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PTSD is three reactions at once, all caused by an event that terrifies, horrifies or renders one helpless. The triad of disabling responses is:
- recurring intrusive recollections;
- emotional numbing and constriction of life activity and,
- a physiological shift in the fear threshold, affecting sleep, concentration, and sense of security.
By definition in DSM IV (the 1994 edition
of the Diagnostic and Statistical Manual, which is the official
lexicon of psychiatric diagnoses, written and published by the
American Psychiatric Association), this syndrome must last at
least a month before PTSD can be diagnosed. Furthermore, a severe
trauma must be evident and causally related to the cluster of
symptoms. There are people who are fearful, withdrawn and plagued
by episodes of vague, troubling sensations, but they cannot
identify a specific traumatic precipitant. (Some clinicians
assume this means abuse occurred and was repressed. The pattern
of PTSD reactions thus may be used, illogically and erroneously,
to "prove" a hidden trauma). PTSD should only be diagnosed when
an event of major dimension - a searing, stunning, haunting
event - has clearly occurred and is relived, despite strenuous
attempts to avoid the memory.
Recurring, intrusive recollections
The core feature of PTSD, distinguishing
the condition from anxiety or depression, is the unavoidable
echo of the event, often vivid, occasionally so real that it
is called a flashback or hallucination. The survivor of a plane
crash feels a falling sensation, re-visualizes the moment of
impact, then fears going crazy because his or her mind and body
return uncontrollably to that harrowing scene.
A victim of the "cooler bandit," whose
modus operandi was to rob urban convenience stores at gunpoint
and force the clerks into refrigerated storage rooms, had nightmares
for more than a year. She still has moments during the day when
she sees the bandit's brown eyes above the mask that hid the
rest of his face. She was sure she would be killed at the moment
when he threw her to the floor. Even though no shots were fired
and the robber was eventually apprehended, her sensations of
terror, her feelings of impending doom, still return with sudden
images of that unforgettable night.
There are important distinctions among
traumatic memories. Some are clearly memories. The beholder
knows this is a recollection, painful but not terrifying. Through
time and (often) through telling and retelling of the trauma
story, the memory is muted, modulated and mastered. It no longer
has a powerful, disruptive presence. It is a piece of personal
history. On the other hand, that personal history may burst
forth into awareness, and a trauma survivor may feel and act
as though bombs are falling, a rapist is ready to strike or
the death of a loved one is witnessed again.
Incidentally, the loss of a loved one
and the consequent bereavement is not, by definition, a source
of PTSD, unless the death evoked images of terror or horror.
Tragic loss is often an aspect of PTSD, but shocking imagery
is not usually part of natural death. Therefore, as painful
as the loss of a spouse or child may be, the diagnosis of PTSD
is reserved for only those losses accompanied by haunting death
imagery.
Some repetitive recollections include
regrettable acts by the person with PTSD. A patient of mine
killed a boy in Viet Nam. It was self defense, in combat, but
indelible and inexcusable in my patient's overactive conscience.
Guilt - crushing guilt - was a major component of his intrusive
recollection.
When the trauma reappears in the mind,
some individuals experience an altered state of consciousness.
They enter a trance, a dissociative disorder that can be dangerous
to themselves or others.
The war veteran confuses his wife with
a Viet Cong woman who tried to kill him many years ago, and he
smothers her with a pillow. Or he leaps from the window. Or he
runs from the room with a weapon and is shot by police. These
are relatively rare situations and, according to most experts,
beyond the boundaries of PTSD.
PTSD may include flashbacks and hallucinations,
but neither is necessary for the diagnosis. When prolonged flashbacks
and prolonged hallucinations, particularly auditory hallucinations
that command violent activity, occur, other diagnoses may be involved,
such as Dissociative Disorder and Brief Psychotic Disorder. These
may coexist with PTSD. They will be discussed later, when considering
consequences of trauma that are not PTSD.
Remember, PTSD is more than a repetitive
traumatic memory. It also is a form of emotional anesthesia and
of generalized anxious arousal.
Emotional numbing and constriction of
life activity
The emotional anesthesia, or numbing,
may protect a person from overwhelming distress between memories,
but it also robs a person of joy and love and hope. While participating
in a national PTSD research effort, I interviewed dozens of soldiers,
decades after their service in Viet Nam. The presence of this
second of the three PTSD diagnostic criteria, this loss of emotional
tone, struck me as the most tragic legacy. Marriages suffered,
child raising was impaired, life was hollow. To these veterans,
"survivor" meant being no more than a survivor and considerably
less than a fully functioning human being. Painful memories might
have subsided. Anxiety attacks were tolerable. But the capacity
for feeling pleasure was gone.
These PTSD victims were anhedonic, meaning
not necessarily sad or morose, just incapable of delight. And
they no longer participated in activities that used to be fulfilling.
Why bowl or ride horses or climb mountains when the feeling of
fun is gone? Some marriages survived, dutiful contracts of cohabitation,
but devoid of intimacy and without the shared pride of watching
children flourish - even when the children were flourishing.
These negative symptoms of PTSD, numbing
and avoidance, are less prominent, less visible and less frequent
than the more dramatic memories and anxieties. Early on, most
survivors of trauma will consciously avoid reminders and change
familiar patterns to prevent an unwanted recollection. For example,
some ex-hostages from a notorious train hijacking in the north
of Holland avoided all trains for weeks. Some only avoided the
particular train on which the hostage incident had occurred. Others
took that train, but changed to the bus for the few miles near
the site of the trauma.
This aspect of PTSD, numbing and avoidance,
is adaptive to a point, then becomes a serious impediment to recovery.
It can also mislead an interviewer of a survivor into seriously
underestimating the severity of a traumatic event. There is a
popular belief that victims of rape, kidnapping and other violent
crimes should be full of feeling, tearful, shuddering, even hysterical,
after the assailant leaves. When feelings are muted, frozen or
numb, the survivor may not be believed. When testimony in court
is mechanical and unembroidered, jurors may assume that damages
were minimal or never incurred. I have testified as an expert
for the prosecution (or for the plaintiff in a civil suit) on
several occasions to explain this phenomenon. The victims were
numb or avoidant or both, and therefore did not come forward immediately.
When they did come forward, they appeared, to untrained observers,
to be indifferent, unconcerned and unharmed, when, in fact, they
were in a state of profound post-traumatic stress.
This dimension of PTSD includes psychogenic
amnesia. Along with loss of emotional tone and limited life pursuits
are holes in the fiber of recollection. For example, an opera
singer, battered by her husband, could not recall the most serious
beatings. She was finally ready to divorce him and she needed
to testify in court at a settlement hearing. After several supportive
sessions, including hypnosis, she remembered him choking, almost
strangling, her. Eventually, all of the memories returned, and
she could joke, "He not only threatened my life but my livelihood!
No wonder I put that out of my mind."
A female police officer shot and killed
a man who threatened her and her partner with a gun. She could
remember everything vividly except for the sound of her pistol
firing. Obviously, the gun went off and the sound was audible.
She repressed that piece of memory for many years, eventually
recalling it as her PTSD subsided.
Physiological arousal
The final dimension of PTSD is a lowered
threshold for anxious arousal. This is physiological. Unexpected
noises cause the person to shudder or jump. The response is automatic
and not necessarily related to stimuli associated with the original
trauma.
A patient of mine, a bank teller who was
robbed, held hostage, then kidnapped, was not exposed to gunfire
or loud sounds during her ordeal. But six months later, she was
visibly startled and upset by the rumble of a train near my office.
It is as though the alarm mechanism that warns us of danger is
on a hair trigger, easily and erroneously set off. A person lives
with so many false alarms that he or she cannot concentrate, cannot
sleep restfully and becomes irritable or reclusive. A normal sex
life is difficult with such apprehension. PTSD therefore impairs
the enjoyment of intimacy, and this, in turn, isolates the sufferer
from loved ones - the ideal human source of reassurance and respect.
Often, the anxiety takes familiar shape:
panic and agoraphobia. Panic is a sudden, intense state of fear,
frequently with no obvious trigger, in which the heart beats rapidly,
respirations are quick and shallow, and fingertips tingle. There
is lightheadedness, there may be sensations of choking or smothering,
and the person feels he or she is dying or going crazy or both.
It is a seizure of the autonomic nervous system. It mimics a heart
attack. Panic lasts a few minutes but is so debilitating that
one is upset for several hours. After experiencing a few panic
attacks, a person will often avoid places where an attack would
be particularly embarrassing, such as shopping malls and supermarkets.
The term agoraphobia, from the Greek words
for market (agora) and fear (phobia), literally means fear of
the marketplace. But it applies to many similar settings that
are shunned by those with a particular pattern of anxiety. Extreme
agoraphobia causes self-imprisonment in one's house or even a
single room within a home.
Few PTSD sufferers reach this condition,
but many of my patients have imposed dramatic restrictions on
their social activity, not out of fear of a traumatic reminder,
but out of embarrassment in anticipation of a panic attack that
would be witnessed by others.
By now it should be evident that PTSD has
not only a variety of dimensions and components, but vastly different
effects and implications. Some trauma survivors are continually
reminded of their victimization and experience relief when they
tell the details to others. Some survivors are humiliated by their
dehumanization or laden with guilt for harming another person.
They refuse to discuss details. Some are dazed, moving in and
out of trance-like states. Some are full of fear, hypervigilant,
easily startled, unable to concentrate, wary of strangers. The
syndrome may be evident soon after the trauma or may emerge years
later.
Acute Stress Disorder
In 1994, a variant of PTSD was added to
the official list of diagnoses: Acute Stress Disorder. This term
is used to describe early effects lasting more than two days but
no more than four weeks. To qualify for ASD, a trauma survivor
must have the PTSD triad of intrusive recollections, avoidance
and anxiety, and also must have several dissociative symptoms
- at least three of the following five:
- A sense of numbing, detachment, and
absence of emotional responses.
- A reduction in awareness of surroundings,
being in a daze.
- De-realization. (The immediate environment
seems unreal, as though it were a movie or a play.)
- Depersonalization. (The self is experienced
as altered, unreal, an actor, a fictional character.)
- Dissociative amnesia. (There are gaps
in memory that cannot be explain by head injury, drug use or
other physical causes.)
The distinction between Acute Stress Disorder
and Post-Traumatic Stress Disorder is important for clinical research
and therapy: Why do some people have persistent symptoms while
others have only short-term effects? What treatments effectively
reduce the immediate and the chronic disabilities? For journalists,
however, it is enough to know that Acute Stress Disorder and Post-Traumatic
Stress Disorder are closely related conditions, almost indistinguishable,
except for timing. ASD refers to debilitating recollections, numbing,
avoidance and anxiety up to a month after a traumatic episode,
and PTSD refers to the continuation of those symptoms thereafter.
Who gets PTSD?
What do we know about vulnerability to
PTSD? Long before there was a PTSD diagnosis, there was a body
of theory and research regarding coping. Scientists described
copers as those who faced major life transitions and major life
disruptions while still achieving four goals:
- they successfully accomplished necessary
tasks;
- they maintained relationships with significant
others;
- they preserved self-esteem;
- they kept anxiety within tolerable limits.
Populations of copers and non-copers were
studied among students adapting to out-of-town colleges, children
entering puberty, soldiers with extensive third-degree burns at
an Army hospital, and many other populations. The coping mechanisms
that enabled some to thrive while others failed or suffered (or,
in the case of the badly burned soldiers, lost their lives) included
denial, role rehearsal, information gathering, positive use of
fantasy or imagination and the ability to anticipate and devalue
failure. For example, soldiers with 50 percent body burns who
denied - who kept from conscious awareness - the realization that
they would be disfigured and that their recovery would be painful,
had a better rate of survival than those who, early on, recognized
grim reality. Of course, there comes a time when unfortunate consequences
must be accepted. Copers delayed such acceptance until their electrolytes
had stabilized and physical healing had begun.
Two employees of the US Information Agency
were captured and held in isolation near Lebanon for 18 months
by terrorists of the PFLP (Popular Front of the Liberation of
Palestine). I interview both men six month later in Washington,
D.C.. The one who coped well occupied his mind while in captivity
by visualizing the designs for a house, down to the last detail.
He categorized favorite restaurants (including the one in which
our interview took place), anticipating future menus. He exercised
and kept his spirits up. I recall our conversation in 1978 as
pleasant for both of us.
The second interview, with his associate,
was far less comfortable. This man spoke guardedly, fearing foreign
agents would overhear. He had no sense of humor and smoked nervously.
During captivity, he counted bricks in his cell and paced. He
had no way of occupying his mind.
The men were treated equally in confinement
and released the same week. One celebrated freedom. The other
was disabled and diminished. I do not recall that either had flashbacks,
nightmares or intrusive recollections. Probably neither would
have therefore qualified for the diagnosis of PTSD, (which was
defined two years later). But one was a coper and the other was
not. One had conscious and unconscious coping mechanisms: denial
of danger, use of fantasy, positive thinking. The other, literally
a plodder, failed to cope.
Most current research shows that the intensity
and duration of traumatic events correlates positively with the
occurrence of PTSD. But individuals exposed to the same extreme
stress will vary in their responses. Heredity could play an important
role. Just as some children are born shy and others exhibit a
bolder temperament, some of us are born with the brain pattern
that keeps horror alive, while others quickly recover. As a varied,
interdependent human species, we benefit from our differences.
Those with daring fight the tigers. Those with PTSD preserve the
impact of cruelty for the rest of us.
An interesting experiential (rather than
hereditary) theory posits that minor traumas, successfully resolved
in childhood, protect against major psychological stressors later
on, much as an attenuated virus creates immunity to full-blown
infection. Other theories emphasize the presence or absence of
social supports, sustaining religious and spiritual beliefs, use
of drugs and alcohol, coexisting medical and emotional disorders
and the age of the trauma survivor.
When children are traumatized, they often
regress. A preschooler will wet the bed, even though he or she
has been toilet-trained for a year. A verbal child may not speak.
Severe childhood traumas will disrupt personality development
and therefore pose major lifelong challenges. Reviewing the relatively
high incidence of PTSD in Viet Nam compared to other conflicts,
researchers noted the younger age of the soldier, the public disapproval
of the war, and the fact that rotations were individual and not
by unit. This meant that veterans were forced to cope with the
demands of adolescence as well as those of war. Their identities
were not complete; they lacked adult experience. They may have
faced ridicule by war protesters back home. There were no comrades-in-arms
to offer support. None of these factors cause PTSD. But each makes
coping with it more difficult and compounds the impact of the
disorder.
I tell patients with PTSD that there is
nothing abnormal about those who suffer. It is a normal reaction
of abnormal events. Anyone could have PTSD, given enough trauma.
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