Conceptualizing Trauma

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Personal and Philosophical Perspectives

A person's worldview or conceptual framework for understanding the world should never be taken for granted. The branches of philosophy known as episte-mology and ontology are devoted to understanding the how of knowledge (epis-temology) and the what of the knowledge (ontology). How we as individuals come to know what we claim to know, our own personal epistemology is an important feature of our educational experience. What is happening when we attend class, listen to lectures, and read books and articles is a complex process of using our existing ways of knowing and current conceptual base to perceive, analyze, process, and integrate the newer incoming information. Basically, none of us is an empty vessel, showing up to the learning experience with a mind void of concepts or ways of knowing.

These points are particularly salient when it comes to the topic of trauma and posttraumatic reactions. Why? Trauma invokes powerful images, thoughts, and feelings. It is a concrete and heavy concept because it is far too real for so many people. Because of this, each of us shows up to the trauma epistemology and ontology game with a lot of conceptual baggage. The philosophy of Edmund Husserl held that each of us possesses conceptual frames or brackets by which we organize and understand the world around us. He supported exploring these brackets in order to understand where our ideas about the world come from. This process was intended to address bias and misconception. I won't be asking you to discard your baggage or explore your frames necessarily, but simply to be aware. Self-awareness in the learning process is a powerful ally. As a therapist working with PTSD patients, I have seen my own conceptual baggage interfere with the listening and empathy process. As a writer, I am aware that to best teach the concept of PTSD, I must respect the diversity of perspectives of the readers picking up this book.

Before I start indoctrinating you with the philosophical, historical, psychological, and psychiatric frames of understanding posttraumatic experience, let's do a quick exercise commonly used in psychological assessment known as the sentence completion technique. The instructions are simple; just fill in the blank at the end of each sentence with a word (or words) that makes sense to you.

Life is full of adversity; the best way to cope with it is to__

Soldiers who break down during combat are .

My own life has been_of trauma.

People who talk a lot about their traumatic experiences are .

An important aspect of history is remembering things such as__

I never knew how_I was until something traumatic finally happened to me.

What were your responses? I hope that these few simple sentences were good enough to get you thinking about your own personal and preconceived views of trauma and posttraumatic reactions. Maybe you view trauma as rare, maybe for the weak of spirit, maybe unavoidable, maybe psychological or neurotic, or maybe physical.

Although it may sound surprising, the recognition that people who experience trauma may suffer adverse consequences and that these people need to be listened to and their experience acknowledged has not always been the case.

Harold Kudler (1999) states that current thinking or the modern paradigm reflects an understanding that there are psychological consequences to exposure to trauma, implying that this may not have always been the case, at least on the same scale as modern thinking. A paradigm is a worldview that "organizes observations, theories, and facts about a given subject." (Kudler, 1999, p. 3) Hopefully, you are becoming more aware of your own paradigm. The paradigms for this book come, most broadly, from the fields of psychology, psychiatry, and the mental health field. Moreover, I am a psychologist writing about PTSD. A psychiatrist, social worker, or anthropologist writing about PTSD may have written a very different book. The language of psychology and the related disciplines is a tool for organizing observations of traumatic experience or reactions.

Certainly, however, humans are or have been able to talk about trauma before the modern language of psychology or psychiatry came along. Literature, folktales, stories, and various other forms of cultural narrative represent their own ways of organizing observations, theories, and facts about trauma. Hopefully, the psychological approach mirrors or reflects these forms as they reveal themselves to be accurate descriptions of the natural phenomenon of posttraumatic experience. A writer's account of the carnage of war can accurately reflect modern psychological understanding of posttraumatic stress, without such writer having ever studied clinical psychology. In fact, this account may have occurred hundreds of years prior to the advent of modern psychological theory or practice. What is most important to gleam from this discussion is that regardless of exactly what language one uses to describe them, posttraumatic reactions do, in fact, exist in the natural realm of human experience. They are not or were not simply invented by mental health professionals.

Again, Harold Kudler states, "prior to the 1980's it was unlikely that a clinician would inquire about a history of trauma or connect current problems to past traumatic experiences" (1999, p. 4). Does this mean that these experiences and connections didn't exist until mental health practitioners started asking about them? Of course not, just as microbes existed prior to the invention of the microscope. Perhaps the microscope that allowed us to see PTSD was an advance in human compassion for those suffering the effects of trauma. Perhaps it was the plethora of traumatic experiences so often found in the form of modern warfare, with its capacity for massive destruction and death that brought trauma closer to our collective consciousness. There is, perhaps, more evidence for the latter as historically it seems that interest in trauma is highest toward the end of or immediately following war (see the Historical Perspectives section in this chapter).

Traumatic reactions are connected to bad things, events, or situations that we typically wish to avoid, such as wars, illness, and other events that speak of death or dying. Our delicate consciousness may steer us clear of facing trauma. Yet Alexander McFarlane argues that despite our desire to avoid a face-to-face meeting with trauma, the "field of inquiry" evidences remarkable, "durability" over time (McFarlane, 1999, p. 12). Perhaps this demonstrates our own schism when dealing with trauma, a type of approach-avoidance conflict. Further, the enduring nature of traumatic symptoms in the form of PTSD holds us to never forgetting.

Historical Perspectives

The modern concept of PTSD has always been with us. It was first officially introduced into the mental health nomenclature—in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III )—in 1980 after a hard-won struggle by activist-professionals.

As is the case with so much in psychology and psychiatry, the professional establishment has obviously been behind the times. Lay people, individual professionals, and, of course, survivors and sufferers have known the reality of PTSD long before it was officially recognized.

Along the way, there have been many "smaller" versions of PTSD, a set of symptoms or syndromes identified more with a specific stressor, rather than as a universal syndrome or disorder resulting from a traumatic stressor of any type, given it is of sufficient intensity.

Allan Young (1999) identifies early clinical interest in posttraumatic symptoms with John Erichsen's 1866 work on railway spine. Victims of railway collisions were experiencing shock, intense fear or fright, and physical and emotional problems. This work is identified as unique because symptoms were not exclusively connected to a physical injury, and the actual injury suspected was essentially "invisible." Experts at that time believed that victims sustained neurological injury, perhaps as a consequence of overwhelming emotions. This was referred to as the nerve-trauma hypothesis.

Jean-Martin Charcot, the famous neurologist that trained Freud and who popularized the clinical use of hypnosis, suspected the symptoms observable in railway spine were the consequence of nerve damage from the train collisions themselves. However, he introduced the importance of memory in such reactions, believing that in some cases a type of traumatic memory, different from normal memories in its formation and maintenance in that it was not integrated with other memories and consciousness, was involved in the maintenance of symptoms. Allan Young cites Charcot's portrayal of traumatic memory as "a coherent group of associated ideas which install themselves in the mind in the fashion of a parasite, remain isolated from all the rest, and may be explained outwardly by corresponding motor phenomena" (cited in Janet, 1901, p. 267). Young further characterizes the understanding of posttraumatic syndromes during this time period as being related to traumatic memory or amnesia in one form or another. Already, in such early work, we can see the centrality of memory in the pathogenesis of PTSD (see the Psychological and Psychiatric Perspectives section in this chapter for more on the role of memory in PTSD).

In France in 1890, Charles Sugois edited a medical sciences volume that contained a discussion of traumatic neuroses as a single concept for grouping the terms railway spine or railway brain. This was an early attempt at unifying the concept of posttraumatic experience. During this time, there was considerable debate among medical professionals regarding the physical versus psychical (mental) nature of the condition.

Sigmund Freud's work (Freud, 1896/1964) with neurosis contributed to the trauma field. He stated that trauma was at the center of the etiology of neurosis and stated that trauma was "a breakthrough of the brain's defense against stimuli. Such a breakthrough set up a great amount of anxiety identifiable in dreams and is followed by an event on the part of the organism to free itself of this anxiety by constant repetition" (Kardiner, 1959, p. 247). Further, Freud's and Josef Breuer's work on hysteria continued to hold that memory is a central component of traumatic syndromes. Breuer believed that traumatic memories somehow became displaced in the mind and were therefore unavailable for normal conscious processing and subsequent resolution. Freud and Breuer disagreed on exactly how such memories came to be displaced, with Freud believing that such a process was an action of the defense mechanism process employed to protect an individual. In either case, once again, memory sat center stage.

Historians identify World War I as the next time period of significance in the conceptual development of PTSD. The casualty toll of World War I was immense and, for some, unfathomable. The harsh conditions of life and death in the trenches inevitably lead to breakdown, both physical and psychological. Those who presented with psychological trauma or related symptoms were not necessarily viewed from a standpoint of compassion. In fact, the medical or health-oriented interpretation of their problems was forgone for more moral or social judgments. Medical experts sometimes would label those suffering from shell shock as morally inferior and weak, not having the wherewithal to face combat and defend their respective nations. These individuals would sometimes receive dishonorable discharges from the military or were treated by a form of disciplinary therapy and returned to the warfront. Some were treated with a form of aversion therapy in which the consequences of being traumatized were more aversive or unpleasant than of actually returning to battle. Alexander McFarlane (1999, p. 20) refers to proponents of the moral and/or social approach to trauma as ascribing to the "disciplinary school" of thought. These views were inherently tied to an emotional view of traumatic responses. Still other proponents of the physical perspective held that the result of shell shock was due to microhemor-rhaging in the brain. McFarlane further claims that these theories essentially fail to comprehend that the "medical or social narrative" simply did not allow for the belief that war had the capacity to "scar the mind."

Abram Kardiner's 1941 book The Traumatic Neuroses of War is considered a direct source of the modern concept of PTSD (Young, 1999). Unlike the predecessors of World War I, Kardiner's work puts the focus back on the (negative) transforming power of traumatic stress and its challenge to adaptation. Working partially from a psychoanalytic perspective, sufferers are thought to experience a reorganization of the sense of self to a state of lesser ego functioning. They are believed to be "fixated on their traumas, their conceptions of the selves and the outer world are distorted, they experience characteristic dreams, they are irritable, and they exhibit a tendency to explosive aggressive reactions" (Young, 1999, p. 57).

The official guide to mental disorders developed and published by the American Psychiatric Association, the Diagnostic and Statistical Manual of Mental Disorders (DSM-I) was first published in 1952 and made no mention of Posttraumatic Stress Disorder. The veterans of World War II and the Korean War were being seen with traumatic symptoms and were described as suffering from gross stress reactions. (DSM-I, p. 40) Conceptually, the symptoms of trauma were viewed as the "aftereffects of previously healthy persons who began having symptoms related to intolerable stress" (Bloom, 1999, p. 34) In 1968, the Diagnostic and Statistical Manual of Mental Disorders, Second Edition (DSM-II) replaced "gross stress reaction" with "transient adjustment disorder of adult life."

Following this period in the late 1960s and early 1970s, deeply compassionate and dedicated professionals began to respond to the traumatized returning from the Vietnam War. Dr. Chaim Shatan and a colleague were working with Vietnam veterans in New York City who had traumatic symptoms. In 1972, Shatan wrote an article in which he referred to these symptoms as part of PostVietnam Syndrome. Shatan and Lifton were intensely involved in helping Vietnam veterans cope with their experiences while advocating for better treatment by the military medical establishment—the Veteran's Administration. Many individuals were being misdiagnosed as a consequence of the lack of an official and accurate concept of posttraumatic stress. Dr. Philip May, Shad Meshad, and William Mahedy were conducting similar work on the West Coast in California. In 1974, Sarah Haley published a paper in the Archives of General Psychiatry titled "When the Patient Reports Atrocities" that got the attention of the American Psychiatric Association. Shatan was asked by the APA to contribute to this developing concept and polled the members of the Vietnam Veterans Working Group for their ideas. What emerged was a classification system resembling Abram Kardiner's 1941 work (Bloom, 1999). Eventually, through the work of these dedicated people and countless others, Posttraumatic Stress Disorder was added to the DSM-III in 1980.

Amidst this important political and social advocacy and during this same period in 1976, Mardi Horowitz, a psychiatrist, introduced his work Stress Response Syndromes (see Chapter 13 for more of Horowitz's work). Horowitz contributed an elegant conception of the response to trauma. In essence, Horowitz held that traumatized individuals are chronically attempting to process their traumatic experiences and memories while engaging in alternating phases of engagement and avoidance. Horowitz's work was undeniably incorporated into the DSM-III conceptual framework.

Professional interest in PTSD has been growing ever since. Although the concept was intensely tied to the experiences of those suffering the ill psychological effects of war, PTSD has grown to apply to a much larger group of stimulus or causal events, including rape, natural disasters, automobile accidents, and child sexual abuse (see Chapter 17 for more on these topics).

Contemporary Psychological and Psychiatric Perspectives

Hopefully, the previous discussions have introduced some ideas central to defining and understanding what PTSD is, for example, that a reaction to trauma involved a persistent memory of that trauma. Essentially, it should be clear by now that exposure to traumatic events has the potential to bring about serious consequences. But historically the focus was on stressor- or event-specific syndromes. As was just discussed, the DSM-III concept of PTSD reflects the seemingly revolutionary idea that the symptoms experienced across events represented a unified pathological process. Harold Kudler states that the eventual development of the DSM-III concept of PTSD was the result of a recognition that different patients with different stressors "had responded in a similar manner" and "were consistent in clinical presentation and course across different populations" (1999, p. 4). That is, it is now widely believed that PTSD represents a distinct clinical entity.

Modern psychological and psychiatric nosology relies on factorial models of clinical disorders in which signs and symptoms are measured across populations and observed to cluster together in a way that form distinct clinical entities. These clinical entities cluster to form a diagnostic core. The signs and symptoms looked for across populations are based on the conceptual core of the observed clinical phenomenon. For example, therapists and mental health professionals were witnessing or observing the presence of PTSD-like symptoms without a formal label to apply to them. As professional dialogue progressed and these professionals got together to discuss their observations, the conceptual core of the PTSD construct began to emerge. Oftentimes in science, observations made by multiple independent investigators and practitioners are pulled together by an acknowledgment of their similarity. In fact, the validation of individual observations is a central tenet of the scientific method and works toward the organization of individual data points into a cohesive theory. It is a collective process of deductive reasoning.

The core signs and symptoms of PTSD first officially identified in 1980 in the DSM-III are currently formally identified in the fourth edition, text revision version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). Posttraumatic Stress Disorder, as recognized in the DSM-IV-TR, comprises two main components:

1. An individual is exposed to a traumatic event that involves either directly experiencing or witnessing death, serious injury, or threat to physical integrity, and his or her response involves intense fear, helplessness, or horror.

2. Reactions involve symptoms of reexperiencing, avoidance and numbing, and hyperarousal.

The first component of the contemporary and formal concept of PTSD necessitates the presence of a stimulus, an event or situation. This event is viewed as "outside the range of usual experience" (DSM-III-R, p. 250), intensely challenging, and often catastrophic. The stressors are necessarily experienced with intense fear, terror, or helplessness.

Case Study 1—Responding to the Unexpected

A man and his 22-year-old daughter were waiting in Line on a sidewalk outside a bookstore to get their favorite author's signature in his latest book. A car on the road beside them had swerved out of control, jumped the curb, and struck both of them. They both sustained serious but not life-threatening injuries and eventually gained a full physical recovery. Because of his obsessive calling and checking on his daughter's well-being for almost 2 years after the accident, the father sought psychotherapy for help. During the intake and initial interview, the man recalled the event and at times began to cry and shake, stating, "We couldn't move. It happened so fast; there was nothing I could do to keep her from getting hit."

The criterion of outside the range of usual experience can be observed here, as the statistical likelihood of being struck by a car while waiting in line on a sidewalk is relatively rare. The criterion of intense fear, terror, or helplessness can be observed in this vignette by the patient's statements, "We couldn't move. It happened so fast; there was nothing I could do to keep her from getting hit."

The required trigger or stimulus for PTSD is referred to as the stressor criterion or Criterion A in the DSM-IV-TR. An individual has to be exposed to war, for example, or a natural disaster and so on. Green (1993) proposed eight dimensions of trauma or examples of traumatic stressors that would qualify for Criterion A:

1. Threat to life and limb.

2. Severe physical harm or injury.

3. Receipt of intentional injury/harm.

4. Exposure to the grotesque.

5. Violent/sudden loss of a loved one.

6. Witnessing or learning of violence to a loved one.

7. Learning of exposure to noxious agents.

8. Causing death or severe trauma to another.

March (1993), another researcher, provides still another list of what he calls characteristic PTSD stressors:

Combat

Criminal assault

Rape

Accidental injury

Industrial accident

Automobile accident

Hostage situation

Prisoner of war (POW) situation

Natural disasters

Human disasters

Witnessing homicide

Sudden illness

Severe burns

He states further that such stressors constitute what we have generally come to believe or expect, that such events elicit "intense fear" and "helplessness" (DSM-IV-TR, p. 463).

With this concept of trauma, we obviously make a distinction between everyday or normal stressors and more extreme stressors. One may assume that traumatic events are not the norm, not everyday, but certainly there are people who live amidst the preceding list of stressors virtually everyday. This is where the second part of the first component of PTSD becomes important. Everyday, critical stressors or critical events may not necessarily result in extreme responses of fear, helplessness, or horror. A combat solider, for example, may witness or cause death nearly everyday without these concomitant emotions and subsequent PTSD (see Chapters 4 to 7 for more on models of PTSD and at-risk populations). Therefore, the subjective experience of the traumatic-stressor survivor is critical in his or her development of symptoms and pathological reactions. Figure 1.1 should help illustrate these concepts.

Qualified Stressor and Qualified Reaction

Symptoms and Signs of PTSD

FIGURE 1.1 Pathways to PTSD.

Professional Alert

The Criterion A issue seems Like a slippery slope, perhaps Leading to the inclusion of events subjectively experienced with intense fear, helplessness, or horror but perhaps not strictly meeting Criterion A-1 in the DSM-IV-TR. Here is where the issue of clinical judgment comes into play. A professional must use his or her best clinical judgment at times of ambiguity. After all, the purpose of diagnosis is to aid in treatment. An adopted stance of overinclusiveness or false-positive diagnosing may contribute to effective treatment. That is, sometimes it is advisable and smart, clinically and ethically, to be conservative. This is, of course, an issue of clinical philosophy, whether you seek to be overinclusive or underinclusive. (For more on this issue, see Chapter 10.) Nonetheless, a stance of best clinical judgment is advised when diagnosing a patient with PTSD based on a nontradi-tional Criterion A-1.

Now that the two requisite components of PTSD have been established, let's take a closer look at its core symptoms. A visual representation of PTSD is shown in Figure 1.2.

Each of these three core areas, reexperiencing, avoidance, and increased arousal, has various and numerous symptoms clustered within it. For example, reexperi-encing can be determined by the presence of recurrent distressing dreams of a traumatic event (Criterion A-1). Avoidance and numbing is sometimes signaled by the presence of an individual's sense of a foreshortened future in which he or she may feel that he or she will have no career or a family. (See Chapter 3 for more detail about the symptoms of reexperiencing, avoidance, and hyper-arousal.) Keep in mind that the symptoms that fall within each of these three categories do not always occur together in the same pattern or patterns and will typically vary in severity and intensity.

Reexperiencing a traumatic event is directly related to the historical conceptions covered earlier in the chapter and the emphasis on the role of memory in traumatic reactions. Reexperiencing is sometimes referred to as intrusion because of the obviously unwanted nature of the recollection.

The following vignette should help illustrate the core phenomenon of reexperiencing in PTSD:

Mr. Jones made several frantic attempts to contact me (his psychologist and therapist) after getting into a severe argument with his wife about stopping for gasoline at a local mini-mart gas station. Once we were face to face, he told me that he had pulled into the station and quickly noticed what he described as "little thugs, gangbangers" standing by the door of the mini-mart. He immediately felt a chill and began to sweat heavily. His heart raced, and he felt he needed to take off running or drive away extremely fast. He did, in fact, hit the accelerator, and took off rather recklessly from the lot. "They looked just like those bastards that shot me, Doc! My wife was yelling at me for driving crazy, asking what the hell I was doing. I yelled back at her, telling her something was gonna go down! Even though I risked running out of gas, there was no way I was sticking around that station!"

Mr. Jones was responding to the stimuli of the "thugs" with intense distress and with a sense that the event (being shot in the head and back over 10 times) or a very similar event was about to occur again. He was reexperiencing his trauma.

This case illustration, or vignette, also demonstrates well the second core phenomenon of PTSD-avoidance. This patient's behavior perfectly demonstrates an attempt to avoid a stimulus that arouses recollections or memories of his trauma. The experience of numbing, also a component of the avoidance component, involves a general reduction in responsiveness to one's environment, such as feeling socially detached and estranged and exhibiting a restricted range of emotional response. Mr. Jones constantly fought with his wife in reaction to her persistent statements that he was "cold-hearted and unloving." She would say, "The only emotion you've got is pissed off!"

This last point illustrates the final core concept of PTSD-increased arousal. These symptoms typically involve feeling on edge or on alert seemingly all the time. Difficulties sleeping, irritability, poor concentration, and being easily startled are common symptoms. Recall the Vietnam veteran from the Introduction who, stimulated by a simple phone call, exhibited the disproportionate response of his jumping out of his seat and crying?

Finally, we have arrived at a point where a good working definition of Post-traumatic Stress Disorder, based on a solid conceptual understanding, can be presented and used for the remainder of the book:

Posttraumatic Stress Disorder is a maladaptive reaction to a traumatic event in which a person experienced, witnessed, or was confronted with an event that involved actual or threatened death or serious injury or a threat to the physical integrity of self or others and experienced intense fear, helplessness, or horror. Afterward the person developed symptoms of reexperiencing the traumatic event in various forms, avoidance of stimuli that are associated with the event, emotional numbing, and hyperarousal to a degree that is disruptive to his or her functioning.

Hopefully this chapter served as a proper conceptual orientation and, along with the working definition at which we have arrived, you can explore PTSD more thoroughly in the chapters that follow. Here is a short summary of what you can expect:

Chapter 2. General theories of stress are covered, along with a discussion of coping in response to stressors.

Chapter 3. An empirical discussion of PTSD and its biological, psychological, and social effect are discussed. The core symptoms of PTSD will be discussed in more detail, along with the clinical course and prognosis. Patterns of recovery are discussed, and there is a discussion of resilience.

Chapter4. Exposure and risk factors for the development of PTSD are discussed.

Chapter5. Cognitive and behavioral models of PTSD will be covered, including memory distortions and associative learning mechanisms.

Chapter 6. This chapter addresses the biological models and underpinnings of PTSD.

Chapter 7. This chapter addresses numerous alternative models and explanations of PTSD such as psychodynamic or narrative models.

Chapter 8. This chapter addresses other potential consequences of trauma such as traumatic grief or Borderline Personality Disorder.

Chapter 9. This chapter will discuss the importance of placing PTSD in a cultural context in research and practice. Recommendations are made to help avoid the pitfalls of approaching the disorder from a culturally biased perspective.

Chapter 10. This chapter will discuss various evaluation methods. The diagnostic criteria of the DSM-IV-TR are presented in more detail as well as the overall approach to psychological assessment of PTSD, including a listing and discussion of specific instruments.

Chapters 11 to16. These chapters cover the various treatment techniques for PTSD, including cognitive treatments, psychodynamic treatments, pharmacological treatments, integrated approaches, and other treatments.

Chapter 17. Specific therapies for specific types of trauma such as rape, child abuse, and car accidents are discussed.

Chapter 18. Cutting-edge research and future directions are reviewed, including a discussion of the use of virtual reality technology in treatment.

Chapter 19. This chapter covers issues relevant to professionals who work with the traumatized, including discussions of compassion fatigue and various pitfalls.

Chapter 20. This chapter addresses children, adolescents, and families with PTSD as special populations.

Chapter 21. This is a special chapter on PTSD in war, combat, and the military. It is set aside as a special section because of the abundance of research and clinical work in these areas.

Chapter 22. This chapter will discuss the issues of hope, resilience, and the path to recovery from trauma.

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