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PTSD: A Primer, part 1
by Peter Goetz, MFT

The letters PTSD have attained an institutional place now in American culture, letters that most people have heard of through the media or from friends, co-workers, family members.......or therapists. PTSD, of course, stands for Post Traumatic Stress Disorder, the working name for a wide set of symptoms, responses, behaviors and conditions people exhibit arising from trauma experienced in their lives.

PTSD has been around a long time but wasn't named as such until 1980 when the APA DSM, 3rd edition* first listed it as a diagnosis. Before that it was called shell shock during World War I and later in World War II as battle fatigue. Both described the intense and debilitating reactions seen in soldiers returning from war. Vietnam War veterans returning with highly visible psychological scars combined with the influence of the women's movement of the 1970s showed that traumatized people, those who had witnessed or been participants in prolonged and intense interpersonal violence, exhibited impairments and symptom profiles that were strikingly similar. Hence, the naming of the condition now called PTSD.

Successive editions and revisions of the DSM have expanded the frame of what establishes a PTSD diagnosis. With humans being the individualized and complex creatures that we are, no 2 people experience the after-effects of trauma in the same way. DSM's description goes a considerable way in sketching a expansive understanding of what PTSD is and how it effects people. That defining process continues in a direction that's more inclusive of the full scope and complexity of trauma. DSM's 5th edition was recently released and with it, another rewriting and expansion of PTSD's diagnosis. Rather than detailing the changes and revisions brought forth with the new edition, let's look at the broad groupings of behaviors and experience that are laid out as criteria that fits PTSD.

PTSD outlines 4 major areas of impairment in functioning following stress exposure, either directly or indirectly to a situation where death, the potential of sexual violence or threatened injury is imminent.

  1. Intrusive symptoms, such as nightmares, dreams, dissociative experiences, intense or prolonged distress when exposed to reminders of the traumatic incident or flashbacks of the incident or physiological distress at recollecting event.
  2. Persistent avoidance symptoms of reminders or triggers of the event either internally (avoiding thoughts or feelings or memories) or external (avoidance of external reminders (people, places, activities, situations)
  3. Negative alterations in cognition and mood, such as inability to recall key aspects of traumatic situation, distortions beliefs about oneself, any perpetrators involved and the world in general, persistent distorted blame of self/others as being at cause for trauma, negative trauma related feelings and also difficulty feeling any positive feelings, diminished interest in usual activities and involvements and a sense of alienation from self
  4. Alterations of arousal and reactivity, such as irritability, hyper vigilance, reckless behaviors, problems in concentration and sleep disturbance.

These stand as diagnostic descriptions** of PTSD. Here's some of the qualitative felt experiences, that is, the interior landscape of PTSD and trauma. Not an exhaustive list but sketches to gather a wider view of PTSD and trauma.

* The experience of trauma is often beyond the scope of words to describe. The advent of brain scans (both fMRI and PET) show the neurological impact of trauma functioning on a sub-cortical level, meaning below levels of conscious awareness. Trauma is largely a right-brain phenomenon, experienced as body sensations, small-detailed impressions or strongly felt emotion with no known reason why. This is why trauma is a bottom-up process. It's often first experienced below the level of time-linked memory or thoughts and feelings. Later, these can be associated, linked into a larger mosaic of personal history and meaning but they don't begin there.

* Since trauma is a bottom-up process, people react (vs. respond) to situations and triggers that are reminiscent of the trauma long after the original event has passed. People in reactive mode often don't know why charged situations they've encountered carry the strength they have. They - and the people around them - may observe these reactions with a 'where the hell did that come from?' response. It is only from fully accessing our thoughts and feelings and being able to reflect upon them and then give them meaning that we respond to painful conditions met in our lives.

* Trauma, by nature, overwhelms our adaptive capacities to cope with what we're confronted with. As such, it is de-resourcing. It takes away from what we come to rely on (knowingly or otherwise) to function, cope, relate and walk about with in our lives. Trauma leaves us feeling in deficit. Palpable experiences of confusion, despair, fear, overwhelm and anxiety are left in its wake. These are biological as well as psychological stress responses.

* A compromised sense of safety is always a factor in trauma response. The innate sense of a protective boundary around ourselves that we take for granted is broached. People are left feeling unsafe in the world at large and in their own bodies. They feel de-stabilized. For many, there is a decreased attachment to life and to their own lives leaving some with feelings of episodic or ongoing suicidally. Feeling an assured security in our bodies should never be assumed with trauma survivors.

* Trauma can threaten our lives and as such our most basic survival strategies are summoned into action. Fight/flight responses are part of this. When a stressful situation is initially encountered, we orient ourselves to the perceived threat, then react through Fight (intensity of affect, by voice, by fists, by making ourselves big) as best we can. If the threat overwhelms us, is too big to be dealt with we respond by taking Flight (running, absenting ourselves through dissociation, addiction or chaos) or by submitting through stillness, becoming quiet, making ourselves small. As mammals, survival is hard-wired in us and as humans, we are supremely skilled at strategizing our own survival.

* Traumatized people often feel an ambient level of vigilance or watchfulness to their surroundings. This, again, is survival based. This is akin to the predator-prey reactions observed with any mammal interchange. Vigilance can take the form of overt watching but may also be more subtle and felt as mistrust, a need for interpersonal distancing or through body tension or readiness, as if the body itself is ready to take action if called to.

* Trauma is a full body experience and as such, effects all body systems. When threat or perceived threat is encountered, a cascade of biochemical, hormonal and physiological events unfold. If the threat is ongoing, these linked systems are 'set off' and fire at lower levels of threat. This is called kindling, a word coined to describe cue-related arousal stemming from seemingly small events. Our bodies become bathed in hormones (e.g., cortisol and adrenaline) that function best as stress responses, not repeating ones. Over time and chronic exposure to trauma, our bodies bear the burden*** of this with known health implications. Numerous chronic health problems have been linked with unresolved trauma and include endocrine problems, hypertension, obesity, cardiovascular disease and, perhaps most notably, chronic pain.

* Trauma disrupts our ability to balance our internal emotional state; our nervous system with its own internal homeostasis, different for every person, becomes disrupted and we are sent us into hyper-arousal (marked by agitation, anxiety, a sense of nerves being frayed) or hypo-arousal (marked by numbing, decreased responsiveness to the world, depression, dissociation) or sometimes, rapid shifts between both extremes. Our nervous systems operate as basic internal operating systems and when they're thrown off, thoughts, feelings, sensations follow that dysregulate the whole of us.

* Trauma is about complexity. Every system of the body-mind-spirit is impacted and inter-connectedly involved. Research shows that trauma effects and changes brain circuitry and structure. Trauma as a full bodied experience impacts and colors how we see ourselves, others, life as a whole and our potential to be active agents in our lives and the vast interconnectedness of the world.

 

American Psychiatric Association, Diagnostic and Statistical Manual (DSM)
** diagnostic descriptions as listed in DSM, 5th edition.
*** thanks to Bessel van der Kolk for the coining of the phrase 'body bears the burden.'

this article was published in condensed form in psyched magazine at psychedinsanfrancisco.com

 

(c) 2014 Peter Goetz

 

 

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