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Understanding the Symptoms of Post Traumatic Stress
Disorder
Nancy Davis, Ph.D.
Background:
Post Traumatic Stress Disorder (PTSD) was first recognized as a
diagnostic category in the 1980 Diagnostic and Statistical Manual of Mental
Disorders, (DSM III) (American Psychiatric Association; van der Kolk et.
al., 1991) and initially described the dramatically altered functioning of
traumatized American soldiers who had served in combat zones (Figley, 1978).
PTSD is the only diagnostic category which is defined chiefly by its cause
(Long, 1996).
Since 1980, when PTSD was established as a diagnostic category,
sophisticated brain scans and other research exploring numerous dimensions of
the causes, symptoms, and effective treatment techniques have dramatically
increased knowledge of the interaction of biological, psychological and
environmental factors relating to the disorder. Although traumatic events are a
critical element in the development of PTSD, it is clear additional factors also
play an important role, because the majority of people exposed to traumatic
incidents do not go develop this disorder (McFarlane & Yehuda, 2000).
Definition:
Post Traumatic Stress Disorder (PTSD) can develop when a person has
been exposed to a traumatic event in which "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". The response to this traumatic event must involve “intense fear,
helplessness or horror" (DSM IV, 1994).
Incidence:
Between 7 - 12% of the general population are felt to be in PTSD at
any given time (Kessler, et. al., 1995; Seedat & Stein, 2001). For men, serving
in combat is the event that has the highest correlation with PTSD; for women,
it is rape and sexual molestation.
Fourteen percent of adults experiencing the sudden and unexpected
death of a loved one develop PTSD. This is the event that most frequently
correlates with PTSD for both men and women, It is estimated that this is the
primary cause of 27% of cases of PTSD in women and 39% in men (Yehuda, 2002).
Studies show that from 15 to 90% of children involved in traumatic
incidents develop PTSD. A recent study found that 40 % of individuals living
near the World
Trade
Center at the time it collapsed on
September 11, 2001 were experiencing
symptoms of PTSD at the time of the study (Washington Post, 2002).
Although the majority of those who develop PTSD appear to gradually
recover without intervention, more than one third of people who develop PTSD
fail to do so after many years (Kessler, et. al., 1995). Furthermore, many of
those who are viewed as having gradually recovered, although no longer meeting
the criteria for a diagnosis of PTSD, continue to experience some of the
life-altering symptoms common to the disorder.
PTSD and
the Body:
Survival is the most basic function of every living creature. The
human brain is structured so that survival is primary, taking precedence over
every other human function. When a threat to survival is received, numerous
brain and body systems are activated. Levels of adrenaline, norepinephrine,
thyroid hormones, testosterone and other hormones rise dramatically to prepare
the body for “fight or flight”. These hormones increase the heart rate, blood
pressure and stimulate numerous other changes in the muscles, senses and other
body structures. In most instances the threat passes or is quickly handled,
so the physical changes are short- lived and subside when the threat has
passed. However, for individuals who develop PTSD after a traumatic incident,
high levels of stimulating hormones and other physical changes continue,
leading to many physical problems. Cortisol production, which can turn off
stimulating hormones and reduce the length of reaction to threatening situations
and triggers, is low in individuals who develop PTSD, and may have some role in
differentiating who does and does not develop PTSD after exposure to a traumatic
incident. As a result, individuals diagnosed with PTSD react more intensely to
stress and for longer periods of time, than do individuals who do not have PTSD.
Causes:
A variety of traumatic incidents can lead
to the development of PTSD:
·
Death of
children, parents, loved ones – especially if the death was violent and
unexpected (Holbrook et. al., 2001; Breslau, et. al.,
1998; Murphy, et al., 2001)
·
The
belief that one’s own death is imminent and certain (Marmar, et. al., 1996;
Robinson, Sigman & Wilson, 1997; Teegen, Domnick & Heerdegen, 1997)
·
Life
threatening injury occurring during accidents, natural disasters, man-made
disasters, military combat, living in a war zone, terrorist attacks, becoming
the victim of a violent crime, (Blanchard, et. al., 1995; Bower, 1992; Brom,
Kleber & Hofman, 1993; Difede & Barocas, 1999; Harvard Mental Health Letter,
1996; Holbrook, et. al., 2001; Maes, 2000; Schnyder, et. al., 2001; Tucker et.
al., 2000; Zatzick et. al., 2001)
·
Witnessing violence and/ or injury to others (Fitzpatrick & Wilson, 1999)
·
Rape;
traumatic symptoms increase when the victim is young, the rape is the victim’s
first sexual experience, the victim does not disclose the rape, the rape goes on
for an extended period of time, the rape is violent, the victim believes he/she
is going to die during or following the rape (Riggs, Rothbaum & Foa, 1995).
·
Traumatic
surgery and 3rd and 4th degree burns involving
disfigurement and permanent changes in the body (Dew et. al., 2001; Difede &
Barocas, 1999; van der Kolk, 2002a)
·
Waking up
during serious surgery, aware of the pain and what is happening, without the
ability to communicate this awareness (Osterman et. al., 2001)
Age plays a significant role in the impact of trauma. The younger
the individual is who is experiencing a trauma; the more likely he or she is to
develop PTSD. Trauma can and also lead to permanent changes in brain
functioning when it occurs at a younger age, while the brain is developing.
Furthermore, problem solving skills, maturity and more advanced abstract
reasoning come with age and the absence of those skills impacts the child’s
ability to cope with trauma.
It also has been established that experiencing multiple traumas over
an extended time period and involve injury and violence, often lead to
development of more severe PTSD, often referred to as “Complicated PTSD”. This
is much more incapacitating and difficult to treat than the PTSD that develops
after exposure to a single incident trauma (Bremner, Southwick, Johnson, Yehuda
& Charney, 1993; Breslau, Chilcoat, Kessler & Davis, 1999; Johnson et. al.,
1996; Long, 1996, van der Kolk, 1997a):
Examples of trauma which can lead to Complicated PTSD:
·
Child
abuse, which can be sexual, physical and/or emotional in nature. This is
particularly the case when the abuse begins at a young age, extends for years,
the abuse is sadistic, or if the abuser is someone who should be protecting the
child (Harvard Mental Health Letter, 1996).
·
Torture
(Hanson, et. al., 2000).
·
Domestic
violence, which may be traumatizing to both to the victim of violence and the
children who observe it (Perry, 1995; van der Kolk, 2002a).
·
Violent
neighborhoods and bullies (Perry, 1995; van der Kolk, 1996).
Previous
Trauma:
Previous trauma has been found to play a
significant role in the development of PTSD. In a research study involving the
interviews of 2181 adults, Breslau, et.
al., (1999) found:
·
A history
of any previous exposure to traumatic events was associated with a greater risk
of developing PTSD.
·
A history
of multiple traumatic events had a stronger impact than a single previous event.
·
Individuals who had experienced multiple traumatic events involving assaultive
violence in childhood were more likely to experience PTSD from trauma in
adulthood.
·
A history
of events involving single or multiple assaultive violence, both in childhood
and at older ages, was associated with a higher risk of PTSD in adulthood.
The likelihood that an individual will
develop PTSD when exposed to a traumatic event increases:
·
In direct
proportion to the time of exposure (Pynoos, Frederick, & Nader, 1987)
·
In direct
proportion to the proximity of the client to the traumatic incident (a higher
percentage of residents living close to the World Trade Center during the
collapse of the World Trade Centers on September 11, 2001 developed PTSD than
did residents living further away) (McFarlane & Yehuda, 2002)
·
When an
individual lacks control over a traumatic incident and cannot escape from it
·
(Milkulencer,
et. al., 1989)
·
An
individual has previously been experiencing psychiatric symptoms (North et. al.,
1999)
·
When
guilt, shame or humiliation is experienced during and/or following the traumatic
event (Southwick, Yehuda & Geller, 1991)
If hundreds of people were equally exposed to the same traumatic
incident, individuals with the following characteristics would have an increased
probability of developing PTSD:
·
A limited
education (Halligan et. al., 2000)
·
Having
been divorced or widowed (Halligan et. al., 2000)
·
Low
intelligence (Halligan et. al., 2000; Long, 1996)
·
Being a
female (Brewin et. al., 1999; Fullerton et. al., 2001; North et. al., 1999;
Stein, Walker & Forde, 2000). Being female increases the probability of
developing PTSD when exposed to intentional or assaultive violence from a male
perpetrator (who would be stronger and more likely to hurt a victim), but does
not increase the possibility of developing PTSD following disasters (Schonfield,
2000)
·
Being
unemployed (Joy, Probert, Bisson & Shepard, 2000)
·
Never
having been married (Creamer, Burgess & McFarlane, 2001)
Protective Factors:
Social support from family, friends and peers has been found to play
an important role in buffering the impact of exposure to traumatic experiences.
Hugs and other forms of touching that re-establish a sense of safety helps the
body regain normal functioning after exposure to traumatic incidents. Children
exposed to traumatic incidents tend to react to a trauma based on the capacity
of their parent(s) to cope with the trauma (Manne, Duttamel & Redd; 2000; Tucker
et. al., 2000; van der Kolk, 2002a). Therefore, it appears that if a family
handles a difficult event well, it substantially decreases the risk of the child
developing PTSD from the situation.
Symptoms:
The impact of exposure to trauma may be layered, so that each trauma
builds upon the others until, at some point; a traumatic event becomes the
trigger which activates PTSD symptoms. In other cases, the symptoms may appear
gradually and progressively (especially to those working in jobs where traumatic
incidents are common), leading an individual to have little awareness of the
negative changes that exposure to traumatic incidents has caused in his or her
functioning. Loved ones and peers often seem to be more aware of these changes
than the individual experiencing them. Even in those with diagnosed PTSD,
symptoms may change in intensity from day to day, or they may disappear for long
periods and re-appear suddenly when activated by a triggering or stressful life
event. To further complicate the diagnosis, PTSD can even occur years after
experiencing a traumatic event, if the traumatic event or some emotionally
powerful aspect of the trauma has been dissociated or "forgotten", then is
suddenly recalled. To qualify for a PTSD diagnosis, symptoms must have been
experienced for more than thirty days; symptoms lasting less than 30 days, are
labeled as Acute Stress Reaction. A high number of individuals diagnosed with
Acute Stress Disorder will go on to develop PTSD.
Example of Immediate Symptoms:
Jim
Forest, an engineer for Amtrak, had been on the job for three months when the
incident happened. He was the engineer operating a train traveling south one
afternoon, when he spotted a woman standing on the tracks, directly in front of
the train. She was holding a young child. Mr. Forest tried in vain to stop the
train, but trains just can’t stop that quickly. Mr. Forest watched, horrified,
as his train struck and killed the woman and her baby. Within 24 hours, Mr.
Forest began to experience flashbacks and panic attacks, accompanied by an
inability to sleep.
Example of Progressive or Cumulative Symptoms:
Eric
Reese, a law enforcement officer, had been working undercover for years when he
developed a full-blown case of acute PTSD. He believed his symptoms to have
resulted from an incident that had taken place just days before his symptoms
began. A drug dealer had stuck an ice pick in Mr. Reese’s ear, threatening that
he would stick an ice pick through the brain of any one who “snitched” on his
operation. Although he believed he was about to die, Mr. Reese managed to
bluff his way out of the situation. In reviewing Mr. Reese’s trauma history, it
was discovered that he had been exposed to quite a number of previous traumatic
incidents. Among these were: a partner being killed in the line of duty; being
a passenger of a car which exploded and burned (he barely escaped death);
investigating the rape and murder of a baby by her father, which included
digging up the baby’s body; as well as several incidents where Mr. Reese
believed he was about to die. His wife described how her husband had gradually
changed following these incidents. In fact, the changes had taken place over 23
years. Clearly Officer Reese had been experiencing PTSD symptoms for many
years. However, the most recent incident had moved these symptoms to an acute
stage, making the symptoms more obvious and the change seem sudden.
Delayed
Symptom- First Example
Mary’s
husband, a law enforcement officer, was shot eight times, while trying to
apprehend a bank robber. She sat beside his hospital bed for days, as he
remained in critical condition. Mary’s employer became abusive to her for
remaining at the hospital with her husband for 10 days rather than returning to
work. After his release from the hospital, as he recovered at home, Mary
provided him with a great deal of support. Although the shooting incident had
caused her husband to develop some PTSD symptoms, such as an inability to read,
Mary herself did not experience any symptoms. However, one year after Mary’s
husband had been shot; she and her husband were interviewed by a newspaper
reporter who was writing an anniversary article about the bank robbery and the
shooting. Three weeks after the interview with the reporter, Mary’s husband
called his therapist for help, “I think you need to see Mary. She can’t sleep;
she isn’t writing her reports, she is irritable, and doesn’t want to talk.” A
session with Mary revealed that the reporter’s interview had somehow integrated
the traumatic aspects of her husband’s critical injury with death and the
abusive treatment by her employer, triggering delayed PTSD symptoms.
Delayed
symptoms- Second Example:
Jane, age
48, was employed in a high level government position. Suddenly one day, for no
reason that Jane could understand, she began to have flashbacks of her father
sexually abusing her as a child. As these flashbacks increased, Jane developed
symptoms of acute PTSD. These symptoms became so incapacitating that Jane was
forced to take leave of absence from her job. Jane informed her sisters about
her flashbacks, who didn’t believe her allegations and responded by telling Jane
that she was crazy and had obviously made up these memories. To deal with these
flashbacks, Jane entered therapy. After a time, Jane found the courage to
confront her parents by telephone. Both denied her abuse accusations. A week
after this confrontation, Jane’s father died. Although she was profoundly angry
with her father, Jane decided to attend her father’s funeral to make sure he was
really dead and couldn’t hurt her anymore. Following his funeral service,
several of her nieces disclosed that Jane’s father had been sexually abusing
them up to a short time before his death.
Delayed
symptoms- Third Example
"As a
teenager, my leg was amputated from my hip down because of bone cancer. One day
I had a normal life, the next day the doctor told I had bone cancer and
immediately removed my leg. I had been a dancer; that was over. My life and my
self image changed dramatically in just one day. For two years after the
surgery I went through chemotherapy. I would have the chemo treatments on a
cancer ward for teenagers and got to know some of the kids.. Several times when
I arrived for a chemo treatment, I discovered that one my friends on the
cancer ward had died. However, at the time I handled all of this well; nothing
seemed to get to me. Now, I’m 36. My nephew was recently diagnosed with a
serious disease and was scheduled for surgery. I went to visit him; he was in
the same hospital where I had cancer surgery. When I got to his room, I
realized that it was the same room where I had regularly taken my chemo
treatments. Now, suddenly, it is as if I am a teenager again and I can’t get
the picture of losing my leg out of my mind. I can’t sleep and I feel sick and
angry all the time.”
Post traumatic stress disorder freezes a victim at the point of the
traumatic incident. Many victims are ashamed at having little control of the
way in which their body responds to reminders of the trauma, because their mind
views this response as ‘weird’. (van der Kolk, 2002a). Their imagination and
problem solving skills have become frozen. They make evaluations through
emotions, rather than judgment and thinking things through. The symptoms
related to PTSD can be so life altering, that a victim feels as if they are
“losing my mind”
According to DSM IV, PTSD symptoms fall into three categories: Intrusive
Symptoms, Arousal Symptoms, and Avoidance Symptoms.
A.
Intrusive
Symptoms
Intrusive symptoms are those which significantly interfere with normal
functioning. Intrusive symptoms can be further sub-divided into the following:
(1) Flashbacks or intrusive memories, (2) Night terrors of distressing dreams.
1) Flashbacks or intrusive memories
which cause a traumatic event to be
re-experienced in such a way that it feels as if the event were actually
happening again. The traumatic event may be re-experienced as intrusive
memories of the event, images, body sensations or other feelings. The event
appears to be "stuck" in the present memory, because the mind is unable to
process the thoughts, feelings, and sensations surrounding the trauma, which is
necessary in order to move them into past memory. Even events that were not
directly experienced but vividly imagined, such as a loved one dying in pain and
alone, can be experienced over and over as a flashback.
First Example:
Three
children of an officer killed in a line-of-duty death, were seen for treatment
four years after his death. Their ages were 14, 12 and 11. Each of the
children was having flashbacks of their father’s death, although none had
witnessed his death. (Their father had been shot as he attempted to give a
speeding ticket to a motorist.) Each child had constructed a unique flashback
(each different from the other two) based on information he or she had been told
regarding the details of their father’s death.
Second Example:
Sharon’s
daughter was tortured to death by a serial killer. Sharon spent hours with the
body of her daughter, touching every wound. She began to have vivid flashbacks
of her daughter being tortured. She became obsessed with how much her daughter
suffered before she died. Wondering if her daughter had known she would die and
if her daughter had thought about her (the mother) before she died. Sharon also
felt guilty for not being able to protect her daughter and had dreams of
attacking the killer and preventing her daughter’s death. (A common theme of
dreams when a parent loses a child in an accident or violently.)
Flashbacks are activated by triggers (or reminders) associated with
the trauma, and may be experienced through any sense, (i.e., smell, sight,
hearing, or touch) or by a thought or feeling. Smell is the most powerful
memory trigger. Re-experiencing the feelings associated with the traumatic
event is often excruciatingly painful. For many individuals, flashbacks are
re-experienced at the same level of intensity and emotion as the original
traumatic incident. Consequently, reminders of the trauma are often avoided,
especially talking about the event. Therapy is rarely sought because "talking
about" the trauma reactivates flashbacks and painful, intrusive memories.
When several different stimuli become associated with the traumatic
incident, the world can become a mine field of triggers leading to painful, and
even overwhelming, emotions. Flashbacks or intrusive re-experiencing of the
trauma must be present for PTSD to be diagnosed.
·
“I
can be doing most anything, and for some reason it will just suddenly pop into
my mind.”
·
“I
felt like I was thinking about it every minute of every day."
·
"I
have flashbacks where I see the gun pointed at me and my stomach is tight, my
head pounds, my whole body feel weak and the fear is so intense that I sweat and
shake".
·
"If
I have too much time on my hands, I start remembering, like it's happening
again."
·
"It's like I get the feeling that I did then. Pictures come in my mind. It
feels like it just happened this morning. I have no control over it."
·
"I
try not to think about it, but I can't. It never leaves my thoughts."
·
"I
think about it every day, 10 times a day. I used to think about it 1000 times a
day."
·
"They opened the casket for me. He was burned all over. I still smell that
smell every time I think of that."
Flashbacks
may be symbolic in form:
Officer
Long was involved in a two car accident in which a baby was killed. The
accident had not been his fault; the other car involved in the accident had run
a red light. The baby who died had been sitting in the lap of the front seat
passenger. Officer Long had watched the paramedics as they tried to revive the
baby. Rather than seeing a flashback of the paramedics working on the baby,
Officer Long began to have flashbacks of a road sign which flashed, “You killed
Johnny Smith, you killed Johnny Smith”.
Flashbacks that have long
faded to long forgotten traumatic incidents may be triggered by a similar
incident, many years later.
"When I
saw that train on the news last night....it was on fire... people were screaming
because they couldn't get out. It took me to a memory where I could see that
guy throwing the fire bomb. I saw a man burn alive. He was screaming and
throwing up. It was 30 years ago, and it seems like it just happened. Now I
can’t get that picture out of my mind".
Because flashbacks are
triggered by reminders in the environment, as the number and the proximity of
triggers increases, so do the frequency and intensity of flashbacks.
Example One:
“When I
am giving my lecture on accident reconstruction, I focus on a particular part of
the slide and my mind goes blank. The slides that make my mind go blank are
those of accidents that really bothered me. I have to cover it up and continue
to talk. I don’t know if anyone notices or not.” (Law enforcement officer)
2) The second category of Intrusive Symptoms
consists of night terrors and distressing dreams of the traumatizing event:
Memories of the traumatic incident intrude into sleeping hours through night
terrors and nightmares. Nightmares are usually related to the event, either
directly or symbolically. When the trauma is a crime, often the dream centers
on lack of safety , i.e., the criminal harming or killing the dreamer and/or
his family. These dreams often begin by mirroring the traumatic event and
become more symbolic over time. In normal sleep, muscles are paralyzed during
dreaming, but PTSD can lead to incomplete muscle paralysis during dreaming,
resulting in physical enactment of nightmares (Whealin & Francis, 2000).
·
"He's shooting me and I'm trying to get away, but I can't move. I wake up with
sweat all over my body".
·
"I wake
up crying, like I'm drowning. I know I'm still asleep, but I have to wake up
but it's so hard."
·
"I
wake up and I'm scared, but I never remember what I'm dreaming about. I'm
getting up at least two times a week and throwing up."
·
"My
husband wakes me up about twice a month. I'm dreaming he has bombs on his
stomach and I'm trying desperately to knock them off before they explode."
·
"I
keep dreaming that I'm being buried alive. When I wake up, I'm so upset I don't
sleep the rest of the night".
·
"He's
shooting at me and I'm trying to get away, but I can't move. I wake up with
sweat all over my body".
B.
Arousal Symptoms
The second major category of PTSD symptoms is referred to as arousal
symptoms. PTSD is associated with hyper-stimulation of the nervous system,
similar to the way a body responds to high levels of caffeine or stimulants.
Consequently, PTSD causes many arousal symptoms. There are five major
categories (1) Tension, Anxiety, Hyperactivity, (2) Hypervigilence, exaggerated
startle response, unreasonable fear, (3) Interruption of sleep cycle, (4)
Problems in concentrating, reading, writing, organization, and (5) A sense of
being “stuck” in time, problems making even routine decisions. Each is
discussed below.
1) Tension, Anxiety, Irritability, and
Hyperactivity: These symptoms
include feeling jumpy, on edge, shaky. Little things become very upsetting.
The response to small irritations may be screaming or tears. Emotions can
instantly move from being absent to being intense, without moving through the
normal stages of escalation.
·
"I
had to stop work. I had a desk job and I loved it, but I couldn't sit still.
Still can't. That would be OK if I was really doing something, but I just
move."
PTSD leads to problems in
modulating anger; anger may leap from non-existent to intense rage within a
matter of seconds.
·
"At work,
everybody says I've changed. I look more angry. It doesn't feel good when
people say they want back the old me."
·
"I
curse a lot. People really get to me".
·
“I
want to hit, to smash my head into a wall.”
·
"I
have to stay in agitation to keep from getting angry."
·
"I
over-react. Like not feeling calm-like. Things are bothering me. I
feel like that all the time."
PTSD can lead to anger which
is expressed in poor judgment and behavior that is dramatically different from
the way the same person would have behaved prior to being traumatized.
·
“After
serving as a rescue worker at the bombing in
Oklahoma
City, I returned home and didn’t talk to anyone about how it had affected me. A
couple months later, I was in state court, testifying about a criminal case I
had investigated. During my testimony, I got in a screaming argument with a
defense attorney. I used to be so calm and let everything roll off my back.
The judge wrote a letter to my supervisor. That’s why I’m here for treatment.”
(Law enforcement officer).
PTSD and symptoms of anger
may lead to aggressive driving and road rage (van der Kolk, 2002a):
·
“I get in
my car and my personality changes. I get into rages. If someone pulls in front
of me, I follow them, giving the finger and honking my horn. I instantly go
from being calm to rage”
2)
Hypervigilence, exaggerated startle response, fear and sense of being unsafe:
People suffering from these types of symptoms often do not feel safe. If the
traumatic event(s) occurred in the home or areas traditionally expected to be
secure, the feeling of loss of safety may be more intense. Phobias or intense
fear may develop, especially about being traumatized again or reminded of the
trauma. Victims may feel constantly on guard against attack, often to the point
of paranoia, with the body seeming continually braced and nerves are on edge.
Small sounds, movement, or shadows may cause intense response of fear or
flight. The sense that attack or traumatization will recur is common. A casual
bystander may be seen as threatening or dangerous.
·
"If
I'm walking someplace, I'm constantly looking behind me. I stop like I'm
paranoid and let them pass. If the leaves shuffle, I jump."
·
"Like when I'm looking at T.V., I try to concentrate but all of a sudden I look
around to see if my blinds are closed. I try to keep them closed all the time."
·
“I
feel like someone is sneaking up on me. If I am by myself in my apartment, it
drives me crazy. I am always looking around to see if someone is there.”
·
"When I go to a restaurant, I have to have my back to the wall. I’m watching
everyone, every minute. When I walk down the street, I try to have eyes
in the back of my head. (Hypervigilence is fairly common in law
enforcement officers and Secret Service Agents. and not necessarily a
symptom of PTSD in these professional groups; it’s a necessary skill of survival
and doing the job.)
·
“I
saw the gas meter man and I thought it was someone trying to get in the house.
I got my gun and barricaded the door. I positioned myself at the side of the
window. When I realized who it was, I felt stupid.” (Law enforcement
officer recovering from being shot while making an arrest)
·
"It
took away some kind of innocence. I feel I'm not safe anymore". (Law
enforcement officer involved in line-of-duty shooting).
An exaggerated startle reaction is a common symptom of PTSD, but
usually does not develop for at least a week after exposure to the traumatic
incident (Yehuda, McFarlane & Shalev, 1998). Traumatized people continue to
react to a series of loud, expected sounds as if each new sound was unexpected
and they are hearing it for the first time. Normally people will habituate (get
used to) loud noises, but PTSD victims often will not (Pitman, et. al., 1999;
Ornitz & Pynoos, 1989). Even when treatment is successful at reducing or
eliminating the flashbacks and other symptoms experienced by a victim, many will
continue to experience this
exaggerated startle reaction. It may be that some neurological changes that
occur as the result of exposure to trauma may be permanent.
Trauma can lead an individual to become fearful of change and to have
problems making decisions. To feel safe, some individuals in PTSD try to
control their environment or other people; this need to control is an effort to
avoid triggers and symptoms by ensuring their environment is safe and
predictable.
3) Interruption of Sleep Cycle:
The inability to experience a night of deep and relaxing sleep is generally
caused by hyper-stimulation of the nervous system, however, a victim’s fear of
experiencing traumatic nightmares and night terrors, also plays a factor.
Difficulty falling asleep, or problems waking up after sleeping for short period
followed by an inability to return to sleep are typical. Walking up numerous
times during the night is an additional way that victims fail to achieve deep
and restful sleep. If interruption of the sleep cycle result becomes chronic,
additional symptoms related to sleep deprivation occur, such as paranoia,
problems with co-ordination and difficulty with memory and co-ordination.
·
"It feels
like something is on my mind, but I can't figure it out and it won't go away.
It keeps me awake".
·
"That's
why I have trouble falling asleep 'cause everything goes to my head."
4)
Problems in Concentrating, Reading,
Writing, Speaking, Organization, and Decreased Attention Span:
The
hyper- stimulation related to PTSD interferes with concentration in a way that
thoughts become fragmented. The inability to concentrate causes problems in
listening because the mind keeps drifting off to other places or re-living the
traumatic event. Reading comprehension as well as written communication may be
dramatically affected, again because thoughts seem to jump from idea to idea or
from one memory to another. People in PTSD miss appointments and forget
important events.
·
“I miss
appointments, I forget important events”
·
“I have
problems in initiating behaviors. I just sit and stare.”
·
“On
certain days, I can’t stay focused.”
·
“I don’t
know how I drove up here today; my mind escapes me. I’ll be talking to someone
and I hear their voice, but I’m not listening.”
·
“I would
start to tell a story and after the first sentence, I would forget what I was
going to say. It happened all the time. I was afraid to talk to anyone.” (Law
enforcement officer who had been in PTSD for 10 years, sleeping 2-3 hours
nightly).
·
"I
stopped teaching police schools. I stopped teaching Sunday school. I couldn't
remember what I was going to say from one minute to the next. I just stopped
doing anything which would let people know I couldn't remember."
·
“I used
to visit people and if there was a lot of noise and confusion, I’d get up and
leave. Now I have the house I used to try to get away from.” (After successful
MTP treatment)
Symptoms of PTSD can cause
even a highly educated adult to become unable to read.
·
“I bought
all these books because I know I will be home at least six months recovering.
But I can’t read; I’m a college graduate and I can’t read. I read the first
sentence and I think of something else. I feel like my mind is racing. It’s the
comprehension; I’m losing it.” (Law enforcement officer recovering from being
shot).
·
“Like, if
I’m reading something, I’m trying to pay attention to it, but I can’t. It’s
like my eyes are on the words, but my mind’s not.”
·
"I used
to read all the time. Now I read the first sentence and I think of something
else. I feel like my mind is racing".
PTSD can also cause problems
in math, writing, memory and completing assignments. Traumatized individuals,
especially children, have problems in providing an organized narrative of the
incident which traumatized them. They may also have difficulty in sequencing a
story, both verbally and in writing. Sequencing problems cause an individual to
skip around in relating a story, rather than starting at the beginning, moving
through it chronologically and following with the end. Chronic PTSD may lead to
fragmented speech, as a victim breaks up sentences into two or three words, with
inappropriate pauses between each set of words.
·
"I do
anything to avoid writing my reports. I take two hour lunches, make phone
calls, and go to the water fountain. I just can’t make myself write them.”
(Attorney whose husband, a law enforcement officer, was shot multiple times).
PTSD led to problems in
learning from experience; consequently the same mistakes are continually
repeated. Failure to learn from experience typically cause major difficulties
in many areas, including work settings, school work and relationships.
·
"He does
the same things over and over, even though I punish him. You’d think he’d
learn, but he doesn’t.” (Mother of elementary school child)
5)
Sense of Being Stuck; Problems in
Making Decisions: Because victims
feel stuck and frozen in the past at the point of their trauma. They often have
problems in making decisions, because this requires a present and future
orientation. Inability to initiate routine activities, use past problem
solving techniques, as well as to shift from one point of view to another, can
be additional symptoms that develop after traumatic incidents.
·
"My
supervisor said that I can get out of this office and move to another one. This
office reminds me of the shooting but I can’t decide what to do. I want to go,
but I just stay here." (Police officer involved in a line of duty shooting;
suspect died).
C.
Avoidance
Symptoms:
The third, and final, major category of PTSD symptoms are referred to
as Avoidance Symptoms. Because flashbacks, as well as feelings and thoughts
associated with the trauma, are terrifying, painful, and sometimes even
disabling, efforts to avoid any thoughts, feelings, conversations, people or
places that trigger these symptoms are common. Numbing of responsiveness to
people and one’s surroundings is an additional symptom, believed to be the
result of changes in brain functioning. Numbing can lead professionals,
friends and co-workers of victims to mistakenly believe that he or she is
functioning well. Avoidance and numbing by the following means is common:
1) Inability to recall parts or the entire
traumatic event:
memory problems are common
in PTSD. Some aspect of the traumatic event may be difficult or impossible to
remember. Additionally, the high level of stimulating hormones present as a
traumatic event is experienced can interfere with the integration of memory,
leading the trauma to be experienced on a sensory level, without words to
describe the experience.
·
"It's like I can remember pieces of it, but it just won't come...I can't
remember."
·
"We have a teenage victim whose whole family burned to death in a house fire.
She was discovered in the burning house beside her mother. We suspect arson,
but she says she can’t remember anything about the fire.” (Police officer)
Suicide is a drastic
and final way distraught victims experiencing disabling symptoms may chose to
avoid further anguish. One research project found that for every suicide
resulting from depression, 15 results from symptoms of PTSD (Davidson, et. al.,
1995). Symptoms can lead a victim to feel both out of control and shameful at
their inability to control the symptoms. In addition, the numbing and
disengagement typical of PTSD can make it easier to choose suicide as an
option.
·
“Every night when I put my weapon away, a voice in my head would say, ‘Just do
it’. I’d put the gun in my mouth, but then I’d get a picture of my son finding
my body and I couldn’t do that to him. I’d put my gun away, but the voice would
talk to me the next evening and I’d have to fight it again.”
Although not actively
suicidal, many traumatized individuals engage in behavior which is clearly quite
dangerous and life-threatening. They may, for example, drive a motorcycle at
120 mph, drive a car too fast and recklessly or place themselves in other very
dangerous situations. Some reckless behavior is a result of an inability to
predict consequences, but high risk behavior may also be a way of trying to
avoid PTSD symptoms without making the final decision to intentionally kill
themselves.
·
“I figure if I die, I die. That way life takes care of it. I don’t really care
if I die, but I’m not going to kill myself.”
·
“I sometimes think I’d be better off dead. I’ll go to the mall and park at the
furthest spot in the dark and hope that someone will jump me and kill me...I’d
be better off. (27 year old mother whose father was killed in a line-of-duty
three years prior to this. She was in PTSD and also experiencing grief.)
In an effort to avoid
symptoms, many victims become addicted to alcohol and/or legal or illegal
drugs. “Alcohol is probably the oldest medication for the treatment of
posttraumatic stress, and may well be an effective short-term medication for
sleep disturbances, nightmares, and other intrusive PTSD symptoms” (van der Kolk,
1996). Alcohol numbs the hippocampus which is highly impacted by traumatic
experiences, reducing symptoms. The ability of alcohol to temporarily reduce
PTSD symptoms may be the reason that many alcoholics have a history of being
traumatized and why professionals in high risk occupations, such as law
enforcement, have institutionalized use of alcohol (sometimes referred to as
“Choir Practice”). Brain imaging has shown that early childhood trauma may lead
to brain changes that make a victim particularly vulnerable to addictions.
However, typically, when used for more than short-term, alcohol and other drugs
lead to even greater problems that did the symptoms of PTSD.
·
“Every night after work, I go out with other cops and have, at least, a couple
drinks. It’s become a regular thing.” (Law enforcement officer in PTSD)
2) Numbing and Diminished
Interest in Significant Activities. Dulled or blunted sense of feelings:
Victims comment that they feel "shut down" and dead inside. Through "numbing"
a sense that nothing is real may evolve. Feeling "not human" or "in another
dimension" while going about daily routines is often related. When asked to
relate details of the trauma, an individual may relate the experience as though
it was watched in a movie. Emotions, particularly positive emotions like love,
may become so numb they are not experienced. When in this state, others may
believe that the trauma is being handled well by the person because there is
little reaction to details of the trauma.
·
"I feel shut-down. I don't have anything to say. I can't join in
conversations. I'm very uncomfortable."
·
"I didn't tell you this. I stopped eating. I stopped drinking. I stopped
talking to my family and friends. I thought I could handle it alone, but what
happened just kept going over and over in my head". (Law enforcement officer
involved in violent encounter).
·
"Sometimes I'm talking and they're listening, but it seems like I'm just having
a conversation with myself or sometimes they're just not there and I'm talking
to myself."
·
"I’m not interested in things. I don’t laugh. I don’t do much of what I used
to. I don’t care.”
·
"I don't want to talk to friends; I don't want to talk to anyone."
·
"In the morning, I pretend I’m asleep so I won’t have to talk to my wife. I
just don’t feel like talking. I’ve turned to another woman on my squad; she
listens to me and understands what I have been through. I love my wife, but I
just feel like I’m pulling further and further away from her.”
4)
Territorial Issues:
The belief that
others are trying to get what is yours and intense feelings of possessiveness
may occur. This may be another indication of withdrawal from significant
relationships or of being easily irritated. In traumatized children,
this symptom may be expressed by fighting or aggression. Children often fight
among themselves over getting their fair share. Stealing may be a way of
symbolically claiming what is theirs.
·
"My brother came to visit me. I didn't want him in my house. I watched him all
the time and I wouldn't tell him anything. He kept asking questions."
·
"You were right about being territorial. A secretary put her coffee cup on my
desk and I went nuts. My partner wanted to put some of his papers in my filing
cabinet and that really upset me. He's my best friend, but I was upset about
sharing my space. I never used to be like that".
·
"I used to have lots of friends at the office, but now I don’t want anyone near
my desk. One day, when I was out sick, my co-worker went through my desk
looking for a report. I went nuts when I found this out.”
5) Absence of Fantasy/No Sense
of Future: Because
PTSD causes thoughts to be stuck in an endless loop which focuses on the past,
planning for the future, fantasizing, daydreaming about being successful, and
making lists of what must be accomplished are negatively impacted. “They can’t
imagine what the outcome of their actions will be” (van der Kolk, 1996).
Traumatized individuals have problems considering the consequences of their
behavior or learning from experience.
·
"I thought everyone in the office was against me, talking about me, trying to
get me fired or put on disability retirement."
·
"I want to do things, but I can't get to it. I want to do it, but I just don't
try."
PTSD can
dramatically change the way an individual functions and the way in which his or
her personality presents itself. A single incident trauma can dramatically
alter the functioning of an individual, even for a life time.
How “The Body keeps the Score”
(van der Kolk, 1995)
PTSD can have a
profound negative impact on many systems of the body:
a) changes which come about
related to high levels of adrenaline, norepinephrine and other hormones, b)
diseases which are the result of a compromised immune system, c) somatoform
illnesses,
A.
Changes related to high levels of adrenaline, norepinephrine and other hormones:
Impact on the Heart:
·
Higher resting
heart rates (Buckley and Kaloupek, 2001; Muraoka, Carlson, & Chemtob, 1998; Orr
et al., 2000).
·
Significantly
higher heart rates during sleep (Muraoka, Carlson & Chemtob; 1998).
·