A Comprehensive Overview of
Post-traumatic Stress Disorder Introduction What is now referred to as Post-traumatic Stress Disorder (PTSD) has been around since recorded history under many different designations and descriptions. As recently as the 1800s it was noted that people involved in railroad accidents had emotional distress that was thought to be caused by injury to their spine and were diagnosed with railroad spine. Even in literature, those who have Stephen Crane’s “Red Badge of Courage,” or “All Quiet On the Western Front” will clearly be able to see all of the signs and symptoms of PTSD as present in these literary accounts of combat from the American Civil War and World War I. During the U.S. Civil War, soldier's heart or irritable heart was the name given to a syndrome similar to today's Post Traumatic Stress Disorder by physician Jacob DaCosta. 1 He later described this syndrome in his paper in 1871 on Irritable Heart. From this, “cardiac neurosis” was the label assigned, as it was thought that the heart was the source of their emotional distress. Other labels began to emerge through out the 20th century as increasing numbers of soldiers seemed to be suffering from emotional difficulties caused by the experience of combat. Shell shock and combat fatigue came into vogue during the world wars along with “combat neurosis” as it became clearer that this was an emotional disorder precipitated by the extreme circumstances of warfare. Clearly, combat veterans seemed to be the primary group of individuals whose experience resulted in this “new” disorder. However, as the field of psychology developed, it was becoming clearer that even non-combatants were vulnerable to similar symptoms. Janet, one of Freud’s earliest colleagues, described, “When people experience vehement emotions their minds become incapable of matching their frightening experience with existing cognitive schemes. As a result memories of the experience cannot be integrated into personal experience and are split off (dissociated).” (2) Freud noted that many of his patients would describe dreams and “flashbacks” in which they were sexually abused or traumatized. Due either to the times or his own personal issues, he determined that these were not real events that had occurred, but rather fantasies that the patient had about adults and coined the theories of Oedipal conflict, penis envy and castration anxiety along with the potentially misogynist notion that these accounts of sexual mistreatment were primarily hysterical fantasies of young woman. (3) One may argue that had Freud taken these recounted events as reality rather than fantasy, the issues of sexual and physical abuse may have received greater scrutiny many decades before it did. Later, the labels of rape trauma syndrome and battered child syndrome were utilized to describe the emotional picture of victims of these tragedies. However, it wasn’t until the 1970-80s, that a clearer understanding of the impact of sexual mistreatment on children developed and it was discerned that the symptomatology of these victims looked very much like those of combat veterans. Thus, PTSD first appeared in the DSMIII as a diagnostic label delineated from other diagnoses and could be applied to a wide variety of individuals who had experienced an intense and traumatic event in their lives. It has now been more than 25 years and the field has grown to have even greater understanding as to how PTSD differs from other diagnoses, the etiology of the disorder, the biological factors and the other types of experiences that may precipitate such a syndrome. Diagnostic Criteria PTSD is characterized by a specific group of symptoms that set it apart from other types of psychological disorders. First noted in the DSMIII and now in the DSMIV, PTSD is described as follows (4): Posttraumatic Stress Disorder (309.81) The patient has experienced or witnessed or was confronted with an unusually traumatic event or events that has both of these elements: The event(s) involved actual or threatened death or serious physical injury to the patient or to others, and The patient felt intense fear, horror or helplessness The patient repeatedly relives the event in at least 1 of these ways: -Intrusive, distressing recollections (thoughts, images)
The patient repeatedly avoids the trauma-related stimuli and has numbing of general responsiveness (absent before the traumatic event) as shown by 3 or more of:
At least 2 of the following symptoms of hyperarousal were not present before the traumatic event:
The above symptoms have lasted longer than one month. These symptoms cause clinically important distress or impair work, social or personal functioning. Specify whether: In children, response to the traumatic event may be agitation or disorganized behavior. Young children may relive the event through repetitive play, trauma-specific reenactment or nightmares without recognizable content. The following is a brief(er) summarization of the aforementioned symptoms of PTSD: The individual had to experience/witness an intense event in their life in which they perceived that they and/or others were in extreme danger. Re-experiencing symptoms involves a sort of mental replay of the trauma, often accompanied by strong emotional reactions. This can happen in reaction to thoughts or reminders (triggers) of the experience when the person is awake or… in the form of nightmares during sleep. For children the re-experiencing may take the place of reenacting the trauma in play, art, etc. Avoidance symptoms are often exhibited as efforts to evade activities, places, or people that are reminders of the trauma. The avoidance may be hidden behind a defensive style, or an anxiety disorder/phobic reaction. Numbing symptoms are typically experienced as a loss of emotions, particularly positive feelings. Alcohol or other drugs may be used to facilitate the numbing. Arousal symptoms reflect excessive physiological activation and include a heightened sense of being on guard as well as difficulty with sleep and concentration. The symptoms must persist for over one month, cause significant distress, and affect the individual's ability to function socially, occupationally, or domestically. “Simple” and “Complex” PTSD While PTSD is characterized by the aforementioned symptoms, it is understood by mental health professionals that there are two types of PTSD, “simple” and “complex.” Complex PTSD (Disorder of Extreme Stress) is defined as the disorder that results from long-term, on-going stress, prolonged trauma especially that is experienced during childhood or adolescence. Usually it is also characterized by disruptive environmental conditions and colors the child’s total life experience. Examples of this would be on-going physical or sexual abuse, severe neglect, growing up/living in a war zone, etc. As will be discussed later in this paper, it is believed that this type of experience may disrupt the child’s normal development resulting in organic and hormonal changes that can impact memory and emotions (See Biology of PTSD). For adults, the same conditions would apply to the same events as well as being imprisoned, tortured, in combat, etc. Simple PTSD is the result of one single event that has occurred in the individual’s life and is over. Examples, range from accidents, assaults, to being the victim of an earthquake, tornado, etc. The event itself has closure and the individual may return to a regular and stable life. Not All Victims Of Trauma Develop PTSD While many individuals who experience traumatic events may develop PTSD, it is essential to note that not all become symptomatic to the point where they would “qualify” for a diagnosis. Studies after WWII of concentration camp survivors indicated that long-term extreme trauma had severe biological, psychological, and social consequences…including a diminished capacity to cope with both psychological and biological stressors later in life. However, not all holocaust survivors had PTSD. In recent years, it seems that the Viet Nam war rocketed the label of PTSD into the regular lexicon of America. Yet, only about 15% of Viet Nam veterans suffer(ed) from long term PTSD. In a study by Foa and Rothman with victims of rape, 94% had symptoms that reached the level of PTSD 1 week after the assault. After two months, only 52% had symptoms at that level and 9 months later only 47% of the victims evidenced the diagnostic criterion. To summarize, “…the experience of traumatic events is extremely common - for example, a random sample of young adults living in urban Detroit found that the prevalence of trauma was 39% (Breslau et al., 1991). Second, only a percentage of people exposed to a traumatic event go on to develop the picture of PTSD, indicating the importance that vulnerability and resilience factors play in the aetiology of the disorder. In the Detroit study, 23.6% of those exposed to traumatic events had lifetime PTSD (Breslau et al., 1991). Third, although only some of those exposed develop PTSD, this disorder is nevertheless highly prevalent, with estimated lifetime prevalence of up to 8% or 9% in the general population of the United States (Davidson et al., 1991; Helzer et al., 1987; Solomon and Davidson, 1987). In vulnerable communities and high-risk groups, such as war veterans and rape victims, the incidence of PTSD is far higher; 30% in war veterans (Kulka et al., 1990), 47% of sexual assault victims (Rothbaum et al., 1992).” (5) It is essential to remember that humans have a great capacity for resiliency and self healing. To overdiagnose does an injustice to the individuals who truly suffer from PTSD. Further, when working in the legal arena, it is essential to be sure that the plaintiff qualifies for a diagnosis that cannot be refuted by the other side’s expert. The Biology of PTSD Until recently, the only way to look into the human brain was to wait until the individual died, perform an autopsy, remove the brain and take gross slices of tissue and look at them under a microscope. This, along with animal studies, allowed for only the most rudimentary observations. With the advent of new technologies such as CAT and PET scans and MRIs, the human brain and its activities may be viewed while the individual remains alive and the brain active. PTSD has always been viewed as primarily a psychological disorder marked by specific symtomatology. Now, studies indicate that there is a significant biological component that may, in fact, be the cause of these psychological symptoms. Although still in the early stages, the findings are pointing to changes in both brain chemistry as well as neuroanatomy. To simplify, the production of neurotransmitters, (the chemicals that are produced in the brain and that keep the brain working) seems to be disrupted by acute stress of a significant level and duration. Further, there is evidence to suggest that parts of the brain infrastructure may be underdeveloped as a result of the types of events that result in complex PTSD. Further, these parts of the brain are located in the limbic system which is thought to be the seat of human emotion. Specifically, the amygdala and the hippocampus are the areas that seem to be uniquely disquieted by trauma. When the brains of victims of PTSD are viewed by the aforementioned technology, it appears as if these areas in the brain are constantly “on” and unable to be regulated as in a normal brain. Thus, intense emotions, hyperarousal, mood swings, agitation are thought to be the result of this trauma to the brain development or even just the brain chemistry. Further, there is evidence to suggest that parts of the brain may shrink or develop abnormally as a result of traumatic experiences. This may account for the often seen comorbidity of substance abuse along with the myriad of other manifestations of long term PTSD. (See Comorbidity) When working with PTSD victims, I often use the metaphor of a computer that has received a virus and thus experiences significant disruption and corruption of the software. The longer the virus remains on board without “treatment,” the greater level of impairment. As individuals attempt to cope with their difficulties, they may develop a wide range of coping mechanisms including some that are inappropriate or maladaptive, yet these mechanisims provide the ability to put the computer into sleep mode, or a screen freeze rather than have a total system crash. The following is a more complex description of some of the recent findings with respect to the biological/neurological issues. A number of biological factors have been linked to PTSD symptoms. It has been claimed that they make people with PTSD hyper-responsive to stressful stimuli, especially stimuli that are reminiscent of the trauma. Chronic Stress Reaction Hypothalamic-pituitary-adrenal axis abnormalities Neuroendocrinological abnormalities
Thyroid function Neuroimaging
A Bio-psycho-social Trap: To sum it up, Shalve & Rogel-Fuchs describe PTSD as a biological-psychological-social trap characterized by: 1) a permanent alteration in the neurobiological processes that results in hyperarousal; 2) The acquisition of conditioned fear/avoidance response to trauma-related stimuli; 3) Altered cognitive schemata and social apprehension result from the dissonance of the traumatic event and one’s previous knowledge of the world. (7) Other Factors Much thought has gone into trying to understand why some individuals develop PTSD, while others may develop other or no symptoms after a dramatic incident. A wide range of factors may account for the variance in reactions. While this list is too long to go into detail, it is important to have an understanding of each factor when dealing with victims of PTSD.
From both a psychological as well as a legal perspective, these issues may generate a significant orientation to both treatment as well as legal strategy. The Role Of Shame One of the key features that often accompanies a diagnosis of PTSD is shame. So often, there is an underlying sense of responsibility for what has occurred. Or, a faulty perception that, perhaps he/she might have been able to avoid the event, perpetrator, accident, etc. Even though he/she may rationally acknowledge that they were a child at the time or that they had no control over the earthquake or their buddy died as a result of a firefight with the enemy, or the rapist assaulted them in their hotel room, there is often an underlying sense of culpability. This sense of guilt and shame is what often leads to greater levels of depression, and suicidality… especially if others in their familial or social circle mirror any of this dynamic. Further, these potential improbabilities are often played upon by the defending side of legal cases. The questioning of plaintiffs around these issues may generate a significant amount of distress leading to an intensification of psychological impairment. The client must understand and be well prepared for this type of “retraumatization.” (See “What lawyers need to know”). As Terrance Real describes in his book, I Don’t Want to Talk About It, when dealing with trauma there are two levels, active trauma and passive trauma. (8) Active trauma is the actual event or incident that has resulted in the injury. Passive trauma refers to the response of others… or lack thereof. As an example, consider a victim of sexual assault, certainly a dramatic and traumatic event. This would be considered the active trauma. Let’s further consider the further emotional impact upon her if her husband or parents responded with the non-nurturing attitude of blaming her for being “in the wrong place” or wearing seductive clothing Another example might be the woman who has the active trauma of a surgery that disfigures her body and the passive trauma of her husband rejecting her sexually. Even on a national level one can see the interaction between active and passive trauma when one reviews how eighteen to twenty year old Viet Nam era soldiers were sent into combat for a year and then were reject upon their return to the US, often labeled as “baby killers,” “war criminals,” etc. What we understand about trauma is that many people have a natural inborn resiliency that can help them to manage and move beyond many terrible and awful situations and events. However, what is most devastating is not the active but rather the passive trauma as it plays on the guilt and shame that must be resolved as part of the recovery process. Co-morbidity The lifestyles of victims of unresolved (and often untreated) PTSD are often characterized by a range of other problems and difficulties. With mood, hyperarousal, and avoidance being difficult to regulate, the individual may be vulnerable to self-medicating with drugs and/or alcohol. In addition, relationships may be fraught with intense bouts of overreactive anger accompanied by distance and remoteness. This, in combination with guilt and shame, may result in a lifestyle punctuated by impulsivity, poor judgment, risk taking behaviors and further incidents of victimization. Clinicians often see patients whose “computer” has been severely infected by a virus to the point where it has interfered with many of individual’s “programs.” Getting to the core PTSD issues often means dealing with a wide variety of other “surface” issues such as drug/alcohol, relational and occupational issues. Many victims of complex PTSD may not present as the most appropriate of clients. PTSD In The Workplace With increasing frequency, more cases are coming forward where the workplace or individuals within are seen as the perpetrators or cause of extreme of stress. Sexual harassment, bullying, wrongful termination, intimidating management style have been cited as the cause of severe emotional duress. While perhaps not rising to the level of PTSD, a number of these types of cases have been settled against the work organization. While this paper cannot cover this topic in appropriate detail, one may review some of the recent cases by visiting the website, www.bullyonline.org/stress/ptsd.htm#Legal. What Lawyers Need To Know Taking on a case that involves a client who is suffering from PTSD (or any other emotional condition) requires a significant amount of care both for the client as well as the attorney him/herself. For victims of complex PTSD, the legal process can re-open the original trauma in a very intense and significant way. Often, the individual has constructed a defensive style that has facilitated a lifestyle allowing the individual to remain distant from the incident. As discussed, the numbing, memory problems, hypervigilance, social isolation (and often times, substance misuse) are all methods to keep the intense emotions at bay. The attorney (and his/her entire staff) must understand that the client is, once again, being placed in harm’s way. Not only is the individual being asked to “revisit” the original trauma in great detail, and in a way that may overwhelm the fragile defenses, the legal process itself can mirror and be experienced as yet, another form of abuse and/or neglect. Safeguards to manage the potential of both types of “retraumatization” must be in place. This usually can be accomplished by the following:
There are concepts known in the mental health field as compassion fatigue and vicarious traumatization. Simply put, these terms refer to the wear and tear experienced when working with individuals who are the victims of significant trauma, abuse, neglect, etc. When intervening in a professional capacity with these victims one must understand the potential for absorbing what I refer to as emotional hazardous waste material. Over the years, well- trained and qualified professionals may become affected by the experience of working with these types of cases and lose a sense of professional boundaries and propriety. This infraction of professional boundary may take the form of financial, emotional and/or sexual involvement. In the mental health field, this is considered a serious lapse in professional ethics and may leave the therapist vulnerable to a range of malpractice suits. For any professional working with victims of intense and extreme trauma, whether it be mental health, legal, medical, law enforcement, clergy, etc, it is essential to remember to take care of one’s self in order to continue to care for others. Additional Resources PTSD, the Traumatic Principle and Lawsuits, C.B. Scrignar, M.D. Psychiatric Times , August 1999 , Vol. XVI , Issue 8 http://www.psychiatrictimes.com/p990853.htm References
|
|
||||||||||||||
