It was seven o’clock in the morning when she awoke, after yet another terrible night’s sleep with her recurring nightmares. As usual, fifteen-year-old Maureen was paralyzed from the waist down. This paralysis had terrified her at first but now she was used to it. It would go away when he left for work. The “he” in this case being her biological father. Reverend Parsons had always told her youth group to honor thy father and mother, yet she found this difficult to accept. Was she a failure at this too? Did Reverend Parsons ever make an exception?
The time frame of suffering had encompassed seven long, lonely, frightening, and physically painful years. Two times a week, fifty-two weeks a year, for seven years: seven-hundred-and-twenty-eight times she had been raped by her father. And he was forceful! Physically pinning her to her bed, forcibly entering her, physically hurting her internally. And always the ever-present butcher knife with the threat that he would slice her throat, if she ever told anyone. Her dreams of a special boyfriend who cared and a marriage that would be happy had long ago turned to ashes. Her heart was irrevocably broken.
Three weeks ago she finally summoned her courage in the face of her terror and told her mother what had been going on. The hoped-for help never came. Her mother had gone into a blind rage and accused her daughter of lying. Maureen was crushed.
Are you there God? Why me, God? Why me?…It was dark.
* * * * * *
Maureen is the victim of the medical conditions known as psychological trauma and posttraumatic stress disorder (PTSD). Unfortunately, traumatic experiences are fairly common and disrupt the lives of many victims. Part 1 of this essay examines the general nature of psychological trauma and PTSD and part 2 presents some intervention strategies to lessen the physical and psychological pain that are associated with these conditions.
Psychological Trauma: Its Psychology
Let us begin with the three domains of good physical and mental health: reasonable mastery, caring attachments to others, and a meaningful purpose in life.
Reasonable mastery refers to the ability to shape our environment to meet our needs. Working for a living, having the skills to rear children are examples of reasonable mastery.
Caring attachments to others are our helpful pro-social interchanges with family, friends and neighbors. These attachments often reduce stress and brighten our lives.
One’s meaningful purpose in life is the main motivation that any of us has for investing our energy in the world around us. Individuals view the world as safe, predictable, and worthy of investing energy in it. Becoming motivated to seek a promotion at work, send their children to college, volunteer for a community project, and so forth are examples of common meaningful purposes. Psychological trauma and PTSD shatter these domains with resultant poor physical and mental health.
Psychological trauma is the physical and psychological response that an individual has when that person experiences, witnesses, or is confronted with an event(s) that involves actual or threatened death, serious injury, or the threat to the physical integrity of the individual or others (1,2). These critical incidents are sudden, usually unexpected, and extremely frightening, and the victim has no control over the onset, no matter how hard he or she tries. A traumatic incident that has occurred within the past six months is known as acute trauma. After six months, it is known as a chronic trauma state. Natural and man-made disasters and the various forms of human-perpetrated violence are examples of potentially traumatic events.
The domains of good health are disrupted, as we noted. By definition, a traumatizing critical-incident individual has no reasonable mastery over the situation. Secondly, caring attachments are often disrupted in two fundamental ways. First, the victim withdraws from others. Having been frightened and/or harmed, the victim judges the situation to be not safe and withdraws. Second, violence teaches us how tenuous our links are to Mother Earth. In apprehension we non-victims withdraw from the victims at a time when they need us. Further, to give ourselves the illusion of safety and maintaining mastery, we blame the victims for the misfortunes that have befallen them. Rather than seeing the victims as the wrong persons in the wrong places at the wrong times, we blame them for the situations over which they had no control. Finally, for victims the world does not seem orderly, predictable, safe, and worthy of investing energy in it. The victim’s meaningful purpose in life is dislodged.
Individuals may become victims of violence and experience these disrupted domains in any of three ways. First, the individual may be a direct victim of the traumatic event. Secondly, the individual may have witnessed this event happening to others. Thirdly, a person may become traumatized by hearing a victim recount in detail what has happened to him or her.
Symptoms of Psychological Trauma
All medical conditions have signs or symptoms of disordered functioning and psychological trauma and PTSD are no exceptions. The signs are threefold. First are the physical symptoms. These largely result from the adrenalin rush that occurs with the onset of the critical incident. Common examples include hypervigilance, an exaggerated startled response, sleeping difficulties, problems with concentration and mood irritability.
The second grouping of symptoms is the intrusive symptoms. These are recurring and distressing recollections of the event. The victim may have thoughts, memories, dreams, or nightmares of the critical incident. Similarly, the victim may experience physical or psychological distress at some symbol that reminds the victims of the trauma. Victims may also experience intrusive symptoms in the form of survivor guilt. Survivor guilt is an intrusive symptom in that it is a constant reminder of those who were lost. Intrusive memories are actually the brain’s way of healing itself. It is saying to the victim: Review what has happened and learn from it so that, if it happens again, you will be better prepared to cope. However, most victims find the memories understandably unpleasant and find ways to put them out of mind.
The third set of symptoms is the avoidant symptoms. Included here is the victim’s desire to avoid the specific thoughts, feelings, activities or situations associated with the traumatic event. If the traumatic event is left untreated, over time the victim will develop diminished interest in non-traumatic significant interests and have a restricted range of emotions. If left untreated, the symptoms of untreated psychological trauma and PTSD will last until death.
Stages of Psychological Trauma and PTSD
The impact of psychological traumatic events unfolds over time. The first stage is that of the acute distress that occurs at the time of the critical incident. This distress would include disruptions in any of the three domains of good health and/or any of the three sets of symptoms. This first stage of acute distress lasts for thirty days.
On the thirty-first day, if the victim has any or all of the six possible disruptions, the victim develops PTSD. PTSD itself is of three types. The first is acute PTSD, which includes the first three months after the onset date of PTSD. If the PTSD remains untreated, the victim then enters the stage of chronic PTSD, which lasts from the fourth month until death. The third type of PTSD is known as delayed onset PTSD. In this later case, the victim appears to have recovered during the initial acute phase and resumes a normal daily routine. However, at some point after six months have passed, the victim encounters some symbolic reminder or significant loss and the original trauma disruptions return.
Significant losses may precipitate delayed-onset PTSD since all traumatic events involve loss. For example, loss of loved ones in disasters, loss of one’s choice in sexual abuse, loss of one’s physical integrity in physical abuse, loss of innocence of the world, and so forth.
Special Aspects of Psychological Trauma and PTSD
Dissociation. Dissociation is a complex process that is not yet fully understood by medicine and behavioral science. It refers to the brain’s capacity to put parts of consciousness on hold in the face of overwhelming events and it does this in the form of memory. The dissociated memory has its own feelings and thoughts and these are stored in the brain during the crisis. When the crisis has passed, these memories return as intrusive symptoms. The process by which the brain puts these memories on hold is called dissociation (that is, dissociated or cut off from consciousness). When these memories return, these intrusive thoughts are referred to as flashbacks.
The Repetition Compulsion. One would think that, if one were a victim of violence, one would avoid going back into the lion’s den but in fact there are some victims who return to the scene of the violence. Battered children may marry domestic batterers as adults. Raped children my become prostitutes as adults (3). Some have speculated that as adults these previously wounded children are seeking to develop some sense of mastery. However, the true cause(s) of these repetitive behaviors remain unknown at this time.
Self-medication. Frequently, victims of violence also have an additional substance-abuse disorder. The symptoms of trauma are frightening and persistent, and many victims choose to self-medicate these unpleasant feelings and thoughts with alcohol and/or various prescripted or street drugs instead of seeking treatment for trauma and PTSD (4).
Psychological Trauma: Its Biology
Many think of psychological trauma as a purely psychological phenomenon. However, traumatic events also have a major impact on the victim’s somatic functioning as well [See (2) for major review.]
The human nervous system is made up of cells. These cells are coupled together by tiny balloon-like microscopic sacs known as synaptic gaps. These synaptic gaps contain chemicals called neurotransmitters. These various transmitters carry the information from one nerve cell to the next until the information reaches the brain and the person responds. There are five neurotransmitters that are important in trauma.
Epinephrine, from the adrenal gland, mobilizes the physical body to cope with the critical incident, such as increasing heart rate, tensing muscles, and releasing blood sugar into the body for energy.
Norephephrine is also an adrenal byproduct but here it acts in the brain and enhances alertness and concentration.
Cortisol, likewise released by the adrenal gland, provides energy and repairs body tissue in cases of injury.
Serotonin is a transmitter in the brain that makes a person feel calm. However, it acts as a catalyst for norepinephrine in stressful situations and the stressed person often becomes irritable, angry, and ultimately depressed.
Lastly, endorphins, which are found in the brain, are similar to serotonin in that they make a person feel calm, when the endorphins are actively circulating. In traumatic situations, the endorphins do not make us feel calm, but act as an analgesic to deaden pain.
These five neurotransmitters interact with the cortex and the limbic system in the brain. The cortex is where a person’s highest reasoning occurs and the limbic system is that part of the brain where feelings are experienced and identified. When the individual encounters a critical incident, epinephrine and cortisol are released in the body to strengthen coping abilities, and norepinephrine and the endorphins are released in the brain to sharpen concentration and problem-solving.
In critical incidents, the endorphins act as an analgesic or pain killer for about ninety minutes. Increases in norepinephrine and the endorphins in their analgesic capacity appear to produce the physical and intrusive symptoms, while subsequent decreases in norepinephrine and the endorphins appear to result in the avoidant symptoms (2). Taken as a whole, it is the changes in the neurotransmitters that result in the fear, anxiety, and distress that may lead trauma victims to self-medicate.
There are at least two additional biological components that should be noted.
The first is that an overwhelming event can overwhelm the brain itself and result in the victim appearing dazed and speechless. This is due to neurotransmitter changes in the part of the brain known as Broca’s area.
Secondly, the limbic system receives information about its feelings from the amygdala part of the limbic system. These feelings are labeled correctly by another part of the limbic system known as the hippocampus. In some trauma victims, the hippocampus atrophies or dies and the victim is unable to access messages in the amygdala to identify how he or she feels.
Untreated Psychological Trauma and PTSD
Much trauma is left untreated and this may result in serious consequences for physical and mental health in addition to the unpleasant trauma symptoms already noted.
These untreated conditions may result in anxiety states that include panic and agoraphobia, in chronic pain states, in depression and suicidal behavior, in the addictions through self-medication, and in cardiac and diabetic illness. There is also a psychiatric condition known as the multiple personality disorder (5). These patients experience extreme dissociation and have “multiple personalities.” There is a host personality that can call forth the other personalities, such as the angry, depressed, or frightened personalities. In eighty percent of these cases, the patient with multiple personality disorder has a history of severe physical or sexual abuse in childhood.
Let us return now to the case study of Maureen from the beginning of this essay. In terms of the health domains, her sense of reasonable mastery in the face of this repeated physical and sexual abuse was beyond her control and is disrupted. When she finally reaches out for help, she is not only rejected but punished. Her caring attachments to her parents are fully absent and her possible normal meaningful purposes in life (e.g., a special boyfriend and a happy marriage have been dashed). She is experiencing the physical symptoms of intense anxiety in the form of hysterical paralysis and intrusive symptoms in the form of recurring nightmares. Since this horrific turmoil has gone on for seven years, she has gone from psychological trauma to chronic PTSD. Even though she is young, she appears to be in a state of depressive despair.
Maureen’s current functioning and the untreated impacts noted above clearly indicate the importance of treating psychological trauma as soon as possible in the acute state and to remediate PTSD quickly, when it has taken root. Disruptions in the health domains and the presence of trauma symptoms with the possible long-term consequences to the victim’s health and well-being need not be.
There is hope. In Part 2 of this essay, we examine some of the common treatment interventions that have proven helpful in remediating psychological trauma and PTSD, including cases of chronic PTSD.
1. American Psychiatric Association. Diagnostic Criteria from “DSM-IV.” Washington, DC: American Psychiatric Association, 1994.
2. Flannery R. B. Jr. Posttraumatic Stress Disorder (PTSD): The Victim’s Guide to Healing and Recovery. Second Edition. New York: American Mental Health Foundation, 2012.
3. Widom, C. S, “Does Violence Beget Violence? A Critical Examination of the Literature.” Psychological Bulletin, 1989, 106: 3-28.
4. Khantzian, E. J., and Albanese, M. Understanding Addictions as Self-Medication: Finding Hope behind the Pain. Lanhan, CO: Rowan and Littlefield, 2008.
5. Putnam, F. W. Jr. Diagnosis and Treatment of Multiple Personality Disorder. New York: Guilford, 1989.
Raymond B. Flannery Jr., Ph.D., FAPM, is an internationally recognized scholar and lecturer on the topics of violence, victimization, and stress management. Dr. Flannery is available for lectures and workshops for all types of groups, and may be reached at the American Mental Health Foundation.Email Evander or call 212-737-9027.