For the purposes of this chapter, the various responses or consequences of exposure to traumatic stress will be divided into two large categories: (1) consequences identified by the American Psychiatric Association in the DSM-IV-TR, consisting of formalized diagnostic criteria and symptoms and (2) the biological, psychological, and social effects identified by researchers independent of the DSM-IV-TR.
The pathological or abnormal responses to exposure to a traumatic stressor identified in the DSM-IV-TR are grouped into three large categories: symptoms of reexperiencing, symptoms of avoidance, and symptoms of arousal.
The consequences of exposure to traumatic stress manifesting as a mental disorder are formally outlined in the DSM-IV-TR (2000, pp. 467-468) as follows:
Diagnostic Criteria for Posttraumatic Stress Disorder
A. The person has been exposed to a traumatic event in which both of the following were present:
1. The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.
2. The person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior.
B. The traumatic event is persistently reexperienced in one (or more) of the following ways:
1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.
2. Recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.
3. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur.
4. Intense psychological distress at exposure to internal or external cures that symbolize or resemble an aspect of the traumatic event.
5. Physiological reactivity on exposure to internal or external cures that symbolize or resemble an aspect of the traumatic event.
C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:
1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma.
2. Efforts to avoid activities, places, or people that arouse recollections of the trauma.
3. Inability to recall an important aspect of the trauma.
4. Markedly diminished interest or participation in significant activities.
5. Feeling of detachment or estrangement from others.
6. Restricted range of affect (e.g., unable to have loving feelings).
7. Sense of foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span).
D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
1. Difficulty falling or staying asleep.
2. Irritability or outbursts of anger.
3. Difficulty concentrating.
5. Exaggerated startle response.
E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than one month.
F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Acute: If duration of symptoms is less than 3 months. Chronic: If duration of symptoms is 3 months or more. Specify if:
With Delayed Onset: Onset of symptoms is at least 6 months after the stressor.
Reexperiencing (Criterion B)
If one had to pick one symptom or sign that was the hallmark of PTSD, reexperiencing may very well be it. Hollywood and television portrayals of the disorder commonly depict the war veteran having a flashback, believing he is back in the combat zone, fighting for his life. When a trauma victim has a reexperience, he or she is in a state similar to the acute stress phase of the traumatic stress or stressor. Individuals may feel that they are in danger in the immediate moment. They may panic and want to escape. They may become aggressive or assaultive in order to protect themselves from the reexperience of threat.
Intrusive thoughts, images, and perceptions are considered major features of PTSD. Kardiner (1941) states that even prior to the formal recognition of PTSD, accounts of traumatic experiences always included features of intrusive imagery and thinking. In literature, intrusive thoughts, images, and perceptions are collectively referred to as intrusive cognitions. Salkovskis (1990, p. 91) defines intrusive cognitions as "mental events which are perceived as interrupting a person's stream of consciousness by capturing the focus of attention." An individual's thinking or mental activity is disrupted. Intrusive recollections can be triggered by stress or seemingly unprompted. (For more on the etiology or cause of intrusive recollections, see Chapters 5 to 7.) They are considered relatively common in individuals suffering from PTSD and occur more frequently than dreams or experiences of recurrence. An example of an intrusive cognition might be a visual image or memory of watching someone being struck by a car. Researchers,
P f*lAlr+ de Silva and Marks (1999) give the following rroTessionai Mierx . . r
good examples: image of a car accident, lying
Accurate assessment of the exact on the road, with leg at an angle, blood around nature of intrusive cognitions him; vivid memory of jacket ablaze, and his fran-
may be relevant to treatment tic movements as he tries to take it off; recollec-
strategies! As de Silva and Marks tion of her body shaking, with the electric cable
(1999) point out, exposure-based stuck to her hand, trying to scream but no sound treatments may be better for coming out. Research has shown that visual intrusive imageswhile cognitive images are a more common form of intrusive techniques may be better suited . . . . . . , r for intrusive thoughts. cognition than thoughts in verbal form.
In addition to images and thoughts, sounds can be reexperienced. Examples of hearing explosions, breaking glass, or screams are not uncommon. Feelings, tastes, and smells can also be reexperienced but are less common.
A type of memory known as a flashbulb memory has been used to describe the types of intrusive visual images reexperienced in PTSD. Flashbulb memories seemingly come out of nowhere, are very vivid and fresh, and give a sense of having recently occurred. Brown and Kulik (1977) suggest that public and personal events that are highly surprising and shocking are conducive to the formation of flashbulb memories. Certainly, traumatic stressors qualify as surprising and shocking.
As J. F. Pagel (2000) states, "nightmares are a defining symptom of PTSD." They are also considered a very common symptom amongst many clinicians. Pagel defines a nightmare as a vivid and terrifying nocturnal-sleep episode. The content of nightmares typically involves the traumatic experience and occurs during REM sleep but has been observed during sleep onset. Complications from nightmares can include insomnia, daytime memory impairment, and anxiety. Alan Siegel holds that PTSD nightmares are different than non-PTSD nightmares in that PTSD nightmares are considered more "emotionally intrusive and anxiety provoking."
Imagine driving to work in the morning, turning on the radio, and hearing a helicopter fly over your car, with machine-gun fire rattling. You swerve to avoid the bullets and end up in the drainage ditch next to the road. As witnesses come to the car you ask them if they saw the helicopter. Their answer of "no" lets you know you've had another flashback-a recurrence of a memory, feeling, or perceptual experience. Although this example may seem dramatic, it is exactly the kind of thing PTSD sufferers may experience. They are different than intrusive images or sounds in that they are perceived as a real experience of the trauma. Illusions are smaller forms of flashbacks that involve the misperception or misinterpretation of a real stimulus, such as perceiving a door slam as an explosion.
Hallucinations can also occur within the context of PTSD. A flashback is an actual memory that comes back into consciousness as a sight, smell, sound, or a complete scene. It has actually happened. Hallucinations are perceptions that seem real but occur without an external stimulus, as is the case with illusions. Within the context of PTSD, flashbacks happened, and hallucinations have not.
Hallucinations can be visual (e.g., seeing a dead person), auditory (e.g., hearing a baby crying), gustatory (e.g., tasting something bad), tactile (e.g., feeling worms under one's skin), olfactory (e.g., smelling rotting flesh), or somatic (e.g., feeling electricity in one's body). Lindley, Carlson, and Sheikh (2000) report that 30 to 40 percent of combat veterans with PTSD report auditory or visual hallucinations or delusions. These occur in the absence of an identifiable Psychotic Disorder or Mood Disorder with psychotic symptoms. They are often considered linked to more severe cases of PTSD, and symptoms include increased levels of paranoia, violent thoughts, and higher depression. They are typically nonbizarre and related to the trauma. Auditory hallucinations may involve hearing a voice of a dead enemy calling to them or even hearing their name called. Delusions can also be trauma related or nontrauma related, such as believing someone is attempting to poison them. In addition to hallucinations occurring within PTSD exclusively, PTSD sufferers also have higher rates of other Psychotic Disorders that involve hallucinations as well, such as Schizophrenia, Substance-Induced Psychotic Disorder, and Personality Disorders such as Borderline Personality Disorder.
The fourth component of Criterion B involves the experience of intense distress at exposure to internal or external stimuli that symbolize or resemble the trauma. A PTSD sufferer may cry uncontrollably at hearing a trumpet play, resembling the playing of taps. Becoming out of breath from running too fast may trigger intense fear in a recent near-drowning survivor. Along with the intense distress in component number four, a PTSD suffer may experience intense physiological reactivity to cues resembling the trauma, such as an increased heart rate, increased respiration, or intense sweating.
Avoidance (Criterion C)
Posttraumatic Stress Disorder also involves a significant change in an individual's responsiveness to his or her environment and the degree to which a person is engaged or detached. Certainly, one way to attempt to cope with a trauma is to try to avoid talking about it or ever thinking about it again. Avoiding thoughts, feelings, conversations, activities, places, or people that arouse recollection is common. People may move out of the town where an event occurred. One's memory for the event may be vague or even absent. "I don't want to think or talk about it" is a common reprise.
Emotional numbing and marked reduction in interest or participation in activities can also occur. For example, a tornado survivor may avoid feeling fear by expressing anger toward the government for not warning her and her family in time. Emotional numbing has been called alexithymia, the inability or difficulty in describing or being aware of one's emotions or moods. In response to the ever-present therapy question, "How does that make you feel?" a patient may respond, "I don't know what I feel!" and actually mean it.
"I feel like a stranger when I'm with my wife. I feel like she's on the other side of the world, even though she's lying right next to me in bed." These statements capture the experience of feeling detached or estranged from other people. It is not uncommon for a PTSD sufferer to feel intensely alone and alienated. He or she may have difficulty feeling love toward anyone, even people the PTSD sufferer can state he or she loves verbally, but without affect.
Finally, PTSD can involve a feeling that one might never grow up, get old, or have a future. They may engage in risk taking because they "know they won't live past 25 anyway." They can't imagine themselves grown up. Lenore Terr discusses this in length in her excellent book about PTSD in children, Too Scared to Cry.
Perhaps considered an ironic twist on the symptoms of avoidance, PTSD sufferers can sometimes engage in the exact opposite of avoidance and immerse themselves in trauma-related activities or stimuli. A Vietnam veteran may obsessively collect and compulsively view movies about the war, for example. van der Kolk (1996) identifies thee ways in which this immersion, or what he calls compulsive reexposure, (p.10) might occur: (1) Inflicting harm on others as a form of reenactment of the original trauma, (2) self-destructiveness such as self-mutilation or parasuicidal behavior, and (3) revictimization or being traumatized again and again in the same manner as before.
Arousal (Criterion D)
Posttraumatic Stress Disorder sufferers' minds and bodies can be in a constant state of alert and arousal. They can suffer sleep difficulties, exaggerated responses to being startled, irritability, outbursts of anger, poor concentration, and hyper-vigilance (always ready for something to occur). They are viewed as overreacting and can see their world as a dangerous or threatening place, reacting intensely to relatively nonintense stimuli. War veterans suffering from PTSD might find themselves on "patrol" of their neighborhoods, looking to "protect" and react to some impending danger. A hyperaroused parent of a child who nearly died from a serious illness might pull out the thermometer at the slightest sign of increased temperature and has the pediatric emergency doctor on speed-dial. Hyperaroused individuals can be "jumpy," becoming startled from the backfire of a passing car. Quite simply, these individuals have lost the ability to down-regulate their mind's and body's danger response system. They cannot "turn it off" so to speak. This experience can sometimes lead to intense feelings of demoralization and powerlessness as a sufferer may become overwhelmed by both the intense arousal and by the inability to deescalate. It can feel as if one's body is "out of control" and they might fear they are "losing their minds."
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