It's been called shell shock, battle
fatigue, accident neurosis and post rape syndrome. It has often been
misunderstood or misdiagnosed, even though the disorder has very specific
symptoms that form a definite psychological syndrome.
The disorder is post-traumatic
stress disorder (PTSD) and it affects hundreds of thousands of people who have
been exposed to violent events such as rape, domestic violence, child abuse,
war, accidents, natural disasters and political torture. Psychiatrists estimate
that up to one to three percent of the population have clinically diagnosable
PTSD. Still more show some symptoms of the disorder.
While it was once thought to be a
disorder of war veterans who had been involved in heavy combat, researchers now
know that PTSD can result from many types of trauma, particularly those that
include a threat to life. It afflicts both females and males.
In some cases the symptoms of PTSD
disappear with time, while in others they persist for many years. PTSD often
occurs with other psychiatric illnesses, such as depression.
Not all people who experience trauma
require treatment; some recover with the help of family, friends, a pastor or
rabbi. But many do need professional help to successfully recover from the
psychological damage that can result from experiencing, witnessing or
participating in an overwhelmingly traumatic event.
Although the understanding of
post-traumatic stress disorder is based primarily on studies of trauma in
adults, PTSD also occurs in children as well. It is known that traumatic
occurrences--sexual or physical abuse, loss of parents, the disaster of
war--often have a profound impact on the lives of children. In addition to PTSD
symptoms, children may develop learning disabilities and problems with attention
and memory. They may become anxious or clinging, and may also abuse themselves
or others.
Symptoms
The symptoms of PTSD may initially
seem to be part of a normal response to an overwhelming experience. Only if
those symptoms persist beyond three months do we speak of them being part of a
disorder. Sometimes the disorder surfaces months or even years later.
Psychiatrists categorize PTSD's symptoms in three categories: intrusive
symptoms, avoidant symptoms, and symptoms of hyper arousal.
Intrusive Symptoms
Of ten people suffering from PTSD
have an episode where the traumatic event "intrudes" into their
current life. This can happen in sudden, vivid memories that are accompanied by
painful emotions. Sometimes the trauma is "re-experienced." This is
called a flashback_a recollection that is so strong that the individual thinks
he or she is actually experiencing the trauma again or seeing it unfold before
his or her eyes. In traumatized children, this reliving of the trauma often
occurs in the form of repetitive play.
At times, the re-experiencing occurs
in nightmares. In young children, distressing dreams of the traumatic event may
evolve into generalized nightmares of monsters, of rescuing others or of threats
to self or others.
At times, the re-experience comes as
a sudden, painful onslaught of emotions that seem to have no cause. These
emotions are often of grief that brings tears, fear or anger. Individuals say
these emotional experiences occur repeatedly, much like memories or dreams about
the traumatic event.
Symptoms of Avoidance
Another set of symptoms involves
what is called avoidance phenomena. This affects the person's relationships with
others, because he or she often avoids close emotional ties with family,
colleagues and friends. The person feels numb, has diminished emotions and can
complete only routine, mechanical activities. When the symptoms of
"re-experiencing" occur, people seem to spend their energies on
suppressing the flood of emotions. Often, they are incapable of mustering the
necessary energy to respond appropriately to their environment: people who
suffer post-traumatic stress disorder frequently say they can't feel emotions,
especially toward those to whom they are closest. As the avoidance continues,
the person seems to be bored, cold or preoccupied. Family members often feel
rebuffed by the person because he or she lacks affection and acts mechanically.
Emotional numbness and diminished
interest in significant activities may be difficult concepts to explain to a
therapist. This is especially true for children. For this reason, the reports of
family members, friends, parents, teachers and other observers are particularly
important.
The person with PTSD also avoids
situations that are reminders of the traumatic event because the symptoms may
worsen when a situation or activity occurs that reminds them of the original
trauma. For example, a person who survived a prisoner-of-war camp might
overreact to seeing people wearing uniforms. Over time, people can become so
fearful of particular situations that their daily lives are ruled by their
attempts to avoid them.
Others--many war veterans, for
example--avoid accepting responsibility for others because they think they
failed in ensuring the safety of people who did not survive the trauma. Some
people also feel guilty because they survived a disaster while
others--particularly friends or family--did not. In combat veterans or with survivors
of civilian disasters, this guilt may be worse if they witnessed or participated
in behavior that was necessary to survival but unacceptable to society. Such
guilt can deepen depression as the person begins to look on him or herself as
unworthy, a failure, a person who violated his or her pre-disaster values.
Children suffering from PTSD may show a marked change in orientation toward the
future. A child may, for example, not expect to marry or have a career. Or he or
she may exhibit "omen formation," the belief in an ability to predict
future untoward events.
PTSD sufferers' inability to work
out grief and anger over injury or loss during the traumatic event mean the
trauma will continue to control their behavior without their being aware of it.
Depression is a common product of this inability to resolve painful feelings.
Symptoms of Hyper arousal
PTSD can cause those who suffer with
it to act as if they are threatened by the trauma that caused their illness.
People with PTSD may become irritable. They may have trouble concentrating or
remembering current information, and may develop insomnia. Because of their
chronic hyper arousal, many people with PTSD have poor work records, trouble
with their bosses and poor relationships with their family and friends.
The persistence of a biological
alarm reaction is expressed in exaggerated startle reactions. War veterans may
revert to their war behavior, diving for cover when they hear a car backfire or
a string of firecrackers exploding. At times, those with PTSD suffer panic
attacks, whose symptoms include extreme fear resembling that which they felt
during the trauma. They may feel sweaty, have trouble breathing and may notice
their heart rate increasing. They may feel dizzy or nauseated. Many traumatized
children and adults may have physical symptoms, such as stomachaches and
headaches, in addition to symptoms of increased arousal.
Other Associated Features
Many people with PTSD also develop
depression and may at times abuse alcohol or other drugs a
"self-medication" to blunt their emotions and forget the trauma. A
person with PTSD may also show poor control over his or her impulses, and may be
at risk for suicide.
Treatment
Psychiatrists and other mental
health professionals today have effective psychological and pharmacological
treatments available for PTSD. These treatments can restore a sense of control
and diminish the power of past events over current experience. The sooner people
are treated, the more likely they are to recover from a traumatizing experience.
Appropriate therapy can help with other chronic trauma-related disorders, too.
Psychiatrists help people with PTSD
by helping them to accept that the trauma happened to them, without being
overwhelmed by memories of the trauma and without arranging their lives to avoid
being reminded of it.
It is important to re-establish a
sense of safety and control in the PTSD sufferer's life. This helps him or her
to feel strong and secure enough to confront the reality of what has happened.
In people who have been badly
traumatized, the support and safety provided by loved ones is critical. Friends
and family should resist the urge to tell the traumatized person to "snap
out of it," instead allowing time and space for intense grief and mourning.
Being able to talk about what happened and getting help with feelings of guilt,
self-blame, and rage about the trauma usually is very effective in helping
people put the event behind them. Psychiatrists know that loved ones can make a significant
difference in the long-term outcome of the traumatized person by being active
participants in creating a treatment plan--helping him or her to communicate and
anticipating what he or she needs to restore a sense of equilibrium to his or
her life. If treatment is to be effective it is important, too, that the
traumatized person feel that he or she is a part of this planning process.
Sleeplessness and other symptoms of hyper arousal
may interfere with recovery and increase preoccupation with the traumatizing
experience. Psychiatrists have several medications--including benzodiazepines
and the new class of serotonin re-uptake blockers--that can help people to sleep
and to cope with their hyper arousal symptoms. These medications, as part of an
integrated treatment plan, can help the traumatized person to avoid the
development of long-term psychological problems.
In people whose trauma occurred
years or even decades before, the professionals who treat them must pay close
attention to the behaviors--often deeply entrenched--which the PTSD sufferer has
evolved to cope with his or her symptoms. Many people whose trauma happened long
ago have suffered in silence with PTSD's symptoms without ever having been able
to talk about the trauma or their nightmares, hyper arousal, numbing, or
irritability. During treatment, being able to talk about what has happened and
making the connection between past trauma and current symptoms provides people
with the increased sense of control they need to manage their current lives and
have meaningful relationships.
Relationships are often a trouble
spot for people with PTSD. They often resolve conflicts by withdrawing
emotionally or even by becoming physically violent. Therapy can help PTSD
sufferers to identify and avoid unhealthy relationships. This is vital to the
healing process; only after the feeling of stability and safety is established
can the process of uncovering the roots of the trauma begin.
To make progress in easing
flashbacks and other painful thoughts and feelings, most PTSD sufferers need to
confront what has happened to them, and by repeating this confrontation, learn
to accept the trauma as part of their past. Psychiatrists and other therapists
use several techniques to help with this process.
One important form of therapy for
those who struggle with post-traumatic stress disorder is cognitive/behavior
therapy. This is a form of treatment that focuses on correcting the PTSD
sufferer's painful and intrusive patterns of behavior and thought by teaching
him or her relaxation techniques, and examining (and challenging) his or her
mental processes. A therapist using behavior therapy to treat a person with PTSD
might, for example, help a patient who is provoked into panic attacks by loud
street noises by setting a schedule that gradually exposes the patient to such
noises in a controlled setting until he or she becomes "desensitized"
and thus is no longer so prone to terror. Using other successful techniques,
patient and therapist explore the patient's environment to determine what might
aggravate the PTSD symptoms and work to reduce sensitivity or to learn new
coping skills.
Psychiatrists and other mental
health professionals also treat cases of PTSD by using psychodynamic
psychotherapy. Post-traumatic stress disorder results, in part, from the
difference between the individual's personal values or view of the world and the
reality that he or she witnessed or lived during the traumatic event.
Psychodynamic psychotherapy, then, focuses on helping the individual examine
personal values and how behavior and experience during the traumatic event
violated them. The goal is resolution of the conscious and unconscious conflicts
that were thus created. In addition, the individual works to build self-esteem
and self-control, develops a good and reasonable sense of personal
accountability and renews a sense of integrity and personal pride.
Whether PTSD sufferers are treated
by therapists who use cognitive/behavioral treatment or psychodynamic treatment,
traumatized people need to identify the triggers for their memories of trauma,
as well as identifying those situations in their lives in which they feel out of
control and the conditions that need to exist for them to feel safe. Therapists
can help people with PTSD to construct ways of coping with the hyper arousal and
painful flashbacks that come over them when they are around reminders of the
trauma. The trusting relationship between patient and therapist is crucial in
establishing this necessary feeling of safety. Medications can help in this
process also.
Group therapy can be an important
part of treatment for PTSD. Trauma often affects people's ability to form
relationships--especially such traumas as rape or domestic violence. It can
profoundly affect their basic assumption that the world is a safe and
predictable place, leaving them feeling alienated and distrustful, or else
anxiously clinging to those closest to them. Group therapy helps people with
PTSD to regain trust and a sense of community, and to regain their ability to
relate in healthy ways to other people in a controlled setting.
Most PTSD treatment is done on an outpatient basis. However, for people whose symptoms
are making it impossible to function or for people who have developed additional symptoms
as a result of their PTSD, inpatient treatment is sometimes necessary to create the vital
atmosphere of safety in which they can examine their flashbacks, re-enactments of the
trauma, and self-destructive behavior. Inpatient treatment is also important for PTSD
sufferers who have developed alcohol or other drug problems as a result of their attempts
to "self medicate." Occasionally too, inpatient treatment can be very useful in
helping a PTSD patient to get past a particularly painful period of their therapy.
The recognition of PTSD as a major health problem in this country is quite recent. Over
the past 15 years, research has produced a major explosion of knowledge about the ways
people deal with trauma--what places them at risk for development of long-term problems,
and what helps them to cope. Psychiatrists and other mental health professionals are
working hard to disseminate this understanding, and an increasing number of mental health
professionals are receiving specialized training to help them reach out to people with
Post-traumatic Stress Disorder in their communities.
Bibliography
General Information
Burgess, Ann Wolbert. Rape: Victims of Crisis. Bowie, Maryland: Robet J. Brady, Co.,
1984.
