Possibly most of the readers of this text will have come across the term “Post-Traumatic Stress Disorder” (PTSD) with regard to veterans returning home from war zones and having problems with reintegration. Still many people don’t realize that PTSD is also a normal reaction to traumatic events that happen outside of the military in everyday life – such as accidents, chronic illnesses or the death of a loved one. And although many people are familiar with the term, I noticed that most of the people using it are unsure about what it really means and the implications of the disorder on the lives of those affected.
For this reason, this text will deal with the psychological after-effects of trauma by taking a closer look at PTSD. Although its primary intention is to teach you about how it is diagnosed and its symptoms, it will also include statements of Mary [not her real name] – a friend of mine who was diagnosed with PTSD after experiencing sexual violence at the age of 16. The intention of doing so is to give you a more vivid picture of how PTSD feels in order to create a greater understanding and empathy towards those suffering from it.
Trigger warning: This text contains graphic descriptions of experiences and symptoms related to PTSD, including those from the dissociative spectrum. There are different triggers mentioned. There are no detailed descriptions of the act of rape as such or of self-harming behavior.
This is part two of a two-part series on trauma and its consequences. Part I gave a definition of the term „trauma“ and presented its neurophysiological effects.
In case you already forgot some of the main points, here are some of the things you could have learned in part I:
- Trauma is to be distinguished from a normal stressful event.
- The severity of the reaction to the trauma depends on its nature.
- Traumatic events are for example natural disasters, torture and rape. Those don’t necessarily need to be experienced directly as traumatization can occur merely through being a witness of a traumatic happening.
- There are different risk and protective factors that have an influence on how a traumatic experience is processed.
- There are different neurotransmitters and forms of neural conditioning involved in trauma, possibly causing dissociation and leading to the storage of traumatic memories in the implicit form as emotions, associations, and senses.
What Happens After the Traumatic Experience?
So, something bad happened. Something really bad. Something so unexpected and far out of your comfort zone that it shakes you to the core. What happens next?
“I really didn’t realize what happened after it was over. I remember walking into the bathroom and looking in the mirror. Something was wrong, terribly wrong, but I couldn’t point my finger at what it exactly was. I was in physical pain and there was blood, but I couldn’t feel anything. I remember staring at myself for what seemed to be ages and it felt like I was looking right through myself. Everything felt strangely numb and dull. It wasn’t until the next day or so when I realized what had actually happened. When it hit me, I had a break-down, both mentally and physically. I was lying on the floor, screaming and crying. My world collapsed. ”
The state of numbness Mary describes here is an acute shock reaction caused by the increased endogenous opioid levels during and shortly after the traumatic situation. Survivors or witnesses of trauma often report feeling numb and apathetic directly after the event, which is a protective mechanism of the brain to help the body cope with the extreme level of stress and pain.
As mentioned in part one of this series, the blood opioid level can rise to what equals up to 8 mg/l of morphine during a traumatic event or a flashback memory. When this level comes back to normal after a few hours, as the body is not able to maintain this protective default setting over a long-term period, the shock reaction turns into an acute PTSD. Approximately 25% of all persons experiencing trauma develop this form of PTSD, depending on a number of different risk and protective factors, which were mentioned in the previous text.
In approximately every tenth case it is also possible to show symptoms of PTSD with a delayed onset – that is if symptoms of PTSD start to show at least 6 months after the event, often caused by external factors reminding the person affected of the trauma. The acute form of post-traumatic stress has the same severe symptoms as chronic PTSD (see below), lasts longer than one month and up to three months after the experience.
After that period of time and under the influence of different protective factors, such as strong social support, the probability for so-called “spontaneous remission” – that is a slow decrease of symptoms without seeking therapeutic support – rises to up to 50% within a year. A lack of social support, further contact to the perpetrator, and other secondary stress factors increase the probability to develop chronic PTSD, which is diagnosed if symptoms persist for longer than three months.
I was feeling desperate and helpless. I remember turning to my friends for support, because I somehow didn’t feel like myself anymore. Something inside of me was ‘broken’, if that makes sense. I didn’t get any help – they all either told me that it was my own fault, that I shouldn’t have been drinking that beer with him, that I shouldn’t have let him into my room. Or they said something along the lines of that ‘stuff like that’ happens to a lot of people and that I will get over it if I just don’t think about it anymore. Some said that I should just go and see a therapist then, but no one offered to go with me or help me in any other way. I felt overwhelmed and alone. That was when I started to feel guilty. Maybe they are right? If I hadn’t gone on that holiday, if I hadn’t drunk that beer, if I were a really good person this wouldn’t have happened to me. I must be a bad person. I am worthless, I deserved it and I will never be the same again. This was the beginning of a destructive mind spiral, which is very hard to exit. During times when I am feeling low, I still catch myself falling back into this train of thought.”
In addition to the storing of the memory as implicit knowledge in the amygdala, evaluative processes play a central role when it comes to developing and maintaining symptoms of PTSD. How the traumatic event and its consequences are assessed is crucial in this regard. A traumatic experience inevitably changes the way the person affected thinks about his/herself, the world, and his/her future. In which direction this change of thinking goes decides whether and how much the person affected suffers from symptoms of PTSD. When Mary thinks that she must be a bad person, because otherwise the rape wouldn’t have happened to her, feelings of anger, shame, guilt and fear are setting in, reinforcing the symptoms of PTSD in the long term.
Diagnosis – Specific Criteria Must Be Met
The Diagnostic and Statistical Manual of Mental Disorders (DSM) specifies clear criteria that must met in order to be diagnosed with PTSD. Published by the American Psychiatric Association, it provides standard criteria and common language for the classification of mental disorders. For the diagnosis of PTSD, a standardized questionnaire, called “The Posttraumatic Stress Disorder Checklist” (PCL), is used.
This checklist was developed by Weathers et al. in 1993 and is a 17-item scale based on the DSM-IV criteria that assesses the domain of PTSD symptoms. There are three different versions of the PCL available: the PCL-C (for civilians), the PCL-S (for addressing a specific stressful experience), and the PCL-M (for military). You can see a version of the PCL-C here.
Although the criteria for being diagnosed with PTSD have been relatively stable over the past 20 years, some slight alterations have been made in the fifth revision of the DSM (DSM-5), which was released in May 2013. It moved PTSD from the class of anxiety disorders into a new class of “trauma and stressor-related disorders”. Also it includes slight changes to the diagnostic criteria for PTSD, such as the division of the previously three clusters of symptoms in DSM-IV into four clusters in DSM-5. The four new symptom clusters now are intrusion, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity. Also other symptoms were revised to clarify symptom expression, a clinical subtype “with dissociative symptoms” was added to include individuals who meet the criteria for PTSD and experience additional depersonalization and derealization symptoms, and separate diagnostic criteria were included for children ages 6 years or younger.
How Does It Feel To Suffer From Posttraumatic Stress?
When asked about her PTSD, it becomes clear that Mary suffers or used to suffer from a large number of symptoms specified in four clusters in the DSM-5.
The DSM-5 states that you need to persistently re-experience the traumatic event in one of several ways:
- Thoughts or perception
- Illusions or hallucinations
- Dissociative flashback episodes
- Intense psychological distress or reactivity to cues that symbolize some aspect of the event
Intrusive symptoms include what people commonly describe as “flashbacks”. Flashbacks are not to be thought as to be only visual, but multi-sensory. This means that the person affected by a traumatic experience will re-live aspects of the trauma if they are confronted with certain stimuli (“triggers”). If for example confronted with a certain smell that reminds the person affected of the traumatic experience, intrusive memories will be triggered. This includes experiencing physiological reactions such as sweating, trembling, difficulty breathing, nausea or gastrointestinal complaints.
“In the first years after the abuse I didn’t know what made me relive the experience over and over again. I had never heard of ‘triggers’ or anything like that at the time. I didn’t know that I was suffering from PTSD. All I knew was that I there were certain situations and people that made me extremely anxious and that caused different very intense fragments of the rape to suddenly pop up without a warning. I could walk home along a dark street at night and I would suddenly start to panic, convinced that someone was following me. I would start running and lock myself in my bedroom crying, because I was convinced that someone was in my flat. The same would happen when I was in a room and suddenly the lights went off. I would start trembling and sweating and feel sick. My heart would beat so fast, I was convinced that I would have a heart attack.
Over time it became worse and worse until I couldn’t even walk through my own flat with the lights off. At that time I was triggered by so many different things that my life started to feel like a nightmare. I was afraid of everything. I thought that I was slowly going crazy. Also I felt extremely ashamed that anyone would find out what was going on, that I wasn’t “normal”, because I didn’t feel supported by my social environment and I thought no one would understand me. I started wearing a mask and tried not to show that something was wrong with me. It wasn’t until therapy that I learned to recognize and categorize my triggers. There I also learned that darkness is one of them as it was dark in the room the abuse happened in. Now that I know, I am able to control it. A big part of that is to allow yourself to feel afraid in certain situations and not to force yourself to do anything because you feel that you ‘have to do’ certain things. Being afraid is okay and something you can admit. If I now for example feel uncomfortable walking home alone in the evening, I will simply ask a friend to accompany me. In the past I wouldn’t have done that, because I didn’t know what was going on. I was forcing myself to be ‘like everyone else’.”
It is important to know your triggers to regain control over what is happening to you. If the person affected also falls into the dissociative subtype of the disorder, he/she might experience dissociations while confronted with triggers and/or lose touch with reality while experiencing a flashback, meaning that he/she wouldn’t be able to distinguish the present from the past.
“One of my triggers is the mixture of the smell of alcohol and cheap perfume. I remember being on the train a couple of years ago and someone in the same wagon smelling that way. I remember feeling like I would throw up, if I didn’t get out of there as soon as possible. I was sweating and trembling. I got out at the next stop and sat on a bench. That was the point when I started to zone out – I was in some kind of trance. The next thing I remember is looking at my watch: 60 minutes had passed and I didn’t even notice it. Another situation I can now categorize as dissociative was when I was having sex with a partner and very suddenly a practice happened that also occurred during the rape. I remember feeling totally numb and apathetic and started to lose touch with my surroundings, while at the same time being extremely anxious and feeling sick. I somehow felt like it was back in that room the abuse happened in, like it was that year again and that I was 16 years old again. In therapy I learned how to get myself out of that dissociative state of mind – for me, this is for example by saying out loud the year and the city that I am in and telling myself that it is okay. I still find it very difficult to stop it once it has started. It is also extremely exhausting every time it happens, both physically and mentally, so I try to avoid those situations by letting partners know as soon as possible what is okay when it comes to sexual practices and what is not in order not to put myself in danger. I also learned that trust is very important when it comes to my sexual relationships as to reduce the risk of being triggered by sexual practices.”
Avoidance includes staying away from stimuli that are associated with the trauma. According to the diagnostic guideline of the DSM-5, one or both of the following criteria must be met in this symptom cluster.
- Avoidance of thoughts, feelings, or conversations associated with the event
- Avoidance of people, places, or activities that may trigger recollections of the event
“As I said: so many different things would trigger me that I started to feel that I lost control over my life. I wanted to regain control without anybody noticing what was going on. One way of doing so was to avoid certain people. There are different people I associate with that period of my life, especially one person who was directly involved with the traumatic event, that I still have a problematic relationship with and try to avoid as much as possible.”
3. Negative Alterations in Cognitions and Mood
As stated in the DSM-5, you will experience two or more of the following symptoms of negative alterations in cognitions and mood when suffering from PTSD. Concerning the inability to experience positive emotions, coupled with social retreat and a high probability of substance abuse (see below), the individual suicide risk increases. According to the National Center for PTSD, considerable debate exists about the reason for the heightened risk of suicide in trauma survivors. Whereas some studies suggest that suicide risk is higher among those who experienced trauma due to the symptoms of PTSD, others claim that suicide risk is higher in these individuals because of related psychiatric conditions. However, a study analyzing data from the National Comorbidity Survey, a nationally representative sample, showed that PTSD alone out of six anxiety diagnoses was significantly associated with suicidal ideation or attempts.
- Inability to remember an important aspect of the trauma
- Persistent and exaggerated negative beliefs about oneself, others, or the world
- Persistent, distorted cognitions about the cause or consequences of the event(s)
- Persistent negative emotional state
- Markedly diminished interest or participation in significant activities
- Feelings of detachment or estrangement from others
- Persistent inability to experience positive emotions
“I was unable to recollect what exactly had happened during the abuse for many years. In therapy I learned to recollect the memory which previously appeared to be somehow distorted and splintered. I would remember a smell or a certain sensation, but there were only fragments and never a coherent picture. Making the impression of being ‘normal’ became more and more difficult for me and I started to feel more and more disconnected from others. I felt like an actor in a play I didn’t choose to be a part of. I wasn’t sad all the time, but I never felt authentic. I forced myself to participate in social interactions, but it became harder and harder. I was also still convinced of the fact that no one liked me anyway, that I was a bad person, and that I had no real friends, because I wouldn’t deserve to have real friends. I just wanted to stay in bed all day. I started to think about suicide, because that was not the life I found worth living.”
4. Alterations In Arousal And Reactivity
The DSM-5 states that two or more of the following symptoms must be experienced in this cluster when suffering from PTSD.
- Irritable behavior and angry outbursts
- Reckless or self-destructive behavior
- Exaggerated startle response
- Concentration problems
- Sleep disturbance
When it comes to self-destructive behaviour, it has to be said that people suffering from the effect of post-traumatic stress, especially those who go without treatment or are undertreated, have a high probability to develop an alcohol or drug addiction in the context of self-medication. The National Center for PTSD reports that “up to three quarters of those who have survived abusive or violent trauma report drinking problems”. In a study conducted by Sonne et al., men with PTSD reported an earlier age of onset of alcohol dependence, greater alcohol use intensity and craving, and more severe legal problems due to alcohol use. In the same study, women had higher rates of positive test results for cocaine use at treatment entry than did men. Furthermore, PTSD more often preceded alcohol dependence in women than men. There is also a high probability of comorbidity – that is to develop other psychological disorders when being diagnosed with PTSD, such as depression and/or borderline personality disorder.
“It felt like the more I tried to push the memory of what had happened away, the more it came back to me and forced itself upon me. It wouldn’t let me sleep at night or I would wake up in panic and tears after having nightmares about what had happened, convinced that the perpetrator was in my flat. During one of my worst phases, this would happen every night and I wouldn’t get more than two or three hours of sleep for months. In the morning I would feel totally knocked up, but at the same time extremely nervous and jumpy, like something bad was about to happen. I would jump up if a car door was slammed on the street. When I tried to concentrate, I couldn’t keep a coherent thought and everything I read would immediately slip away. It was agonizing. I started drinking and smoking weed as a measure of self-medication. Concerning anger issues, I know that I can get extremely angry if I have the impression that I am not taken seriously, because it reminds me of the time directly after the abuse when my friends failed to show me support. I also used to be – and at times still am – self-destructive with regard to substance abuse, reckless and self-harming behavior. This is personally the worst part of PTSD for me, because I feel like it doesn’t only negatively affect me, but also has a negative effect on people close to me that I don’t want to hurt. There were many times when I wished I would have acted differently, felt incredibly sorry and regretted my actions. Improving myself and not hurting those around me is a big part of my healing process and something I still work on every day.”
Christoph-Dornier-Klinik für Psychotherapie. Posttraumatische Diagnose: www.c-d-k.de/psychotherapie-klinik/Stoerungen/posttraumatische_diagnose.html
Medscape. Posttraumatic Stress Disorder Clinical Presentation: http://emedicine.medscape.com/article/288154-clinical
National Center for PTSD: www.ptsd.va.gov
Sonne SC, Back SE, Diaz Zuniga C, Randall CL, Brady KT. Gender differences in individuals with comorbid alcohol dependence and post-traumatic stress disorder. Am J Addict. 2003 Oct-Dec. 12(5):412-23.
The National Center for Biotechnology Information. Appendix E: DSM-IV-TR Criteria for Posttraumatic Stress Disorder: http://www.ncbi.nlm.nih.gov/books/NBK83241/