    
POST-TRAUMATIC
STRESS DISORDER:
Identification and Diagnosis
Invited article
for Soziale Arbeit Schweiz (The Swiss Journal of
Social Work) February 1998
.
© 1997 Babette Rothschild, MSW, LCSW Member:
International and European Societies for Traumatic
Stress Studies National Association of Social
Workers (USA)
Post-traumatic Stress Disorder (PTSD) disrupts the
functioning of those afflicted by it, interfering
with the ability to meet their daily needs and
perform the most basic tasks. Trauma continues to
intrude on the lives of people with PTSD as they
relive the life-threatening experiences they have
suffered with visual, auditory and/or somatic
reality, reacting in mind and body as though such
events were still occurring. Not everyone
experiencing traumatic events develops PTSD; it is a
complex psychobiological condition that can emerge
in the wake of life-threatening experiences when
normal psychological and somatic stress responses to
a traumatic event are not resolved and released. In
this paper it is proposed that Autonomic Nervous
System hyperarousal is at the core of PTSD and the
driving force behind phenomena such as dissociation,
freezing and flashbacks. Acute traumatic reactions
are differentiated from PTSD and strategies for
intervention are suggested.
INTRODUCTION
Events that are threatening to life or bodily
integrity will produce traumatic stress in its
victim. This is a normal, adaptive response of the
mind and body to protect the individual by preparing
him to respond to the threat by fighting or fleeing.
If the fight or flight is successful, the traumatic
stress will usually be released or dissipated
allowing the victim to return to a normal level of
functioning. PTSD develops: when fight or flight is
not possible; the threat persists over a long period
of time; and/or the threat is so extreme that the
instinctive response of the victim is to freeze.
The following are examples of people with PTSD:
- A firefighter quits his
job two years short of retirement because of
persistent fiery nightmares and chest pains.
- A young girl has become
hyperactive since her tonsillectomy nine
months before.
- A previously studious
teenaged boy is no longer able to
concentrate on his school work and is
failing his classes since the death of his
grandmother last year. He no longer enjoys
going to school, and is becoming
increasingly house-bound.
- A Middle Eastern refugee
is arrested after a fight in a bar. He says
all he remembers is a smell that reminded
him of the prison where he was tortured,
then he woke up in a police cell.
- A war veteran still
awakes screaming from nightmares of combat,
thirty years after he was discharged from
service.
- A woman who was molested
when she was six years old begins to be
disturbingly over-protective of her own six
year old daughter.
- A man seeks psychotherapy
because he is suffering from persistent
anxiety and panic attacks.
- A boy is observed
aggressively trying to stick pencils and
crayons under the tails of his stuffed
animals.
POST TRAUMATIC STRESS DISORDER (PTSD)
There is a mistaken assumption that anyone
experiencing a traumatic event will have PTSD. This
is far from true. Studies vary, but confirm that
only a fraction of those facing trauma will develop
PTSD (Elliott 1997, Kulka et al 1990, Breslau et al
1991). What distinguishes those who do not is still
a hot topic of discussion, but there are many clues.
Factors mediating traumatic stress appear to
include: preparation for expected stress (when
possible), successful fight or flight responses,
prior experience, internal resources, support from
family, community, and social networks, debriefing,
emotional release, and psychotherapy.
PTSD is a relatively new diagnostic category in the
history of psychology. It first appeared in 1980 in
the internationally accepted authority on PTSD, the
DSM (Diagnostic and Statistical Manual of the
American Psychological Association), 3rd Edition
(APA 1980). At that time the DSM had a limited view
of what could cause PTSD, defining it as developing
from an experience that anyone would find traumatic,
leaving no room for individual perception or
experience of an event. This definition was expanded
when the DSM III was revised in 1987, and the DSM IV
(APA 1994) provides even broader criteria. The
currently accepted definition as presented in the
DSM IV accepts that PTSD develops in response to
events that are threatening to life or bodily
integrity, witnessing threatening or deadly events,
and hearing of violence to or the unexpected or
violent death of close associates. Events that could
qualify as traumatic, according to the DSM IV,
include: combat, sexual and physical assault, being
held hostage or imprisoned, terrorism, torture,
natural and man made disasters, accidents, and
receiving a diagnosis of a life threatening illness.
PTSD can also develop in children who have
experienced sexual molestation, even if this is not
violent or life-threatening. The DSM IV adds, "The
disorder may be especially severe or long lasting
when the stressor is of human design (e.g. torture,
rape)." (APA 1994).
Symptoms associated with PTSD include, 1)
reexperiencing the event in varying sensory forms
(flashbacks), 2) avoiding reminders associated with
the trauma, and, 3) chronic hyperarousal in the
Autonomic Nervous System (ANS). PTSD is present when
these symptoms last more than one month and are
combined with loss of function in areas such as job
or social relationships (APA 1994). I believe that
at the core of PTSD is the last symptom - increased
ANS arousal. People who suffer from PTSD are plagued
with frightening body symptoms which are
characteristic of hyperarousal: accelerated heart
beat, cold sweating, rapid breathing, heart
palpitations, hypervigilance, and hyper startle
response (jumpiness). These symptoms lead to sleep
disturbances, loss of appetite, sexual dysfunction
and difficulties in concentrating, which are further
hallmarks of PTSD. Hyperarousal both instigates
flashbacks and is also increased by them, and
hyperarousal is the underlying cause of the symptom
of avoidance, as traumatic reminders increase ANS
arousal. Through understanding hyperarousal the
phenomenon of PTSD, becomes comprehendible.
SURVIVAL AND THE NERVOUS SYSTEM
Arousal, and therefore hyperarousal, is mediated by
the Limbic System which is located in the center of
the brain between the brain stem and the cortex.
This part of the brain regulates survival behaviors
and emotional expression, being primarily concerned
with tasks of survival such as eating, sexual
reproduction and the instinctive defenses of fight
and flight. It also plays a central role in memory
processing.
The Limbic System has an intimate relationship with
the Autonomic Nervous System (ANS). The ANS
regulates smooth muscles and other viscera: heart
and circulatory system, kidneys, lungs, intestines,
bladder, bowel, pupils. It has two branches, the
Sympathetic branch (SNS) and the Parasympathetic
branch (PNS), which usually function in balance with
each other, meaning when one is activated, the other
is suppressed. The SNS is primarily aroused in
states of stress, both positive and negative. Signs
of SNS arousal include increased heart rate and
respiration, cold and pale skin, dilated pupils,
raised blood pressure. The PNS is primarily aroused
in states of rest and relaxation. Signs of PNS
arousal include decreased heart rate and
respiration, warm and flushed skin, normally
reactive pupils, lowered blood pressure.
The Limbic System responds to extreme traumatic
threat, in part, by releasing hormones that tell the
body to prepare for defensive action, activating the
SNS, which prepares the body for fight or flight
through increasing respiration and heart rate to
provide more oxygen, sending blood away from the
skin and into the muscles for quick movement. When
death may be imminent or the traumatic threat is
prolonged (as with torture, rape, etc.), the Limbic
system can simultaneously release hormones to
activate the PNS and a state of freezing can result
- like a mouse going dead when caught by a cat, or a
frightened bird becoming stiff (Gallup 1977, Levine
1997).
These nervous system responses - fight, flight and
freeze - are survival reflexes. If perception in the
Limbic System is that there is adequate strength,
time and space for flight, then the body breaks into
a run. If the Limbic perception is that there is not
time to flee, but there is adequate strength to
defend, then the body will fight. If the Limbic
System perceives that there is neither time nor
strength for fight or flight and death could be
imminent, then the body will freeze. In this state,
the victim of trauma enters an altered reality - it
is one form of dissociation. Time slows down and
there is no fear or pain. In this state, if harm or
death do occur, the impact is not so great. People
who have fallen from great heights, such as over
cliffs, and survived, report just such a reaction.
This freezing response may also increase chances of
survival. If the cause of the freeze is an attack by
man or beast, the attacker may lose interest when
the prey has gone dead, as a cat will lose interest
in a lifeless mouse.
It is important to understand that these Limbic
System/ANS responses are instinctive, not chosen by
thoughtful consideration, but are reflex actions.
Many who have suffered trauma feel great guilt about
freezing or "going dead" and not doing more to
protect themselves or others by fighting back or
running away. Understanding that freezing is a
reflex, often helps the process of self-forgiveness.
DEFENSIVE RESPONSE IN THE ABSENCE OF THREAT
When the Limbic System of the brain activates the
ANS to meet the threat of a traumatic event, it is a
normal, healthy, adaptive survival response. When
the ANS continues to be chronically aroused even
though the threat has passed and has been survived,
that is PTSD. The body continues to respond as
though it were under threat. This is the most
perplexing feature of PTSD.
Within the Limbic System of the brain are two
related areas that are central in memory storage:
the hippocampus and the amygdala. The last few years
have produced a growing body of research that
indicates these two parts of the brain are
essentially involved in response to, and memory of,
traumatic events. (van der Kolk 1994, Nadel & Jacobs
1996) It is believed that the amygdala stores highly
charged emotional memories, such as terror and
horror and it has been shown that the amygdala
becomes very active when there is a traumatic
threat. The hippocampus, on the other hand, stores
memory of time and space - puts our memories into
their proper perspective and place in our life's
time line. During traumatic threat, it has been
shown, the hippocampus becomes suppressed. Its usual
function of placing a memory into the past is not
active. The traumatic event is prevented from
becoming a memory in the past, causing it to seem to
float in time, often invading the present. It is
this mechanism that is behind the aforementioned
PTSD symptom of "flashback" - episodes of reliving
the trauma.
DISSOCIATION, FREEZING AND PTSD
Dissociation, a splitting in awareness, is not
mentioned by either the DSM III or IV as a symptom
of PTSD, but there is growing debate in the
professional literature as to whether PTSD is a
Dissociative Disorder (Brett, EA. 1996) - it is
currently classified in the DSM IV under Anxiety
Disorders. There is also research that is beginning
to point to the possibility that dissociation during
a traumatic event may be a predictor of PTSD
(Bremmer, et. al. 1992, Marmar, et.al. 1994). No one
really knows what dissociation is or how it occurs,
though there is much speculation. It appears to be,
not one thing, but a set of related splitting
responses. Bennett Braun, MD has studied
dissociation for many years, treating clients with a
variety of Dissociative Disorders. He proposes a
continuum of dissociation that begins with simple
forgetting, includes amnesia and PTSD and ends at
the extreme of Multiple Personality, now referred to
as Dissociative Identity Disorder (Braun 1988). The
kind of dissociation described by those with PTSD -
altered sense of time, reduced sensations of pain,
absence of terror or horror - resembles the
characteristics of those who have responded with
freezing to a traumatic threat. There will need to
be more research before it can be known if the
freezing reflex is a form of dissociation, but it
looks as though it is. This is important because it
appears that the greatest consequences of PTSD
result from dissociation. While dissociation is an
instinctive response to save the self from suffering
- and it does this very well - it also exacts a high
price in return.
CONSEQUENCES OF TRAUMA AND PTSD
The consequences of trauma and PTSD vary greatly
depending on the age of the victim, the nature of
the trauma, the response to the trauma and the
support to the victim in the aftermath. In general,
victims of PTSD suffer reduced quality of life due
to the intrusive symptoms which restrict their
ability to function. They may alternate periods of
overactivity with periods of exhaustion as their
bodies suffer the effects of hyperarousal. Reminders
of the trauma they suffered may appear suddenly,
causing instant panic, and possible flashbacks. They
become fearful, not only of the trauma itself, but
of their own reactions to the trauma. Body signals
that were once providers of essential information,
become dangerous. For example, heart beat
acceleration that might indicate over-exertion or
excitement, becomes a danger signal in itself
because it is a reminder of the trauma response, and
therefore is associated with the trauma. The ability
to orient to safety and danger becomes decreased
when many things, or even everything, in the
environment become perceived as dangerous. When the
reminders of trauma become extreme, freezing or
dissociation can be activated, just as if the trauma
was occurring in the present. It can become a
terribly vicious circle. Victims of PTSD can become
extremely restricted, fearing to be together with
others or go out of their homes.
Child victims of trauma are a special area for
study. Robert Pynoos at the University of California
at Los Angeles is a pioneer in researching the
impact of trauma on children and adolescents.
Psychological and motor development can be arrested
in child victims of trauma, leading to increasingly
negative impact on their lives if they continue to
mature without intervention to restore lost or
undeveloped resources and skills (Pynoos 1993)
.
DISTINGUISHING ACUTE TRAUMA FROM PTSD
Discussion with professionals who work with both the
acute and the long-term aftermath of trauma has led
me to conclude that aside from physical injury due
to trauma, acute traumatic reactions may be
indistinguishable from PTSD in the body and behavior
of the victim. The same disorientation, fear, and
indications of ANS activations - elevations in heart
rate, blood pressure, respiration, shaking, etc. -
may be present.
In the aftermath of a disaster, for example, most of
those suffering from acute trauma will be easy to
spot. Those who have been injured will be obvious.
Among the uninjured there will also be many who look
stunned, appear pale and faint, or be shaking. Some
of those who appear to be suffering from trauma may
not even be the actual victims of the disaster, but
witnesses or rescuers who may be deeply affected by
what they have or are seeing. Some may not be
immediately identifiable, they may be highly active
- looking for others or after others, organizing
help and rescue. A percentage of these may, in the
next days or weeks, develop symptoms of trauma.
Months or years later, the vast majority of the
survivors, witnesses and rescuers will no longer be
suffering psychologically from the after effects of
the event. However, a minority will be suffering to
an extreme degree, their lives decreased in quality,
and a diagnosis of PTSD will be appropriate.
While symptoms of acute trauma and PTSD may not
differ very much, response to these must differ
significantly.
Response to acute trauma may include emergency
medical intervention for treatment of injuries
and/or medical shock. On the psychological side
reassurance and comfort will be the key. Often
talking about what happened will be important for
the survivor in the immediate aftermath of the
event. Telling and re-telling the story to caring
individuals may help prevent dissociation, and aid
in integrating the experience. Providing physical
support - holding, an arm around the shoulders, a
comforting hand - may be appropriate, especially if
the survivor is hysterical or shaking violently. The
victim may be cold and in need of blankets and warm
beverages. The victim may need to be reminded that
the event is passed and they have survived it,
"You're safe now." The more complete and appropriate
the response to acute trauma, the greater the chance
of preventing subsequent PTSD.
Later, working with those who do develop PTSD may
resemble some of the aspects of response to acute
trauma. Certainly a reassuring and comforting
attitude on the part of the psychotherapist is
important. But when the trauma is long past, simple
comfort and reassurance will not be enough. The
victim of PTSD will feel unable to contain his
traumatic experience(s), will have become afraid of
his body, and will have lost the sense of what was
then and what is now. It is these three areas -
containment, positive body awareness, dual time
awareness - that must first be strengthened, before
addressing the memory of a traumatic event can be
done productively.
Containment of out-of-control emotions and thinking
processes will help restore a feeling of control
over the psychological self. Positive body-awareness
will help restore a sense of the body and its
sensations as friend, not foe. Dual time awareness
will help to separate that the trauma occurred in
the past even though it feels as if it is occurring
now (Rothschild 1996, Rothschild 1997).
CONCLUSION
Identification of a portion of those suffering from
PTSD will be straightforward. But others may be
difficult to spot owing to complicated life or
defensive systems. Evaluation of the state of the
ANS will assist in diagnosis and in setting
treatment objectives where appropriate.
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