PTSD 101

Adjustment Disorder

There are psychiatric disorders other than PTSD and ASD that follow traumatic events. Most commonly, the diagnosis is an Adjustment Disorder. This is a relatively mild, relatively brief disruption of functioning. Mood may be anxious or depressed or both. Conduct, especially in children, may be impaired. The diagnosis is often applied during marital and occupational difficulties and need not have a major trauma to justify its use. When a major trauma causes minor impairment, but enough disability to warrant psychiatric treatment, the diagnosis will be Adjustment Disorder. At the other end of the spectrum are psychotic and severe dissociative states. These are not common.

Psychosis is usually defined as a break with reality. Brief psychotic disorder may include hallucinations and delusions unrelated to the trauma. Voices may order the person to harm another or to harm himself, even though the trauma had no such content. Delusions are fixed false beliefs, often of persecution or grandiosity or both. Delusions may be intricate and bizarre, with or without accompanying hallucinations.

Dissociation is an altered state of consciousness. One is not oneself, but not out of touch with reality. In a fugue state, people can travel long distances for no apparent reason, converse with strangers, appear normal, have no hallucination and no delusion, but eventually return to their original self and original awareness, baffled by finding themselves in a city hundreds of miles from home. Depersonalization, de-realization, psychogenic amnesia and multiple personality are also dissociative conditions.

I once evaluated a young gay man in Florida who stabbed his lover-roommate 17 times, after being attacked himself. This man had no prior history of violent behavior, no grudge against the roommate and no memory of anything between the onset of the altercation and calling the police. In my pinion, he had a brief psychotic disorder and psychogenic amnesia (a combination of psychosis and dissociation). The jury agreed.

Many traumatized people will develop physical diseases or exacerbate preexisting conditions. Psychosomatic pathways are involved, so these medical problems have psychiatric labels as well. The cardiovascular system, the gastrointestinal tract and the respiratory system are well recognized by the general public as vulnerable to stress. Hypertension, heart attack, stroke, ulcers and asthma can follow intense events.

A baffling array of symptoms follows exposure to organic compounds in war zones. The effects of Agent Orange and Gulf War Syndrome are examples. Neurologic, psychologic and other medical symptoms are difficult to diagnose and treat. We still do not know, with certainty, how various organic toxins impair brain function and why some people who may have been exposed have far more disability than others. Symptoms include short-term memory deficit, reduced intellectual function, concentration problems, fatigue, chronic pain and depression.

A very different, well-publicized post-traumatic condition was known until recently as Multiple Personality Disorder (MPD). It is now renamed Dissociative Identity Disorder (DID). More than 90 percent of the sufferers are female and more than 90 percent were abused as children, often father-daughter incest. There are many more cases in treatment in the United States than anywhere else in the world.

I am convinced that incest is a major problem in many countries. Currently, there is a debate raging about false memories, pitting adults who recall childhood sexual abuse decades later against parents who deny being sexual abusers. Hospital records and child protective services document hundreds of thousands of cases of child sexual abuse each year in this country and roughly half involve fathers or stepfathers, so there can be no doubt that incest is occurring.

Both boys and girls are usually abused by men. The children chosen for these deviant acts are quite young, five or six being the preferred age. One way that little girls defend themselves psychologically is by going into a trance. Little Mary says to herself, "Daddy isn't doing this to me, he's doing it to Belinda." Belinda exists, at first, only during abuse episodes. She is an altered state of consciousness, or, in the language of DID specialists, "an alter." As she matures, her personality develops. She becomes a separate self who may or may not communicate with Mary. If this separation into two personalities is effective, Mary may then generate three or four - or dozens - of alters in response to abuse and other life traumas.

Why are there so few male "multiples"? It may be that men end up in prison rather than in a therapist's office. It may be that they respond aggressively rather than passively to parental abuse. There is certainly confusion and controversy in the field. But no one should doubt that father-daughter incest is a pervasive problem and that the emotional damage is profound. The worse trauma is often the incest secret, not the sexual activity itself. Whether or not Dissociative Identity Disorder occurs, there will be problems with intimacy, self-esteem and trust. The PTSD elements of flashback and anxiety are not as prominent as the distorted relationships with father and mother and the damage to a coherent sense of self. Multiple selves are the ultimate incoherence.

Victims of human cruelty (as opposed to victims of natural disasters) experience additional emotional difficulties which are not listed in the official diagnostic manual and are not part of PTSD. Foremost among these is shame. Although violent criminals should feel ashamed, they seldom do. Instead, the victim who has been beaten, robbed or raped is humiliated. This person has been abruptly dominated, subjugated, stripped of dignity, invaded and made, in his or her own mind, into a lower form of life.

Who cannot recall being bullied as a child, forced to admit weakness, mortified by the process? As an adult, this shame quickly becomes self- blame: Why was I there? What could I have done differently? Why did I let it happen? Self-blame may actually be a good sign, correlating with self- reliance and self-regard. But it may also be hostility turned inward, a relentless self-criticism and downward spiral into profound depression.

Hatred is another human emotional response to trauma with no reference in the diagnostic manual. Victims of cruelty are entitled to hate their abusers, on the path to recovery and possible forgiveness. But survivors often do less hating than one might expect. Sometimes they are simply grateful to be alive. They may, ironically and paradoxically, love the kidnapper who could have killed them, but instead gave them life. This is called the Stockholm Syndrome, named for the bizarre outcome in a bank vault in Sweden in 1974 when the hostage-taker, Olsson, and the bank teller, Kristin, fell in love and had sex during the siege. Like Patty Heart and countless others, Kristin denied that her assailant was a villain, but responded passionately to his power to spare her life.

It is the Mothers Against Drunk Drivers who are MADD. The co-victims, the next of kin of the injured and dead, are more often the ones moved to rage and vengeance, if not hatred. Obsessive hatred is a corrosive condition, seldom the focus of psychiatric treatment, but of major concern to historians and journalists.

This is a good point to pause and consider the ultimate reason for a new theme in journalism education: in-depth coverage of the way victims experience emotional wounds, particularly wounds that are deliberately and cruelly inflicted.

A relatively recent area of clinical science, traumatic stress studies, teaches us that victims of violence have several distinguishable patterns of emotional response. These patterns are easily recognized once their outlines are understood. Seeing the logic in a set of psychological consequences re-humanizes and dignifies a person who may feel dehumanized and robbed of dignity. The process of recovering from post-traumatic wounds, with or without expert help, is beyond the scope of this chapter. But a sensitive explanation of the traumatic stress response aids recovery. And when we as a society pay attention to the victim as he or she heals, we are less likely to be consumed by hate, focused on perpetrators, contributing to a contagion of cruelty.

Journalists can report on victims, help victims as multi-dimensional human beings and possibly, just possibly, reduce the impulse toward vengeance in the process.