For Demi Knight Clark, the 2013 Boston Marathon began like any other race.
Rather than trying to beat her times from previous marathons, she ran with her friends from the Dream Big Foundation.
Together, they had raised enough money to get Clark’s husband and two young daughters special tickets for the VIP stands at the race’s finish.
Over the first 25 miles of the race, Clark, who is left-handed, ran on the left side of the course with her friends. Just after the four-hour mark, her group approached the finish line. So, Clark cut through the crowd of runners to the right side of the course, where her family was waiting to see her finish.
She was 10 feet from the finish line when the first explosion rang out from the left.
Demi Knight Clark, Boston Marathon runner
At first, Clark didn’t understand what was going on. She thought that maybe an event organizer had set up a cannon as part of the marathon’s theatrics. But that moment of confusion didn’t last.
“I didn’t process it until I saw nails at my feet and shards of glass and turned around and smelled the sulfur,” said Clark, a 38-year-old resident of Charleston, South Carolina.
As the dust cleared, she saw her family. Her husband was in the stands with their daughters held tightly to his sides. Had they been in the general viewing area, instead of the VIP stands, then Clark and her family would’ve been at the heart of the blast.
Only a chance occurrence saved them that day. They were safe.
Safe, but not unharmed. Although they would carry no outward marks from their ordeal, they would go on to develop post-traumatic stress disorder (PTSD).
It’s normal to experience a strong reaction to traumas, explained David Yusko, Psy.D., associate director at the Center for the Treatment and Study of Anxiety in the Perelman School of Medicine at the University of Pennsylvania, in an interview with Healthline.
In the week following a trauma, more than 90 percent of people will experience some sort of symptoms of acute stress, which can include nightmares, panic attacks, flashback memories, or simply avoiding things that remind them of the trauma.
Over the next three weeks, these symptoms will gradually subside.
“What we use is this term called ‘natural recovery,’” explained Yusko. “So, most people who experience a trauma naturally recover over time.”
But for a percentage of people, natural recovery doesn’t occur. Instead of healing over time, the mind becomes locked into new patterns of avoidance and vigilance. The nightmares and flashbacks don’t go away.
Clark and her family were no exception.
“For that six month period after, I think I ran it in my head so many times,” she said. “What could I have done differently? There’s this guilt factor, this survivor’s guilt that comes along with it. Not just what happened, but now what? What do you do with yourself? You can’t tell people on the street how you feel. There’s no card you can hand to somebody that says ‘Hey, I’ve been through this, so cut me a break today.’”
Although they weren’t injured in the Boston Marathon attacks, Clark and her family still showed signs of PTSD.
“There are folks that were there who have physical scars because of where they were,” said Clark. “I would never say that my family’s suffering is anything close to what they have had to endure. But it has been a challenge in that when you don’t have those physical scars, there’s nothing outward to say that something’s wrong, mentally, spiritually, emotionally.”
Clark couldn’t handle being around large crowds, such as at fairs or festivals.
For her youngest daughter, Willa, then age 7, enclosed spaces were the problem. She would panic if asked to enter a movie theater or small shop.
Clark’s older daughter, Maizie, then age 9, had her PTSD manifest in a different way. Whenever she saw an ambulance or police officer, instead of seeing them as symbols of social protection, she thought another crisis was under way.
For Clark’s husband, survivor’s guilt was what hit hardest.
“They weren’t directly in danger, but they’re still traumatized by their experience of it,” explained Albert “Skip” Rizzo, director for medical virtual reality at the Institute for Creative Technologies and research professor at the Keck School of Medicine department of psychiatry and behavioral sciences at the University of Southern California, in an interview with Healthline.
Simply witnessing or being near a traumatic event can be plenty, says Yusko.
“Being in close enough proximity where your life was not necessarily at risk, but you were close enough to see it happen [..] The impact of it becomes more real, even though you didn’t directly experience it,” he said. “You were so close to it, it’s possible that that could have been you.”
And while most people who witness such traumas recover quickly, everyone is different.
“The biggest challenge is that there’s no way to quantify a personal experience of trauma,” said Rizzo. “Some people get out of a car wreck and they’re fine. Other people have a hard time getting back into a car.”
He added, “In the end, it’s a personal experience. There’s no shame in somebody having a strong reaction to these things. It’s just how people are wired.”
Such wiring can trigger PTSD from witnessing a wide range of events.
Seeing someone get injured or die in a car crash, surviving the suicide of a loved one, watching someone drown — all these events can cause PTSD just as readily as having survived the events yourself.
However, while personal variation is vast, there are a few basic trends in which types of events are more traumatic than others.
For example, among people who have directly experienced trauma, rates of PTSD among natural disaster survivors run around 30 to 40 percent, while as many as 80 percent of rape survivors may develop PTSD.
The data on PTSD caused by solely witnessing traumatic events is a little spottier. That it can happen is clear. For example, one study of children who witnessed a public hanging outside their school in Isfahan, Iran, found that 52 percent of the children still experienced PTSD symptoms three months after the event.
The World Trade Center attacks on September 11, 2001 brought up an interesting question. Can someone get PTSD simply from watching traumatic events on television?
According to the New York Times, at least 10,000 people in the New York City area have been diagnosed with PTSD related to the tragedy. The real number could be far higher. Could the numbers be higher still when taking into account those who only saw the event secondhand?
Probably not, says Rizzo.
“After the World Trade Center, people were saying that by the news channels repeatedly running the scene over and over, that they were going to see hundreds of thousands of people develop PTSD just by watching it on television,” he said. “And that never came to pass. Most people [who got PTSD] were either there or in the vicinity.”
In fact, when the updated DSM-V (the handbook of psychological disorders) was released, it added a new criterion to PTSD’s diagnosis: “This does not include indirect non-professional exposure [to trauma] through electronic media, television, movies, or pictures.”
Once new mental patterns from PTSD are locked into place, they generally don’t go away on their own.
“PTSD can last for decades,” said Yusko. “If you look at Vietnam-era veterans, we still have many veterans suffering from PTSD symptoms dating back to the 70s. PTSD becomes a chronic illness over time and can become difficult to treat the longer it’s there. And so, PTSD can last forever once it’s there, if it’s not adequately treated.”
And PTSD doesn’t just exist within the mind. It changes the body’s entire chemical profile. This can trigger autoimmune problems, muscle and bone problems, and drastically elevates the risk of cardiovascular disease. One scientist described PTSD’s wear and tear on the body, especially the heart, as roughly equivalent to smoking two or three packs of cigarettes a day.
PTSD can also take a considerable toll on quality of life. Sufferers may find that the world they live in seems more and more dangerous, until going outside is incredibly anxiety-provoking or outright impossible.
And in addition to this being burdensome on a person level, it’s also expensive. The RAND Corporation estimated that the lost work productivity, cost of treatment, and 10-fold elevated risk of suicide cost the nation billions a year.
Clark, who places a strong personal value on resilience, was determined to get back on her feet again.
She and her family sought out therapy. Her therapist taught her something important: how to be nonjudgmental with herself.
“It’s OK to feel whatever you feel, right now, today, and every day,” she explained. “Whatever crazy emotion you’re going through today, which will be different tomorrow, which will be different in the next hour, is OK. Don’t judge yourself about what you’re feeling.”
Although she returned to work immediately, Clark struggled with her daily life. She felt like she was full of emotions that had no place in her calm, civilian world.
For Clark, true solace came in her clients and friends, returning Iraq and Afghanistan war veterans who employed her in her business as a life coach.
“They were the ones who got me through it,” she said. “They knew exactly what I was talking about. They said, ‘We’ve seen the same types of things, we see it every day.’”
They taught her that it was OK to coexist with the demons in her head. That she could’ve experienced what she did, and still live her life.
“We need to start being accepting of the fact that it’s OK for people not to clean out the closet,” she said.
The following year, Clark returned to the Boston Marathon. Although her daughters had their misgivings at first, when the day came, they were proud to see their mother’s strength.
“I owe it to myself, it’s my responsibility to be resilient,” she said.
Having a strong social network and a positive attitude both go a long way toward recovering from PTSD. But at the end of the day, the cornerstone of treatment is therapy.
Therapy for witnessing trauma, says Yusko, isn’t so different from therapy for having experienced trauma. Either way, treatment must be customized to the nature of each individual patient’s trauma.
The various types of therapy include cognitive processing therapy, prolonged exposure therapy, and eye movement desensitization and reprocessing therapy.
Although they use different techniques, they all have the same foundation: gradually exposing the patient to imagery or self-authored stories of their trauma to decouple the association of the events with fear symptoms.
New technologies may offer ways to improve these treatments.
For example, virtual reality programs like the one Rizzo is developing can turn an imagination exercise into a full-sensory immersive experience. He and his colleagues hope to soon produce research that shows that virtual reality can enhance exposure therapy.
Rizzo also hopes that the flashy, high-tech allure of virtual reality may be attractive to younger people with PTSD and draw them into treatment that they might not seek otherwise.
Another approach involves augmenting psychotherapy with chemical aids that suppress the body’s fear reactions, allowing emotional healing to occur. D-cycloserine, propranolol, and MDMA are all chemicals in clinical trials with promising preliminary results.
Yusko urges people with PTSD to get help.
“PTSD is pretty surprisingly debilitating and it’s a serious problem that we need to pay attention to,” he said. “Without treatment, it can last forever. So there’s a lot of folks who are just telling themselves ‘I’ll get through this, I’ll get through this.’ The reality of it, though, is that it doesn’t go away, and people, once they get stuck with it, they really do need help. It’s not something they can do by themselves.”
Clark offers a final word of advice for people who want to help a loved one with PTSD.
“You shouldn’t feel pressured to ask a lot of questions,” she said. “All you have to do is be there for them and treat them normally. If anything, just encourage them to keep having something to strive for. They’ve got to have something that they are living for, and you just support them in that, and that’s the best family you could be.”