Survivor Guilt: Living Through Major Trauma

Marjory Stoneman Douglas High School students — Two students hug in front of Marjory Stoneman Douglas High School where 17 people were killed on Feb. 14, 2018 in Parkland, Florida. Two surviving students committed suicide within a few days of each other in March 2019. Joe Raedle/Getty Images

The soldier coming home. The teen who escapes a mass shooting at her school. The office worker who doesn't get laid off. The loyal caretaker sitting by his mother's deathbed. The driver who walks away from a fatal, multi-car accident.

Devastating trauma happens to most us all, sooner or later. To an unfortunate number of us, that trauma is amplified by an emotion that, in many cases, seems entirely out of place. It's called survivor guilt, a subset of post-traumatic stress disorder (PTSD). And it can last for months, years, even an entire lifetime after the initial event.

"Survivor guilt can happen in people even after a year, even after a few years," says Dr. Asim Shah, a professor and executive vice chair in the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine in Waco, Texas. "Grieving is something that is different for everyone. You cannot put a time frame on grieving."

Pain, Grief and Survivor Guilt

The recent suicides of three people connected with two notorious school shootings in the U.S. — known in sad shorthand now simply as Sandy Hook and Parkland — have brought new attention to the pain suffered by those who survive but still are affected by trauma. Dorothy R. Novick, a pediatrician in Philadelphia, explains in The Washington Post:

[S]tories such as these remind us that trauma has far-reaching and devastating effects. It reminds us that the victims are not only the deceased but also the survivors. And not only the deceased and the survivors, but also each member of their families. And not only each member of their families but also every person who loves each member of their families. And so on.

Those survivors often deal with crippling feelings of guilt. They may exhibit symptoms; becoming irritable, depressed, anxious, and fearful. They may suffer from a lack of sleep and nightmares, and can be crushed under a sense of hopelessness and helplessness. "The fear is enormous," Shah says. "The fear doesn't go away."

According to Shah, survivor guilt is separated into three different categories:

The first type is that in which a person who survives a potentially deadly trauma wonders: Why am I alive?
The second, and what Shah calls the most prevalent, occurs when survivors feel guilty for not doing something at the time of the trauma that may have changed the outcome of the event. Tackling a gunman, for example. Holding a child back from school that day. Braking sooner to avoid an accident. Working harder so the company doesn't have to lay off people. Changing up a care program.
The third is a feeling some have that in order to save themselves from the immediate trauma, they left others behind.

Survivor guilt, as a medical concept, has been around since the 1960s and was associated with those who survived the Holocaust. At one time, the term was included in the Diagnostic and Statistical Manual of Mental Disorders, the main tool that mental health practitioners use to diagnose and treat mental illness.

In the most recent DSM, survivor guilt was wrapped into the general heading of PTSDs, and is effectively placed under a related condition called "acute stress disorder." From the latest DSM:

Acute stress disorder occurs in reaction to a traumatic event, just as PTSD does, and the symptoms are similar. However, the symptoms occur between three days and one month after the event. People with acute stress disorder may relive the trauma, have flashbacks or nightmares and may feel numb or detached from themselves. These symptoms cause major distress and cause problems in their daily lives. About half of people with acute stress disorder go on to have PTSD.

Whatever the classification, survivor guilt is identifiable by health professionals — and others — and is widespread. According to the DSM, some 13 to 21 percent of car accident survivors develop acute stress disorder. And between 20 and 50 percent of survivors of assault, rape and mass shootings suffer from some sort of survivor guilt or acute stress disorder. Shah says that some studies say that top figure may be as high as 60 percent of survivors of life-threatening events experience some form of survivor guilt.

Surviving Survivor Guilt

The National Institute for Mental Health says, to be diagnosed with PTSD (again: survivor guilt is considered a form of PTSD), adults must have all of these for at least a month:

A re-experiencing symptom (a flashback to the event, a bad dream or bad thoughts)
An avoidance symptom (staying away from reminders or thoughts of the event)
At least two arousal/reactivity symptoms (being startled, angry, sleepless or on edge)
At least two cognition and mood symptoms (feelings of guilt or blame, negative thoughts, trouble remembering details about the event, loss of interest in enjoyable events)

To treat those with survivor guilt, Shah says, it's first critical to recognize the symptoms: the irritability, the lack of sleep, the depression, the anxiousness, the fear.

"First of all, you need to be aware that you're suffering from survivor guilt, or your family or friends need to recognize it," Shah says. "You try to tell the person that you're not alone in this."

Allowing time to grieve is important, Shah says. And you can't put a timeframe on that. "You need to grieve in a way you would like to grieve," he says.

That said, taking the guilt and the grief and using them in a positive fashion — educating people, say, or advocating for change — is something that many find helpful, Shah says. Getting back to a normal routine as soon as possible can help with the healing.

It's important, too, to assess whether guilt and grief is affecting the ability to function in the everyday world. If it is, that's time for professional help, which can involve psychotherapy and medications.

How long can a person feel guilty or suffer through grief before looking for help? "The point is not related to timeframe," Shah says. "It's related to your function and capability."

There is a danger, as with the recent suicides of a Sandy Hook parent and two Parkland students, that those grappling with survivor guilt may find the struggle too much to bear. It is trauma beget from trauma.

"Please keep a watch on them, especially during those milestones [anniversaries of the event, birthdays, etc.] and if you see something ... that is the time to get them attention," Shah says. "You can save them."

Learn more about survivor guilt in "Survivor Guilt: How to Survive It" by Braden Daniels. HowStuffWorks picks related titles based on books we think you'll like. Should you choose to buy one, we'll receive a portion of the sale.

Now That's Interesting

More than 45,000 Americans died by suicide in 2017, according to the American Foundation for Suicide Prevention. But many more, some suffering with mental illnesses like PTSD and survivor guilt, attempt suicide unsuccessfully. In 2016, according to the Centers for Disease Control and Prevention, 1.3 million Americans survived a suicide attempt. If you or someone you know is in crisis, the National Suicide Prevention Hotline is at 800-273-TALK (8255), or you can use the National Suicide Prevention Hotline chat here.