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It's been called shell shock, battle fatigue, accident neurosis and
post rape syndrome. It has often been misunderstood or misdiagnosed,
even though the disorder has very specific symptoms that form a
definite psychological syndrome.
The disorder is post-traumatic stress disorder (PTSD) and it
affects hundreds of thousands of people who have been exposed to
violent events such as rape, domestic violence, child abuse, war,
accidents, natural disasters and political torture. Psychiatrists
estimate that up to one to three percent of the population have
clinically diagnosable PTSD. Still more show some symptoms of the
disorder. While it was once thought to be a disorder of war veterans
who had been involved in heavy combat, researchers now know that
PTSD can result from many types of trauma, particularly those that
include a threat to life. It afflicts both females and males.
In some cases the symptoms of PTSD disappear with time, while in
others they persist for many years. PTSD often occurs with other
psychiatric illnesses, such as depression.
Not all people who experience trauma require treatment; some
recover with the help of family, friends, a pastor or rabbi. But
many do need professional help to successfully recover from the
psychological damage that can result from experiencing, witnessing
or participating in an overwhelmingly traumatic event.
Although the understanding of post-traumatic stress disorder is
based primarily on studies of trauma in adults, PTSD also occurs in
children as well. It is known that traumatic occurrences--sexual or
physical abuse,loss of parents, the disaster of war--often have a
profound impact on the lives of children. In addition to PTSD
symptoms, children may develop learning disabilities and problems
with attention and memory. They may become anxious or clinging, and
may also abuse themselves or others.
Symptoms
The symptoms of PTSD may initially seem to be part of a normal
response to an overwhelming experience. Only if those symptoms
persist beyond three months do we speak of them being part of a
disorder. Sometimes the disorder surfaces months or even years
later. Psychiatrists categorize PTSD's symptoms in three categories:
intrusive symptoms, avoidant symptoms, and symptoms of hyperarousal.
Intrusive Symptoms
Often people suffering from PTSD have an episode where the
traumatic event "intrudes" into their current life. This
can happen in sudden, vivid memories that are accompanied by painful
emotions. Sometimes the trauma is "re-experienced." This
is called a flashback_a recollection that is so strong that the
individual thinks he or she is actually experiencing the trauma
again or seeing it unfold before his or her eyes. In traumatized
children, this reliving of the trauma often occurs in the form of
repetitive play.
At times, the re-experiencing occurs in nightmares. In young
children, distressing dreams of the traumatic event may evolve into
generalized nightmares of monsters, of rescuing others or of threats
to self or others.
At times, the re-experience comes as a sudden, painful onslaught
of emotions that seem to have no cause. These emotions are often of
grief that brings tears, fear or anger. Individuals say these
emotional experiences occur repeatedly, much like memories or dreams
about the traumatic event.
Symptoms of Avoidance
Another set of symptoms involves what is called avoidance
phenomena. This affects the person's relationships with others,
because he or she often avoids close emotional ties with family,
colleagues and friends. The person feels numb, has diminished
emotions and can complete only routine, mechanical activities. When
the symptoms of "re-experiencing" occur, people seem to
spend their energies on suppressing the flood of emotions. Often,
they are incapable of mustering the necessary energy to respond
appropriately to their environment: people who suffer post-traumatic
stress disorder frequently say they can't feel emotions, especially
toward those to whom they are closest. As the avoidance continues,
the person seems to be bored, cold or preoccupied. Family members
often feel rebuffed by the person because he or she lacks affection
and acts mechanically.
Emotional numbness and diminished interest in significant
activities may be difficult concepts to explain to a therapist. This
is especially true for children. For this reason, the reports of
family members, friends, parents,teachers and other observers are
particularly important.
The person with PTSD also avoids situations that are reminders of
the traumatic event because the symptoms may worsen when a situation
or activity occurs that reminds them of the original trauma. For
example, aperson who survived a prisoner-of-war camp might overreact
to seeing people wearing uniforms. Over time, people can become so
fearful of particular situations that their daily lives are ruled by
their attempts to avoid them.
Others--many war veterans, for example--avoid accepting
responsibility for others because they think they failed in ensuring
the safety of people who did not survive the trauma. Some people
also feel guilty because they survived a disaster while
others--particularly friends or family--did not. In combat veterans
or with survivors of civilian disasters, this guilt may be worse if
they witnessed or participated in behavior that was necessary to
survival but unacceptable to society. Such guilt can deepen
depression as the person begins to look on him or herself as
unworthy, a failure, a person who violated his or her pre-disaster
values. Children suffering from PTSD may show a marked change in
orientation toward the future. A child may, for example, not expect
to marry or have a career. Or he or she may exhibit "omen
formation," the belief in an ability to predict future untoward
events.
PTSD sufferers' inability to work out grief and anger over injury
or loss during the traumatic event mean the trauma will continue to
control their behavior without their being aware of it. Depression
is a common product of this inability to resolve painful feelings.
Symptoms of Hyperarousal
PTSD can cause those who suffer with it to act as if they are
threatened by the trauma that caused their illness. People with PTSD
may become irritable. They may have trouble concentrating or
remembering current information, and may develop insomnia. Because
of their chronic hyperarousal, many people with PTSD have poor work
records, trouble with their bosses and poor relationships with their
family and friends.
The persistence of a biological alarm reaction is expressed in
exaggerated startle reactions. War veterans may revert to their war
behavior, diving for cover when they hear a car backfire or a string
of firecrackers exploding.At times, those with PTSD suffer panic
attacks, whose symptoms include extreme fear resembling that which
they felt during the trauma. They may feel sweaty, have trouble
breathing and may notice their heart rate increasing. They may feel
dizzy or nauseated. Many traumatized children and adults may have
physical symptoms, such as stomachaches and headaches, in addition
to symptoms of increased arousal.
Other Associated Features
Many people with PTSD also develop depression and may at times
abuse alcohol or other drugs as a "self-medication" to
blunt their emotions and forget the trauma. A person with PTSD may
also show poor control over his or her impulses, and may be at risk
for suicide.
Treatment
Psychiatrists and other mental health professionals today have
effective psychological and pharmacological treatments available for
PTSD. These treatments can restore a sense of control and diminish
the power of past events over current experience. The sooner people
are treated, the more likely they are to recover from a traumatizing
experience. Appropriate therapy can help with other chronic
trauma-related disorders, too.
Psychiatrists help people with PTSD by helping them to accept
that the trauma happened to them, without being overwhelmed by
memories of the trauma and without arranging their lives to avoid
being reminded of it.
It is important to re-establish a sense of safety and control in
the PTSD sufferer's life. This helps him or her to feel strong and
secure enough to confront the reality of what has happened. In
people who have been badlytraumatized, the support and safety
provided by loved ones is critical. Friends and family should resist
the urge to tell the traumatized person to "snap out of
it," instead allowing time and space for intense grief and
mourning. Being able to talk about what happened and getting help
with feelings of guilt, self-blame, and rage about the trauma
usually is very effective in helping people put the event behind
them. Psychiatrists know that loved ones can make a significant
difference in the long-term outcome of the traumatized person by
being active participants in creating a treatment plan--helping him
or her to communicate and anticipating what he or she needs to
restore a sense of equilibrium to his or her life. If treatment is
to be effective it is important, too, that the traumatized person
feel that he or she is a part of this planning process.
Sleeplessness and other symptoms of hyperarousal may interfere
with recovery and increase preoccupation with the traumatizing
experience. Psychiatrists have several medications--including
benzodiazepines and the new class of serotonin re-uptake
blockers--that can help people to sleep and to cope with their
hyperarousal symptoms. These medications, as part of an integrated
treatment plan, can help the traumatized person to avoid the
development of long-term psychological problems.
In people whose trauma occurred years or even decades before, the
professionals who treat them must pay close attention to the
behaviors--often deeply entrenched--which the PTSD sufferer has
evolved to cope with his or her symptoms. Many people whose trauma
happened long ago have suffered in silence with PTSD's symptoms
without ever having been able to talk about the trauma or their
nightmares, hyperarousal, numbing, or irritability. During
treatment, being able to talk about what has happened and making the
connection between past trauma and current symptoms provides people
with the increased sense of control they need to manage their
current lives and have meaningful relationships.
Relationships are often a trouble spot for people with PTSD. They
often resolve conflicts by withdrawing emotionally or even by
becoming physically violent. Therapy can help PTSD sufferers to
identify and avoid unhealthy relationships. This is vital to the
healing process; only after the feeling of stability and safety is
established can the process of uncovering the roots of the trauma
begin.
To make progress in easing flashbacks and other painful thoughts
and feelings, most PTSD sufferers need to confront what has happened
to them, and by repeating this confrontation, learn to accept the
trauma as part of their past. Psychiatrists and other therapists use
several techniques to help with this process.
One important form of therapy for those who struggle with
post-traumatic stress disorder is cognitive/behavior therapy. This
is a form of treatment that focuses on correcting the PTSD
sufferer's painful and intrusive patterns of behavior and thought by
teaching him or her relaxation techniques, and examining (and
challenging) his or her mental processes. A therapist using behavior
therapy to treat a person with PTSD might, for example, help a
patient who is provoked into panic attacks by loud street noises by
setting a schedule that gradually exposes the patient to such noises
in a controlled setting until he or she becomes
"desensitized" and thus is no longer so prone to terror.
Using other such techniques, patient and therapist explore the
patient's environment to determine what might aggravate the PTSD
symptoms and work to reduce sensitivity or to learn new coping
skills.
Psychiatrists and other mental health professionals also treat
cases of PTSD by using psychodynamic psychotherapy. Post-traumatic
stress disorder results, in part, from the difference between the
individual's personal values or view of the world and the reality
that he or she witnessed or lived during the traumatic event.
Psychodynamic psychotherapy, then, focuses on helping the individual
examine personal values and how behavior and experience during the
traumatic event violated them. The goal is resolution of the
conscious and unconscious conflicts that were thus created. In
addition, the individual works to build self-esteem and
self-control, develops a good and reasonable sense of personal
accountability and renews a sense of integrity and personal pride.
Whether PTSD sufferers are treated by therapists who use
cognitive/behavioral treatment or psychodynamic treatment,
traumatized people need to identify the triggers for their memories
of trauma, as well as identifying those situations in their lives in
which they feel out of control and the conditions that need to exist
for them to feel safe. Therapists can help people with PTSD to
construct ways of coping with the hyperarousal and painful
flashbacks that come over them when they are around reminders of the
trauma. The trusting relationship between patient and therapist is
crucial in establishing this necessary feeling of safety.
Medications can help in this process also.
Group therapy can be an important part of treatment for PTSD.
Trauma often affects people's ability to form
relationships--especially such traumas as rape or domestic violence.
It can profoundly affect their basic assumption that the world is a
safe and predictable place, leaving them feeling alienated and
distrustful, or else anxiously clinging to those closest to them.
Group therapy helps people with PTSD to regain trust and a sense of
community, andto regain their ability to relate in healthy ways to
other people in a controlled setting.
Most PTSD treatment is done on an outpatient basis. However, for
people whose symptoms are making it impossible to function or for
people who have developed additional symptoms as a result of their
PTSD, inpatient treatment is sometimes necessary to create the vital
atmosphere of safety in which they can examine their flashbacks,
re-enactments of the trauma, and self-destructive behavior.
Inpatient treatment is also important for PTSD sufferers who have
developed alcohol or other drug problems as a result oftheir
attempts to "self medicate." Occasionally too, inpatient
treatment can be very useful in helping a PTSD patient to get past a
particularly painful period of their therapy.
The recognition of PTSD as a major health problem in this country
is quite recent. Over the past 15 years, research has produced a
major explosion of knowledge about the ways people deal with
trauma--what places them at risk for development of long-term
problems, and what helps them to cope. Psychiatrists and other
mental health professionals are working hard to disseminate this
understanding, and an increasing number of mental
healthprofessionals are receiving specialized training to help them
reach out to people with Post-traumatic Stress Disorder in their
communities.
(c) Copyright 1988 American Psychiatric Association
Produced by the APA Joint Commission on Public Affairs and the
Division of Public Affairs. This document contains the text of a
pamphlet developed for educational purposes and does not necessarily
reflect opinion or policy of the American Psychiatric Association.
Additional Resources
Burgess, Ann Wolbert. Rape: Victims of Crisis. Bowie, Maryland:
Robert J. Brady, Co., 1984.
Cole, PM, Putnam, FW. ";Effect of Incest on Self and Social
Functioning: A Developmental Psychopathology Perspective."
Journal of Consulting and Clinical Psychology, 60:174-184, 1992.
Eitinger, Leo, Krell, R, Rieck, M. The Psychological and Medical
Effects of Concentration Camps and Related Persecutions on Survivors
of the Holocaust. Vancouver: University of British Columbia Press,
1985.
Eth, S. and R.S. Pynoos. Post-Traumatic Stress Disorder in
Children. Washington, DC: American Psychiatric Press, Inc., 1985.
Herman, Judith L. Trauma and Recovery. New York: Basic Books,
1992.
Janoff, Bulman R. Shattered Assumptions. New York: Free Press,
1992.
Lindy, Jacob D. Vietnam: A Casebook. New York: Brunner/Mazel,
1987.
Kulka, RA, Schlenger, WE, Fairbank J, et al. Trauma and the
Vietnam War Generation. New York: Brunner/Mazel, 1990.
Ochberg F., Ed. Post-traumatic Therapies. New York:
Brunner/Mazel, 1989.
Raphael, B. When Disaster Strikes: How Individuals and
Communities Cope with Catastrophe. New York: Basic Books, 1986.
Ursano, RJ, McCaughey, B, Fullerton, CS. Individual and Community
Responses to Trauma and Disaster: the Structure of Human Chaos.
Cambridge, England: The Cambridge University Press, 1993.
van der Kolk, B.A. Psychological Trauma. Washington, DC: American
Psychiatric Press, Inc., 1987.
van der Kolk, B.A. "Group Therapy with Traumatic Stress
Disorder," in Comprehensive Textbook of Group Psychotherapy,
Kaplan, HI and Sadock, BJ, Eds. New York: Williams & Wilkins,
1993.
Other Resources
Anxiety Disorders Association of America, Inc.
(301) 831-8350
International Society for Traumatic Stress Studies
(708) 480-9080
National Center for Child Abuse and Neglect
(205) 534-6868
National Center for Post-traumatic Stress Disorder
(802) 296-5132
National Institute of Mental Health
(301) 443-2403
National Organization for Victim Assistance
(202) 232-6682
U.S. Veterans Administration-Readjustment Counseling Service
(202) 233-3317
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