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Post Traumatic Stress DisorderRe-Living the TraumaPost Traumatic Stress Disorder or PTSD has been described as a normal, human response to an abnormal life situation or event. Post Traumatic Stress Disorder has been diagnosed across age, gender, racial, and socioeconomic boundaries as an adaptive response due to exposure to extreme stress under horrific, violent, or life threatening conditions (DSM-IV) PTSD was not a diagnostic category in the DSM-III until studies of Vietnam War Veterans explicated a predictable pattern of symptoms. PTSD is the condition of World War I and World War II veterans that was referred to as “Shell Shocked”. According to John Wilson, PhD, this discovery sparked interest among social science professionals in defining a specific diagnostic category in which to classify Post Traumatic Stress Disorder. Post Traumatic Stress Disorder is a disorder with symptoms of depression but is classified as an anxiety disorder. The re-experiencing of the trauma through dreams and waking thoughts. Emotional numbing to other life experiences, feelings and relationships. Symptoms of autonomic instability, depression, and cognitive difficulties such as poor concentration. According to the DSM-IV, the “essential” feature of Post Traumatic Stress Disorder “is the development of characteristic symptoms, following a psychologically traumatic event that is generally outside the range of usual human experiences”, and such symptoms which were not present before the individual experienced the trauma. Depression and PTSD are common as well as alcohol and drug abuse. War, the holocaust, famine, and large scale natural and man-made disasters are such events that affect many people simultaneously and which might produce the symptoms of Post Traumatic Stress Disorder. Witnessing a murder, suicide, or other violent act, experiencing a violent or life-threatening event, dealing with a prolonged terminal illness, rape, experiencing serious threat to one’s life or the unexpected loss of a loved one are examples of situations and events resulting in Post Traumatic Stress Disorder. The individual’s sense of self is crucial in the organization of the meaning of life’s experiences. A serious trauma and subsequent disruption of that organization constitutes a trauma in and of itself. That is, an individual’s unconscious meaning of real occurrences can cause trauma by shattering the central organizing meaning structures of the self in relation to the self/object (Ulman & Brothers, 1988). In effect, a traumatic experience can alter one’s experience of self in the world and this alteration is expressed in the symptoms associated with Post Traumatic Stress Disorder. A shattered sense of self circumvents the reconstruction of the meaning of the trauma which prevents successful restoration of the self as the center of organization along with the absence of a sense of selfhood in either a physical or mental dimension. Without the ability to organize experiences into knowledge, the victim’s knowledge base is faulty in interpreting further experiences which in turn provides signals which further reinforce the subjectivity of the trauma. These issues are responsive to cognitive therapy techniques by uncovering and the restructuring faulty and underlying thoughts and beliefs. There is an overlap of symptoms of depression, anxiety, and the symptoms of Post Traumatic Stress Disorder. The etiological perspective of PTSD is reiterated by Kohut (1971, p. 225) as the shattering and faulty restoration of the central organizing fantasies of self in relation to self object in response to “objectively ascertainable factors” such as combat, rape, or incest that elicit the genetically decisive experience. The model of Post Traumatic Stress Disorder proposed by Horowitz is described as a cyclical intrusion-numbing response to an overwhelming degree of stress. He describes a “completion tendency” as the normative, cognitive progression of sorting through and assimilating the stimuli we encounter daily as we evolve through life. This completion tendency describes the cognitive process whereby we take in new information, either assimilate or reprocess that information, so as to return to a state of psychic balance. This normal process is disturbed in the aftermath of an experience that is too stressful to accept and process upon encounter. The individual who is exposed to this high level of extreme stress is overloaded with the task of the completion tendency. And, as a result of this overload, the unresolved and undigested experience remains in active memory storage where it occupies much of the space where the normal cognitive process would ideally be functioning. A thought or experience that is in active memory dominates consciousness. The representations of the experience are perceived as important although there is no way to resolve or store this information so as to continue on normally. Defense mechanisms must be used to avoid complete breakdown. Psychic numbing, for instance defends against the persistent and uncontrollable intrusion of thoughts associated with the trauma. This numbing causes the processing of information, particularly trauma-related representations, to cease for a period of time. When there is a break through of a thought or feeling that has been kept from conscious awareness, the person experiences a flashback or intrusion of imagery in the cycling of numbing and intrusion. At the point of break through, the employed defense mechanisms breakdown or temporarily cease to operate successfully. Listed here are the defense mechanisms most commonly associated with Post Traumatic Stress Disorder: • Dissociation, whereby a segment or segments of the stressful event are “lost” – a partial amnesia dissociating the person from a segment of their own experience. • Blocking is being out of touch with a feeling or thought that relates to stimuli that have already been taken in or realized. • Denial can be described as cognitive distortion in an attempt to circumvent feelings that are uncomfortable or stressful (denial is not letting a thought, for example, in whereas blocking is letting stimuli in). • Repression is the defensive process of remaining unaware to, so as to ward off feelings of anxiety. Thoughts and/or feelings that were once conscious are repressed and subsequently are now unconscious. • Detachment is the absence of a connection between some event or condition and the person who has experienced that event or condition, i.e., a traumatic event. In the case of the Vietnam Combat Veteran, with the average age ranging from 18 to 20 (Wilson, 1988), a self-identity has not yet been fully developed. According to Erikson (1968), transition from childhood to adulthood occurs between the ages of 17 to 25. The developmental tasks associated with this stage of life are: • Separation from parents • The initial formulation of a career plan • The development of defined patterns of interdependence with others that are congruent with personality dynamics • The process of making commitments to initial career and life-style choices • The formulation of a broader sense of ideological perspectives in terms of political, moral, and social issues • Integrating all of the above into an identity structure that has a sense of continuity and self-sameness through time such that further development in life may proceed in a normative fashion. It would follow that an individual’s personality characteristics would emerge while coping with PTSD. For example, if a combat veteran was quiet, introverted, passive, submissive, and lacked self-confidence before the war experience, modes of coping with PTSD might be passivity, withdrawal, and an introverted personality style in the aftermath of his war service. If, according to Dr. Wilson, an individual’s personality propensity is proactive and initiating, he will be more likely to show sensation-seeking, paranoid, antisocial, histrionic and acting-out forms of coping with the hyperarousal of trauma-related imagery and affect. The disruption in the normal developmental process facilitates dysfunction as seen in the treatment and diagnostic process with the combat veteran. For example, the combat veteran with PTSD has difficulty maintaining an intimate interpersonal relationship due to the inability to trust and the subsequent vulnerability due to hyperarousal which lead to highly defensive states of being and interacting. The individual suffering from Post Traumatic Stress Disorder might present him or herself for treatment with a myriad of issues ranging from marital, family, social, employment, substance abuse, and physical impairment, or depression to name a few of many possibilities. One underlying theme which requires addressing in the treatment of such an individual is the fact that in order to recover from PTSD, victims must let go of the survivor-mode of functioning, i.e., hyperarousal leading to emotional constriction, depression, affective flooding, or sensation seeking, which counter feelings of vulnerability, perceived threats, and being in a position of unguardedness (Wilson, 1988, p. 244). The survivor-mode of functioning is what has enabled emotional survival for the person with PTSD and yet this protective façade must be removed in order to recover. • support • modulation of work and activities • facilitating sleep • awareness of cognitive impairment and risk of injury as a result • need for empathic listening • educating the person about the stages of stress recovery • low pressure during the denial phase • structuring time-limited therapy if the trauma is not too extreme and/or complicated by personality disorders • time-unlimited therapy for certain chronic stress syndromes According to Dr. Wilson (1988) worldwide there are cultural rituals and practices for the treatment of emotional disorders, stress, and states of “dispiritedness”. These cultures reward the bravery of those inflicted by centering attention on them and directing positive energy toward them as a means of expressing honor, purification, and the healing of both physical and psychological wounds. The existing theories of treatment for PTSD incorporate empathy and non-judgmental listening as the client is in a traumatized state resulting from the stressful event. The therapist is encouraged to seek understanding from the victim as each has had experiences which are unique and individualistic. Humility and openness on the part of the therapist presents the opportunity for trust and interaction which is in itself a part of the healing process in the treatment of PTSD. PTSD and Modern WarfareIraq and AfghanistanPost Traumatic Stress Disorder (PTSD) was initially considered as a separate category for the Diagnostic and Statistical Manual of Mental Disorders (DSM) after the Vietnam War. The social, emotional, and psychological problems of the returning war veterans were noticeably similar. The compilation of their information and further research into their symptoms concluded that exposure to life threatening stressors resulted in PTSD. In fact, at the 50th anniversary of Pearl Harbor in Hawaii, questionnaires were completed by veterans of WWII and produced astounding results: those veterans still suffered the symptoms and problems of PTSD. In the days following the return to the United States of WWII veterans, the description of the troubled and traumatized veterans was “shell shocked”. The changes in the pre-war soldier were obvious and evident; “shell shocked”. The soldiers fighting in Iraq and Afghanistan face some critical aspects of war that the earlier fighting men and women did not and the WWII veterans faced some critical aspects of war that the Vietnam and Iraqi war veterans do not face. That being said, modern warfare in the Middle East has some unique stressors that impinge upon the psyche and emotional stability of the modern soldier. Upon returning to the United States the soldier who suffers from PTSD might first contact his or her primary care physician with physical complaints resulting from their war trauma and PTSD is not an easily recognizable diagnosis outside the mental health providers or the Veterans Administration Hospital facilities. A study conducted by Magruder et al(1) showed that out of 746 veteran patients 40 patients out of 86, who met the DSM-IV criteria for a PTSD were diagnosed with PTSD. Stressors of Modern Warfare The American soldiers stationed in the Middle East are exposed to many stressors that are unique to modern warfare. The following stressors may or may not contribute to PTSD depending upon the individual and his or her distinct experiences: • combat exposure: firing weapons and being fired upon; danger of death or severe injury; exposure to the death of fellow soldiers and/or other individuals; exposure to the destruction of communities and those who live there • anxiety and fear associated with sustained exposure to life threatening situations • fear of exposure to chemical, biological, and radiological and the long-term health problems associated with that exposure • continued exposure to difficult working conditions, a foreign culture, extreme weather conditions, unfamiliar and strange foods, and poor living arrangements • sexual harassment • terrorist tactics which make it difficult if not impossible to identify suicide bombers from civilians • potential abuse or execution if captured
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