Post-Traumatic Stress Disorder:

-Birdy

After an extreme psychological trauma, people tend to respond with stress symptoms that include re-experiencing the trauma through nightmares or unwanted thoughts, avoiding reminders of the traumatic event, loss of interest in daily life, and increased arousal; these symptoms can range from mild and temporary to severe, chronic, and psychologically disabling.

Introduction

It is common knowledge that there are psychological aftereffects from experiencing an intense psychological trauma. This discussion of post-traumatic stress symptoms will be organized around post-traumatic stress disorder (PTSD), one of the diagnostic categories of anxiety disorders recognized by the American Psychiatric Association. It should be realized at the outset, however, that it is normal for people to experience at least some of these symptoms after suffering a psychological trauma. The first step in understanding PTSD is to know its symptoms.

The first criterion for PTSD is that one has suffered a trauma. The American Psychiatric Association’s definition of PTSD states that the trauma must be something that “is outside the range of usual human experience and that would be markedly distressing to almost anyone.” It is not so much the objective event as one’s perception of it that determines the psychological response. For example, the death of one’s parents is not “outside the range of usual human experience,” but it can result in some of the symptoms described later. Some of the traumatic experiences deemed sufficient to cause PTSD include threat to one’s own life or the life of a close relative or friend, sudden destruction of one’s home or community, seeing another person violently injured or killed, or being the victim of a violent crime. Specific experiences that often cause PTSD include combat, natural or man-made disasters, automobile accidents, airplane crashes, rape, child abuse, and physical assault. In general, the more traumatic the event, the worse the post-traumatic symptoms. Symptoms of stress are often more severe when the trauma is sudden and unexpected. In addition, when the trauma is the result of intentional human action (for example, combat, rape, or assault), stress symptoms are worse than when the trauma is a natural disaster (flood or earthquake) or an accident (automobile crash). It has been found that combat veterans who commit or witness atrocities are more likely than their comrades to suffer later from PTSD.

The central symptom of post-traumatic stress disorder is that the person reexperiences the trauma. This can occur in a number of ways. The person can have unwanted, intrusive, and disturbing thoughts of the event or nightmares about the trauma. The most dramatic means of reexperiencing is through a flashback, in which the person acts, thinks, and feels as if he or she were reliving the event. Another way in which reexperiencing might be manifested is intense distress when confronted with situations that serve as reminders of the trauma. Vietnam veterans with combat-related PTSD will often become very upset at motion pictures about the war, hot and humid jungle-like weather, or even the smell of Asian cooking. A person with PTSD often will attempt to avoid thoughts, feelings, activities, or events that serve as unwanted reminders of the trauma.

Another symptom that is common in people with PTSD is numbing of general responsiveness. This might include the loss of interest in hobbies or activities that were enjoyed before the trauma, losing the feeling of closeness to other people, an inability to experience strong emotions, or a lack of interest in the future. A final set of PTSD symptoms involves increased arousal. This can include irritability, angry outbursts, and problems with sleeping and concentrating. A person with PTSD may be oversensitive to the environment, always on the alert, and prone to startle at the slightest noise.

The paragraphs above summarize the symptoms that psychologists and psychiatrists use to diagnose PTSD; however, other features are often found in trauma survivors that are not part of the diagnosis. Anxiety and depression are common in people who have experienced a trauma. Guilt is common in people who have survived a trauma in which others have died. People will sometimes use alcohol or tranquilizers to cope with sleep problems, disturbing nightmares, or distressing, intrusive recollections of a trauma, and they may then develop dependence on the drugs.

Post-traumatic stress disorder is relatively common in people who suffer serious trauma. In the late 1980’s, the most extensive survey on PTSD ever done was undertaken on Vietnam combat veterans. It found that more than half of all those who served in the Vietnam theater of operations had experienced serious post-traumatic stress at some point in their lives after the war. This represents about 1.7 million veterans. Even more compelling was the fact that more than one-third of the veterans who saw heavy combat were still suffering from PTSD when the survey was done-about fifteen years after the fall of Saigon. Surveys of crime victims are also sobering. One study found that 75 percent of adult females had been the victim of a crime, and more than one in four of these victims developed PTSD after the crime. Crime victims were even more likely to develop PTSD if they were raped, were injured during the crime, or believed that their lives were in danger during the crime.

Symptoms of post-traumatic stress are common after a trauma, but they often decrease or disappear over time. A diagnosis of PTSD is not made unless the symptoms last for at least one month. Sometimes a person will have no symptoms until long after the event, when memories of the trauma are triggered by another negative life event. For example, a combat veteran might cope well with civilian life for many years until, after a divorce, he begins to have nightmares about his combat experiences.

From War to Everyday Life

Most of the theory and research regarding PTSD have been done on combat veterans, particularly veterans of the Vietnam War. One of the most exciting developments in this area, however, is that the theory and research are also being applied to victims of other sorts of trauma. This has a number of important implications. First, it helps extend the findings about PTSD beyond the combat-veteran population, which is mostly young and male. Second, information gathered from combat veterans can be used to assist in the assessment and treatment of anyone who has experienced a serious trauma. Because a large proportion of the general population experiences severe psychological trauma at some time, understanding PTSD is important to those providing mental health services.

An extended example will illustrate the application of theory and research findings on PTSD to a case of extreme psychological trauma.  This trauma can be so severe as to cause psychological debilitating behavior.  The case involves a woman who was attacked and raped at knife-point one night while walking from her car to her apartment. Because of injuries suffered in the attack, she went to an emergency room for medical treatment. Knowledge about PTSD can help in understanding this woman’s experience and could aid her in recovery.

First, research has shown that this woman’s experience-involving rape, life threat, and physical injury-puts her at high risk for symptoms of post-traumatic stress. Risk is so great, in fact, that researchers have proposed that psychological counseling be recommended to all people who are the victims of this sort of episode. This suggestion is being implemented in many rape-recovery and crime-victim programs around the United States.

Knowing what symptoms are common following a traumatic event can help professionals counsel a victim about what to expect. This woman can expect feelings of anxiety and depression, nightmares and unwanted thoughts about the event, irritability, and difficulties in sleeping and concentrating. Telling a victim that these are normal responses and that there is a likelihood that the problems will lessen with time is often reassuring. Since research has shown that many people with these symptoms cope by using drugs and alcohol, it may also help to warn the victim about this possibility and caution that this is harmful in the long run.

One symptom of PTSD-psychological distress in situations that resemble the traumatic event-suggests why combat veterans who experience their trauma in a far-off land often fare better than those whose trauma occurs closer to home. Women who are raped in their home or neighborhood may begin to feel unsafe in previously secure places. 

Some cope by moving to a different house, a new neighborhood, or even a new city-often leaving valued jobs and friends. If an attack occurred after dark, a person may no longer feel safe going out after dark and may begin living a restricted social life. Frequently, women who are raped generalize their fear to all men and especially to sexual relations, seriously damaging their interpersonal relationships. Given the problems that these post-traumatic symptoms can cause in so many areas of one’s life, it may not be surprising that one study found that nearly one in every five rape victims attempted suicide within the first few months after the rape.

The main symptoms of post-traumatic stress are phobialike fear and avoidance of trauma-related situations, thoughts, and feelings, and the most effective treatment for PTSD is the same as for a phobia. 

Systematic desensitization and flooding, which involve confronting the thoughts and feelings surrounding the traumatic event, are the treatments that appear to be most effective. It may seem paradoxical that a disorder whose symptoms include unwanted thoughts and dreams of a traumatic event could be treated by purposefully thinking and talking about the event; however, Mardi Horowitz, one of the leading theorists in traumatic stress, believes that symptoms alternate between unwanted, intrusive thoughts of the event and efforts to avoid these thoughts. Because intrusive thoughts always provoke efforts at avoidance, the event is never fully integrated into memory; it therefore retains its power. Systematic desensitization and flooding, which involve repeatedly thinking about the event without avoidance, allow time for the event to become integrated into the person’s life experiences so that the memory loses much of its pain.

Another effective way to reduce the impact of a traumatic event is through social support. People who have a close network of friends and family appear to suffer less from symptoms of trauma. After a traumatic experience, people should be encouraged to maintain and even increase their supportive social contacts, rather than withdrawing from people, as often happens. Support groups of people who have had similar experiences, such as Vietnam veteran groups or child-abuse support groups, also provide needed social support. These groups have the added benefit of encouraging people to talk about their experiences, which provides another way to think about and integrate the traumatic event.

Psychotherapy can help trauma victims in many ways. One way is to help the patient explore and cope with the way the trauma changes one’s view of the world. For example, the rape victim may come to believe that “the world is dangerous” or that “men can’t be trusted.” Therapy can help this person learn to take reasonable precautions without shutting herself off from the world and relationships. Finally, symptoms of over-arousal are common with PTSD. A therapist can address these symptoms by teaching methods of deep relaxation and stress reduction. Sometimes mild tranquilizers are prescribed when trauma victims are acutely aroused or anxious.

History

The concept of post-traumatic stress is very old and is closely tied to the history of human warfare. The symptoms of PTSD have been known variously as soldier’s heart, combat neurosis, and battle fatigue. Stephen Crane’s novel The Red Badge of Courage, first published in 1895, describes post-traumatic symptoms in a Civil War soldier. It was the postwar experiences of the Vietnam combat veteran, however, studied and described by scholars such as Charles Figley, that brought great attention to issues of post-traumatic stress. It was not until 1980 that the American Psychiatric Association recognized post-traumatic stress disorder in its manual of psychiatric disorders. Since then there has been an explosion of published research and books on PTSD, the creation of the Society for Traumatic Stress Studies in 1985, and the initiation of the quarterly Journal of Traumatic Stress in 1988. Since these developments, attention has also been directed toward post-traumatic symptoms in victims of natural disasters, violent crime, sexual and child abuse; Holocaust survivors; and many other populations. Surveys have found that more than 80 percent of college students have suffered at least one trauma potentially sufficient to cause PTSD, and many people seeking psychological counseling have post-traumatic stress symptoms. Thus, it is fair to say that the attention garnered by Vietnam veteran readjustment problems and by the recognition of PTSD as a disorder by the American Psychiatric Association has prompted the examination of many important issues related to post-traumatic stress.

Because research in this area is relatively new, many important questions remain unanswered. One mystery is that two people can have exactly the same traumatic experience, yet one will have extreme post-traumatic stress and one will have no problems. Some factors are known to be important; for example, young children and the elderly are more likely to suffer from psychological symptoms after a trauma. Much research is needed, however, to determine what individual differences will predict who fares well and who fares poorly after a trauma.

A second area of future development is in the assessment of PTSD. For the most part, it is diagnosed through a self-report of trauma and post-traumatic symptoms. This creates difficulty, however, when the person reporting the symptoms stands to gain compensation for the trauma suffered. Interesting physiological and cognitive methods for assessing PTSD are being explored. For example, researchers have found that Vietnam veterans with PTSD show high levels of physiological arousal when they hear combat-related sounds or imagine their combat experiences. Finally, the future will see more bridges built between post-traumatic stress and the more general area of stress and coping.

Sources for Further Study

Crane, Stephen. The Red Badge of Courage. Reprint. New York: Pearson/Longman, 2008. This classic novel vividly portrays post-traumatic symptoms in Civil War soldiers, particularly in the main character, young Henry Fleming; first published in 1895, the book has been called the first modern war novel.

Figley, Charles R., ed. Trauma and Its Wake: The Study and Treatment of Post-traumatic Stress Disorder. New York: Brunner/Mazel, 1985. This book is one of the most often cited references in the field of PTSD and contains some of the most influential papers written on the subject. It is divided into sections on theory, research, and treatment; a second volume with the same title was published in 1986. It is part of the Brunner/Mazel Psychosocial Stress Series, the first volume of which was published in 1978; through 1990, this valuable series had published twenty-one volumes on many aspects of stress and trauma.

Figley, Charles R., and Seymour Leventman, eds. Strangers at Home: Vietnam Veterans Since the War. 1980. Reprint. New York: Brunner/Mazel, 1990. Containing chapters by psychologists, sociologists, political activists, historians, political scientists, and economists, this book presents a look at the experience of the Vietnam veteran from different perspectives. Many of the authors were Vietnam veterans themselves, so the book has a very personal, sometimes stirring view of its subject.

Grinker, Roy Richard, and John P. Spiegal. Men Under Stress. Philadelphia: Blakiston, 1945. Long before the term “post-traumatic stress disorder” was coined, this classic book described the stress response to combat in Air Force flyers. It is written in jargon-free language by men who had unusual access to the flight crews.

Horowitz, Mardi Jon. Stress Response Syndromes. New York: Jason Aronson, 1976. Horowitz is one of the leading psychodynamic theorists in the area of post-traumatic stress. In this readable book, he describes his theory and his approach to treatment.

Kulka, Richard A. Trauma and the Vietnam War Generation. New York: Brunner/Mazel, 1990. Presents the results of the federally funded National Vietnam Veterans Readjustment Study. In contrast to Strangers at Home, which is a subjective view of the Vietnam veteran’s plight, this book is very factual. It contains dozens of tables and figures filled with statistics about the mental and physical health of Vietnam veterans. The same authors published The National Vietnam Veterans Readjustment Study: Tables of Findings and Technical Appendices in 1990. This companion volume contains hundreds of tables of detailed results from this comprehensive study.

Schiraldi, Glenn. The Post-Traumatic Stress Disorder Sourcebook: A Guide to Healing, Recovery, and Growth. New York: McGraw-Hill, 2009. Designed as a self-help program for those suffering from post-traumatic stress disorder, this book discusses emotional triggers, drug addiction, and successful treatments.

Smyth, Larry. Overcoming Post-Traumatic Stress Disorder—Therapist Protocol: A Cognitive-Behavioral Exposure-Based Protocol for the Treatment of PTSD and the Other Anxiety Disorders. Oakland, Calif.: New Harbinger, 2008. Written for the therapist, this book outlines a protocol that has worked successfully with those who are experiencing post-traumatic stress disorder. The sessions involve assessment, goal setting, developing coping skills, and assimilation.

For further study, you might want to search the Internet, though when I did it at the start of this Article, I received more than 380,000+ Hits.

-Birdy