usual.
Difficulty concentrating.
Being restless, agitated and unable to relax; or on the other hand just sitting around and moving very little.
Not wanting to go out and/or socialise; or on the other hand socialising more than usual.
Not wanting to be left alone.
Stuttering or stammering more than usual.
Trying to avoid anything that reminds the survivor of the rape. So for example, someone who was raped at a party may stop going to parties. Many rape survivors don't want to talk about what happened, because it makes them remember the rape.
Being more easily frightened or startled than usual. Rape survivors often get very scared when someone walks up behind them without warning.
Being very alert and watchful.
Getting very upset by minor things that didn't worry them before the rape.
Losing interest in things that used to be of interest to them before the rape.
Problems in relationships with people like family, friends, lovers and spouses. Rape survivors may become irritable and so may quarrel with others more easily; or they may withdraw from people with whom they had been close before the rape. They may also become very dependent on others, or on the other hand overly independent.
Sexual problems like a fear of sex, a loss of interest in sex or a loss of sexual pleasure.
Changes in work or school such as: dropping out of school, truanting from school, changing jobs, or stopping work altogether.
Moving house.
Increased use of substances like alcohol, cigarettes and/or drugs. A person who didn't use a substance before the rape may start to use it after a rape.
Increased washing and/or bathing, because of a feeling of being dirty from the rape.
Acting as if the rape never happened. It is quite common for rape survivors to try and carry on with their lives as if nothing has happened, because they don't want to face their feelings about the rape. This is called denial.
PSYCHOLOGICAL SYMPTOMS OF RAPE TRAUMA SYNDROME
Intrusive thoughts about the rape that upset the rape survivor.
Intrusive thoughts and feelings about being dirty from (contaminated by) the rape. These feelings often make rape survivors wash or bath more frequently. These thoughts are known as obsessional thoughts.
Flashbacks - the sudden feeling that the rape is happening again, which makes the survivor very frightened and upset.
Nightmares about the rape.
Being very upset by anything that reminds the survivor of the rape.
Becoming extremely afraid of certain things that remind the survivor of the rape. Such extreme fears are called phobias. Rape survivors often develop extreme fears of men, of strangers, of being alone, of leaving their homes, of going to school or to work, and of sex. These phobias are called traumatophobias, because they are caused by a trauma.
A loss of memory for all or part of the rape, which is called psychogenic amnesia.
Being unable to feel certain feelings like happiness, or feeling very 'flat'. On the other hand, rape survivors can feel emotionally confused and have mood swings (quick changes of mood).
Feeling that they will not live for very long and/or feeling very negative about their future prospects.
Feeling depressed and/or sad, and sometimes having thoughts of suicide.
Feeling irritable and angry.
Feeling more fearful and anxious than usual. Rape survivors are often very afraid that their assailant/s will return, that they may be pregnant or have been infected with a disease from the rape.
Feelings of humiliation and shame.
Feeling different and/or distant from other people.
Feelings of guilt and self-blame about the rape. Rape survivors often feel that they were somehow responsible for being raped.
Feelings of helplessness and powerlessness.
A loss of self respect and self confidence. Many rape survivors feel that the rape has made them worth less than other people.
Human beings respond to trauma in different ways. Although many rape survivors suffer from the symptoms of Rape Trauma Syndrome, not all survivors respond to rape in the same way - some rape survivors may have none of these symptoms and others may suffer only a few. Therefore, if a person experiences many of the symptoms of Rape Trauma Syndrome, it is highly likely that s/he has been raped; but if a person claims to have been raped, yet experiences none of these symptoms, or only a few, it is not a sign that s/he has not actually been raped. Because most rape survivors are afraid to tell anyone that they have been raped, any person who claims to have been raped, should be treated as if they have been raped.
It is important to treat each rape survivor as an individual and to try and understand what the rape means to that particular person. A person's religion, culture, class, race and gender may affect how they feel about being raped. The impact of a rape may be worse if the victim is physically or mentally handicapped, if they were raped by more than one person, or on more than one occasion; and/or if they were raped by someone they knew. Coping with being rape may also be more difficult if family, friends and colleagues are not supportive and/or blame the survivor.
Rape survivors seem to experience different symptoms of Rape Trauma Syndrome over time. In the first couple of days immediately after a rape, a survivor usually experiences a state of shock. After this shock has passed, some survivors try to act as if nothing has happened. This is their way of trying to block out the rape, because they feel that they won't be able to cope if they let themselves remember what happened to them. So, they may look as if they have not been affected by the rape. This has been called the stage of denial or pseudo-adjustment.
However, if a rape survivor is going to recover well from the impact of a rape, s/he must let her/himself remember the rape and feel whatever s/he is feeling inside. When s/he does start remembering and feeling, s/he will also start suffering from symptoms, but these usually improve gradually over time. It often helps a survivor to have counselling if s/he is experiencing symptoms that upset her/him.
The effects of rape are long term. Rape survivors never forget being raped, but many learn how to deal with the memory. Studies have shown that the symptoms suffered by a rape survivor three months after a rape usually continue over the next three to four years, although they do seem to improve over time. Rape survivors who have strong self-esteem before being raped, those who have good relationships with people and those who have few major changes in their fives in the year, before a rape; seem to recover more quickly from the effects of rape.
Rape Trauma Syndrome has been introduced in court cases overseas in a number of ways: to corroborate a victim's claim that s/he did not consent to having sex; to explain a rape survivor's poor memory about a rape; and to help the court decide on a sentence for a rapist. The negative effects of rape are not yet widely known or recognised in South Africa. Many of our courts are still operating under the false impression that rape is merely unwanted sex and therefore, that it does not damage rape survivors especially in the long term. Rape Trauma Syndrome is only now being introduced as evidence in South African courts.
Dissociative Identity Disorder
WHAT IS DISSOCIATION?
Dissociation is a mental process, which produces a lack of connection in a person's thoughts, memories, feelings, actions, or sense of identity. During the period of time when a person is dissociating, certain information is not associated with other information as it normally would be. For example, during a traumatic experience, a person may dissociate the memory of the place and circumstances of the trauma from his ongoing memory, resulting in a temporary mental escape from the fear and pain of the trauma and, in some cases, a memory gap surrounding the experience. Because this process can produce changes in memory, people who frequently dissociate often find their senses of personal history and identity are affected.
Most clinicians believe that dissociation exists on a continuum of severity. This continuum reflects a wide range of experiences and/or symptoms. At one end are mild dissociative experiences common to most people, such as daydreaming, highway hypnosis, or "getting lost" in a book or movie, all of which involve "losing touch" with conscious awareness of one's immediate surroundings. At the other extreme is complex, chronic dissociation, such as in cases of Dissociative Disorders, which may result in serious impairment or inability to function. Some people with Dissociative Disorders can hold highly responsible jobs, contributing to society in a variety of professions, the arts, and public service -- appearing to function normally to coworkers, neighbors, and others with whom they interact daily.
HOW DOES A DISSOCIATIVE DISORDER DEVELOP?
When faced with overwhelmingly traumatic situations from which there is no physical escape, a child may resort to "going away" in his or her head. Children typically use this ability as an extremely effective defense against acute physical and emotional pain, or anxious anticipation of that pain. By this dissociative process, thoughts, feelings, memories, and perceptions of the traumatic experiences can be separated off psychologically, allowing the child to function as if the trauma had not occurred.
Dissociative Disorders are often referred to as a highly creative survival technique because they allow individuals enduring "hopeless" circumstances to preserve some areas of healthy functioning. Over time, however, for a child who has been repeatedly physically and sexually assaulted, defensive dissociation becomes reinforced and conditioned. Because the dissociative escape is so effective, children who are very practiced at it may automatically use it whenever they feel threatened or anxious -- even if the anxiety-producing situation is not extreme or abusive.
Often, even after the traumatic circumstances are long past, the left-over pattern of defensive dissociation remains. Chronic defensive dissociation may lead to serious dysfunction in work, social, and daily activities.
Repeated dissociation may result in a series of separate entities, or mental states, which may eventually take on identities of their own. These entities may become the internal "personality states" of a DID system. Changing between these states of consciousness is often described as "switching."
WHAT ARE THE SYMPTOMS OF A DISSOCIATIVE DISORDER?
People with Dissociative Disorders may experience any of the following: depression, mood swings, suicidal tendencies, sleep disorders (insomnia, night terrors, and sleep walking), panic attacks and phobias (flashbacks, reactions to stimuli or "triggers"), alcohol and drug abuse, compulsions and rituals, psychotic-like symptoms (including auditory and visual hallucinations), and eating disorders. In addition, individuals with Dissociative Disorders can experience headaches, amnesias, time loss, trances, and "out of body experiences." Some people with Dissociative Disorders have a tendency toward self-persecution, self-sabotage, and even violence (both self-inflicted and outwardly directed).
CAN DISSOCIATIVE DISORDERS BE CURED?
Yes. Dissociative Disorders are highly responsive to individual psychotherapy, or "talk therapy," as well as to a range of other treatment modalities, including medications, hypnotherapy, and adjunctive therapies such as art or movement therapy. In fact, among comparably severe psychiatric disorders, Dissociative Disorders may be the condition that carries the best prognosis if proper treatment is undertaken and completed. The course of treatment is longterm, intensive, and invariably painful, as it generally involves remembering and reclaiming the dissociated traumatic experiences. Nevertheless, individuals with Dissociative Disorders have been successfully treated by therapists of all professional backgrounds working in a variety of settings.
Grounding Tecniques
Why do you dissociate? Because it numbed the pain during the trauma.
How did you do that? How do you dissociate? How did you do it back then? How do you do it now? Ever thought about it?
In order to dissociate, your mind must take you away from the trauma. How does it do that? Well, it must disconnect you from the very thing that keeps you in the here and now- your five senses.
It is your senses that tell you where you are and what is going on around you. They tell you who is talking to you. They help you read this article. Your senses keep you connected.
Dissociation is the process of disconnecting you from your senses. You must dis-associate from reality.
And it worked.
It removed you from the horrible realities of trauma. It keeps the memories from flooding you with pain today. Dissociation helped you survive; without it you might be crazy or dead.
Unfortunately, this tremendous ability now interferes with your life. It can interrupt daily living. It can make it hard to concentrate or do simple tasks. It can even prevent you from sleeping.
Dissociation can even be a little irresponsible. Not only does it block past pain but it can be used as an excuse not to do uncomfortable things now. "Gee, I just don't know why younger parts of me keep coming out every time we need to have a serious talk…"
So, the great gift has become an anvil around your neck. What do you do about it? Learn effective grounding techniques.
And what are you grounding? Your senses. If dissociation is the process of blocking senses, grounding is the process of using your senses to stay in the here and now.
There are two important aspects to this grounding: using the senses and breathing.
Let's talk about using the senses first.
If you want to live in the past pain, sit in the corner, cover your eyes and ears and don't move much. Now, no one wants to relive pain. And yet, this is what some survivors do during painful flashbacks. By sitting in the corner and shutting out life and sounds around them, they make it easier to stay inside that painful memory.
Using your senses is as simple as keeping your eyes open, as easy as stroking the couch with your hand. It can be as simple as listening to someone's voice or the sound of the radio or television. How about chewing ice or really sour candy?
You must use your senses to literally hang on to today and now.
And everyone is different.
Some people ground more easily by touch. Others rub their feet on the floor. Still others carry Redhots or really sour candy in their purse and eat them when they start to dissociate.
Music can also be a powerful grounding technique - or it can make things worse. Keep some music on hand just to help you stay grounded. Keep in mind, though, that the music that grounds may not be the music that relaxes you. They are probably two different styles of music. One keeps you present while the other mellows and relaxes. The most grounding music may just be the type of music you like the least.
The other factor in getting grounded is breathing. When you are scared or nervous your breathing changes. It can get very shallow and rapid. This will cause you to hyperventilate. Hyperventilation triggers certain responses in the body that make grounding pretty difficult.
For instance, many people report feeling "unreal" or "spaced out" when they hyperventilate. This is due to changes in the brain chemistry during shallow breathing. Hyperventilation also restricts the flow of blood to your hands and feet. This physical response will quickly contribute to not being grounded.
For this reason, always pair any grounding technique with deep breaths that move your stomach. A couple of deep diaphragmatic breaths alert the body's fight or flight response to "turn off" and this changes the blood flow in the body. The combination of grounding techniques and 'stomach' breathing is very powerful and can work very quickly.
Finally, as you master the grounding techniques, you'll find that dissociation will control you less. This will allow you to function in situations that may have been triggering and debilitating in the past. And while these situations may still cause some anxiety, they simply will not have power over you that they had in the past.