Other Biological Psychological and Social Responses and Consequences

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Physical Health

Research has consistently shown that individuals diagnosed with PTSD have higher rates of medical services use and increased levels of fatigue, headaches, chest pains, gastrointestinal disorders, cardiovascular disorders, and impaired immunity functioning when compared to individuals not diagnosed with PTSD. There is also a tendency for such individuals to rate themselves as less physically healthy overall when asked. Keep in mind that the jury is still out as to the exact nature of the relationship between PTSD and physical health problems and disease. Some researchers propose the existence of mediating variables such as drug or alcohol abuse to be responsible for the observed relationships thus far. It is not clear from the research so far whether physical health problems associated with PTSD are the result of somatization; physical health problems resulting from the actual physical aspects of the event (e.g., smoke inhalation from a fire, starvation as a prisoner of war, or exposure to Agent Orange); nonspecific physical responses associated with PTSD but not caused by it; or associated behaviors related to PTSD, such as alcohol abuse, smoking, or medication side effects.

Here is a list of some identified health problems related to PTSD:

■ Greater frequency of medically explained and unexplained symptoms (Golding, 1994)

■ More chronic physical limitations and a higher likelihood of a chronic medical condition (Ullman & Siegel, 1996)

■ Increased risk for obesity (Felitti et al., 1998)

■ Increased cardiovascular reactivity, disturbed sleep physiology, and adrenergic dysregulation (Friedman & Schnurr, 1995)

■ For rape or incest survivors, more frequent gastrointestinal distress, recurrent headaches, dysuria, vaginal discharge, and chronic abdominal pain (Felitti, 1991; Rimsza, Berg, & Locke, 1988)

■ For ex-POWs, higher rates of tuberculosis, cardiovascular disease, respiratory disease, and both gastric and duodenal ulcers (Eitinger, 1973)

■ Increased occurrence of unspecified pain complaints and disorders (Wolfe et al., 1994)

■ Enhanced thyroid functioning and altered hippocampal-pituitary-adrenal axis activity (Friedman & Schnurr, 1995)

Friedman and Schnurr (1995) have proposed that the pathophysiology associated with PTSD is directly implicated in the development of physical health problems, including excessive sympathetic reactivity, adrenergic dysregulation, endocrinological abnormalities, and a dysregulated immune system. They also hold that psychological states such as hostility, anger, and behavioral avoidance through alcohol or drug use have dire health consequences as well.

In addition to actual physical health problems and complications, exposure to traumatic stress sometimes leads to somatization, which is the occurrence of numerous bodily or physical complaints without an underlying disease process or physical illness to account for them. Symptoms reported under the heading of somatization are considered associated with psychological problems and, in a classic sense, are viewed as conversions of psychological difficulties or stress into physical complaints. Examples of somatization complaints are pain (head, neck, chest), diarrhea, nausea, erectile dysfunction, localized limb weakness, double vision, or fainting.

Neurological and Psychophysiological Consequences

Numerous investigators have observed alterations in the brain's neurochemistry in response to exposure to traumatic stressors. In general, the findings suggest that neurochemical alterations occur within specific locations in the brain, particularly those involved in arousal and memory. For example, investigators have found increased noradrenergic levels and sensitivity in the locus coeruleus, hypothalamus, hippocampus, amygdala, and cerebral cortex and increased nor-epinephrine levels in the locus coeruleus, which has been shown to interfere with memory consolidation for long-term memory storage.

Under conditions of acute stress, dopamine levels can be altered, and an observed increase in metabolism in conditions of acute stress can be seen. Specifically, an increase in dopamine enervation in the prefrontal cortex (PFC) is thought to play a role in a victim's sensitivity to future stress (Charney, Deutch, Southwick, & Krystal, 1995). Further, the PFC is implicated in working memory functioning and attention and is thought to contribute to hypervigi-lance because of its neural connectivity to the amygdala, the entorhinal cortex, and the locus coeruleus.

The comorbid presence of depression in those who suffer from PTSD may be connected to decreased monoamine oxydase inhibitor (MAOI) activity. In addition to depression, trauma victims sometimes complain of increased pain sensitivity or, conversely, a decrease in their overall pain tolerance levels. A decrease in endogenous opioids has been found that may account for these complaints.

Posttrauma alterations in brain chemistry have been implicated in actual anatomical or structural neural damage. The posttraumatic release of gluco-corticoids and other neurotransmitters has been shown to lead to actual damage to the hippocampus, which has been connected to verbal memory deficits (Bremner, Krystal, Southwick, & Charney, 1995).

Increased sympathetic nervous system response to acute stress and threat is considered a normal, expectable, and adaptive response. But researchers have found that once the stressor has dissipated or the threat has been reduced, sympathetic nervous system activation may continue, such as increased resting and reactive heart rate, increased resting and reactive blood pressure, increased resting muscle tension, altered electroencephalogram (EEG) alpha rhythms, and increased resting and reactive respiration (Blanchard, Kolb, Pallmeyer, & Gerardi, 1982; Dobbs & Wilson, 1960; Wenger, 1948). An individual may remain in a state of acute physiological activation as a response to a present stressor that is not actually present. Such high baseline levels of arousal are observable in the exaggerated startle reflex often seen in PTSD.

Sleep disturbance is a common problem found in those exposed to traumatic stressors. Friedman (1995) states that there can be a disruption in the sleep

Professional Alert

A patient's or client's comorbid sleep disturbance should be a priority in treatment. Sleep disturbance can lead to numerous complicating factors, such as irritability, suppressed immune functioning, and poor attention and concentration that may impede recovery and successful treatment. If necessary, seek a consult from a sleep expert or a sleep clinic.

architecture, with changes in the generally predictable patterns of sleep. Stage 1 and Stage 2 sleep are longer than typical. Delta rhythm sleep and rapid eye movement (REM) latency is decreased, while the overall REM percentage of sleep is increased.

Personality Changes

When one thinks of personality, the ideas of a stable, predictable, and consistent pattern of behavior and mental processes come to mind. A good working definition of personality is given by Allport (1961) as a dynamic organization, inside a person, of psychophysical systems that create the person's characteristic patterns of behavior, thoughts, and feelings.

So can a traumatic stressor and the development of PTSD really alter someone's personality? Research seems to suggest that this is possible. Ruth Williams (1999) states the perception that personality changes in those who suffer from PTSD is common among families and the victims themselves.

Sherwood, Funari, and Piekarski (1990) propose a connection between PTSD and certain abnormal or pathological personality styles: Passive-Aggressive Personality Disorder, Avoidant Personality Disorder, Schizoid Personality Disorder, and Borderline Personality Disorder. (For more on Borderline Personality Disorder and PTSD, see Chapter 8.) Hyer, Woods, and Boudewyns (1991) developed the concept of the traumatic personality, which is very similar to but less severe than Borderline Personality Disorder. Most notable are an individual's ambivalence and needy, but suspicious, behavior.

Talbert et al. (1993), using the Neuroticism, Extraversion, Openness-Personality Inventory (NEO-PI), a personality assessment instrument, found higher levels of the personality features of Neuroticism and low levels of Agreeableness. Neuroticism refers to a person's degree of emotionality and excitability. People high in neuroticism are more easily upset and considered more high strung. Agreeableness refers to an individual's social warmth and friendliness. Openness was also in the low range, which refers to a tendency to be open to new ideas and experiences and to be curious. Conscientiousness was average, which refers to a person's sense of responsibility, planfulness, and concern. The excitement-seeking feature of the Extraversion scale was very high. Finally, there were low levels of warmth, gregariousness, and positive emotions. However, it is important to note that this research was conducted with Vietnam veterans with chronic PTSD and histories of high levels of social and occupational dysfunction. Critics have argued that these individuals may have displayed these personality characteristics before they were traumatized.

In their work with severe burn victims, Roca, Spence, and Munster (1992) suggest the existence of what they call a scar syndrome to depict long-term changes in personality. Individuals with scar syndrome express less Openness, lower Extraversion, and higher Neuroticism.

Trauma victims have been known to struggle with their views of themselves after the trauma. The shame some experience after suffering from something they may view as their fault can be intense. Social rejection can complicate these issues. Feelings of self-hatred, self-loathing, lack of competence, and inner worth can result. They may feel unlovable, despicable, or weak. A trauma victim may escape with his or her life only to feel that he or she cannot rely on his or her abilities to cope successfully with the aftermath, including the PTSD symptoms themselves. Not being able to calm oneself down or to relax may have a demoralizing effect. They doubt their ability to cope with upcoming stress or strain in a successful and consistent manner. This can lead to isolation, withdrawal, failures to protect oneself in the future, and poor self-care.

Perhaps van der Kolk (1996) states it best:

What is striking about the impact of trauma on character is that, regardless of preexisting vulnerabilities, a previously well-functioning traumatized adult can experience an overall sharp deterioration in his or her functioning.

Cognitive and Neuropsychological Consequences

Deficits in learning and memory are commonly reported difficulties in PTSD sufferers. Poorer recall of both verbal and visual information as well as poorer verbal learning overall has been observed. Overall memory deficits in recalling specific memories from long-term memory and vague, convoluted recollections are also common, specifically for autobiographical information such as important events or dates. Memories for trauma can be exceptionally vivid or fragmented. Some researchers believe that traumatic memories are distinctly different from normal memories. Perceptual and emotional elements may be more prominent than with nontraumatic memories (Grinker & Spiegel, 1945; Kardiner, 1941; Terr, 1995). Environmental triggers do not typically evoke vivid images, sounds, smells, or other sensory experiences the way traumatic memories can and often do. Traumatic memories are thought to be recorded differently, in an almost dissociated state, typically unavailable to everyday consciousness in the form of a clear, integrated narrative or story. It is only with time that these memories begin to be organized in a coherent fashion. This is considered one of the tasks of recovery and treatment—to put the pieces of these fragmented memories together into a meaningful whole. (For more on this goal in treatment, see the discussion of narrative treatment in Chapter 15.)

Professional Alert

Keep in mind that over the Last 15 to 20 years or so there has been a significant amount of controversy regarding the issue of recovered memories of trauma. This issue has typically arisen when a patient or client reports that he or she is remembering for the first time as an aduLt being physically or sexuaLLy abused as a child. Some professionals have claimed that these recollections are false memories that were created or implanted by a zealous therapist. StiLL others claim that recovered memories are Legitimate. SamueL Knapp and Leon VandeCreek (2000, TabLe 1, p. 2) derived professionaL consensus statements for deaLing with the issue of recovered memories in therapy: (1) Continuous memories of abuse are LikeLy to be accurate; (2) "Some memories of past traumas can be Lost and Later recovered"; (3) "Memories from infancy are highLy unreLiabLe"; (4) "FaLse memories of abuse can be created"; (5) Magnification and minimization may be better ways to conceptuaLize memory recaLL with some patients; (6) It is difficuLt to separate accurate memories if memory recovery techniques have been used. Repeated suggestion, confrontation, and highLy suggestive techniques such as hypnosis can cause the creation of faLse memories. ULtimateLy, a cLinician shouLd maintain his or her standard of care and ethicaL boundaries when working with such issues and stay cLear of controversiaL techniques. (For more on this issue, see Knapp and VandeCreek [2000].)

Trauma victims' memories seem biased toward the recall or remembering of traumatic information overall. That is, they tend to have better memories for trauma material than for nontrauma material despite poorer memory functioning overall as cited earlier.

In addition to exhibiting a biased memory system, trauma sufferers have been found to suffer from attentional biases. Research done with the Stroop Task has suggested that trauma victims are biased toward or fixated on traumatic stimuli in their environment. They are more vigilant or aware of such information relative to nontrauma information. The Stroop Task is a procedure that involves showing subjects words with differing emotional content in varying colors. The subjects are asked to name the color of the word and ignore what the actual word is or means. For trauma victims, response times to colored trauma-related words were slower or longer, indicating that the word itself or its meaning interfered with the simple color-naming task. Attention is more attentive, if you will, to trauma-related stimuli, thus interfering with the everyday, nontrauma related attention functioning.

Vasterling, Brailey, Constans, and Sutker (1998) found significant deficiencies in sustained attention, mental manipulation of information, initial acquisition of information, and retroactive interference in PTSD sufferers. They propose that symptoms of hyperarousal and frontal-cortical brain dysfunction contribute to these cognitive difficulties. In essence, PTSD sufferers have difficulty acquiring new information. They also have trouble remembering old information in part because they are distracted by newer, incoming information. They have trouble performing tasks in the immediate moment, such as mental arithmetic (math "inside one's head") and staying focused.

Hagh-Shenas, Goldstein, and Yule (1999) argue that these Stroop Task findings lend support to Mardi Horowitz's (1997) theory that traumatic information remains in active memory as incompletely processed material. It is too readily accessible and interferes with a patient's ongoing activity. This is also akin to the intrusiveness of traumatic memories, thoughts, images, and perceptions identified in the DSM-IV-TR. (For more about Horowitz's theory, see Chapter 5.)

Dissociation

Dissociation can be an integral part of posttraumatic reactions. There are numerous accounts of individual's "leaving their bodies" or "observing" the trauma from a "distance." For a more in-depth discussion of dissociative phenomenon in PTSD, see Chapter 5. For now, it is important to note that dissociation is defined as a disruption in the usually integrated functions of consciousness, memory, and identity; and altered perception of the environment that can occur during or after a traumatic stressor (peritraumatic dissociation). Examples of dissociative experiences or symptoms can take the form of an altered sense of time going faster or slowing down, feeling as if one is dreaming or that what is happening is not real, confusion, or disorientation.

Suicide and Self-Harm

According to the suicide expert Edwin Schneidman, suicide is often considered a response to the psychic pain of being completely overwhelmed and of feeling as if one has absolutely no resources. This description resonates with the phenomenology and subjective experience of PTSD sufferers. Are PTSD sufferers at greater risk for suicide than those diagnosed with the other mental disorders or the general population? To date there is no good available data to answer this question, yet some estimates have claimed as many as 150,000 Vietnam veterans have committed suicide since returning from the war. The experience of alienation, readjustment problems, disturbing images, feelings of unfairness, helplessness, unexpressed rage, and feeling dead are identified as common experiences associated with suicide risk in PTSD sufferers. Individuals that suffer from depression are commonly evaluated for suicidality. A safe approach for professionals would be to evaluate all clients and patients for suicidality, especially those presenting with PTSD.

Self-harm is defined to be the intentional or deliberate destruction of body-tissue through means of cutting, burning, or other means. It is not seen as an attempted suicide. Zlotnick, Mattia, and Zimmerman (1999) report 33 percent of PTSD sufferers in an outpatient psychiatric setting engaged in self-harm such as cutting or burning themselves. Higher rates in victims of childhood sexual abuse have also been identified. Some researchers and clinicians consider this behavior an attempt to bring one back to reality from a dissociative state through the experience of pain. Still others believe it is a deliberate attempt to induce a dissociative state in order to avoid other PTSD symptoms. van der Kolk (1996) reports that in children, self-harm in the form of head-banging, self-biting, self-burning, self-cutting, or self-starving can be considered attempts at dealing with dissociation or numbing.

Social and Relationship Consequences

The social or interpersonal costs of exposure to trauma can be immense. For example, scholars studying and writing about the development of Israeli society in response to the Holocaust have long proposed that the long-term effects of this collective trauma run deep in the very structure and fabric of modern Israeli society. Americans post-September 11, 2001 may feel a deep sense of change, such as lost innocence. War and disaster can lead to dislocation and a complete disruption of the structure and functioning of a community. Such large-scale changes are paralleled on the smaller scales of family and of the individual.

Posttraumatic Stress Disorder sufferers may struggle with fulfilling typical family roles. A father returning home from combat may struggle to provide financially. Family and other interpersonal realms of functioning may be impacted, for example, increased intimacy issues, increased intrafamilial irritability, increased fighting, decreased enjoyment of shared activities, increased marital discord, and increased intrafamilial and interpersonal violence.

Trust is an area of particular risk in PTSD sufferers who have been exposed to violence. Victims of interpersonal violence such as rape, child physical abuse, and torture may find themselves acutely attuned to even the slightest suggestion of dishonesty, betrayal, or distortion in their relationships. Such interpersonal suspicion is a hallmark of Borderline Personality Disorder, considered a consequence of childhood trauma by some professionals.

One's ability to be appropriately assertive may suffer. A PTSD sufferer may be inappropriately aggressive or hostile in social situations perceived as threatening. Interpersonal cruelty may result. Dysfunctional family patterns from childhood may be repeated in ways that replay victim-perpetrator dynamics. This is sometimes referred to as a behavioralreenactment (p.199) involving victimizing others. van der Kolk (1996) refers to this as the "compulsion to repeat the trauma" (p. 199). Lewis et al. (1988), for example, found that 12 out of 14 juveniles condemned to death for murder were brutally physically abused, and 5 were sodomized by relatives.

The issue of identifying with the perpetrator is complicated and goes well beyond the scope of this section. However, it has been recognized that some PTSD sufferers engage in increased attachment behavior in the face of danger. Attachment is an attempt by an individual to keep primary caregivers within close proximity in the face of danger or threat. In some cases, trauma victims have been known to form close relationships with those perpetrating the trauma. They may believe they are seeking protection from those who are perceived as in control or powerful. This identification with the traumatizing person or group has sometimes been called Stockholm Syndrome.

Other Consequences

The comorbid occurrence of other mental disorders is considered the rule rather than the exception. Generalized Anxiety Disorder and depression are considered some of the most common residual symptoms and disorders. (For more on co-occurring disorders, see Chapter 8.) Here is a quick list of common co-occurring disorders: Alcohol Abuse or Dependence (estimated 51 percent), Major Depressive Disorder (47.0 percent), Conduct Disorders (43.3 percent), Substance Abuse or Dependence (48.5 percent), Simple Phobia (29 percent), and Social phobias (28.4 percent).

Another consequence of survival guilt can occur when someone who survives a traumatic experience in which other people died feels intensely guilty for having lived. They may doubt their worthiness of survival. These feelings can trigger intense depressions. Pathological grief can occur as well in which someone is unable to come to terms with his or her loss of a loved one or friend. Finally, a phenomenon known as immersion can occur in which an individual with PTSD becomes almost obsessed with the trauma itself and anything thematically or directly related to it. A Vietnam veteran may become an obsessed collector of war memorabilia and an avid viewer of war films, for example.

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