PTSD is three reactions at once, all caused by an event that terrifies, horrifies or renders one helpless.
The triad of disabling responses is:
recurring intrusive recollections;
emotional numbing and constriction of life activity and,
a physiological shift in the fear threshold, affecting sleep, concentration, and sense of security.
By definition in DSM IV (the 1994 edition of the Diagnostic and Statistical Manual, which is the official lexicon of psychiatric diagnoses, written and published by the American Psychiatric Association), this syndrome must last at least a month before PTSD can be diagnosed. Furthermore, a severe trauma must be evident and causally related to the cluster of symptoms. There are people who are fearful, withdrawn and plagued by episodes of vague, troubling sensations, but they cannot identify a specific traumatic precipitant. (Some clinicians assume this means abuse occurred and was repressed. The pattern of PTSD reactions thus may be used, illogically and erroneously, to "prove" a hidden trauma). PTSD should only be diagnosed when an event of major dimension - a searing, stunning, haunting event - has clearly occurred and is relived, despite strenuous attempts to avoid the memory.
Recurring, intrusive recollections
The core feature of PTSD, distinguishing the condition from anxiety or depression, is the unavoidable echo of the event, often vivid, occasionally so real that it is called a flashback or hallucination. The survivor of a plane crash feels a falling sensation, re-visualizes the moment of impact, then fears going crazy because his or her mind and body return uncontrollably to that harrowing scene.
A victim of the "cooler bandit," whose modus operandi was to rob urban convenience stores at gunpoint and force the clerks into refrigerated storage rooms, had nightmares for more than a year. She still has moments during the day when she sees the bandit's brown eyes above the mask that hid the rest of his face. She was sure she would be killed at the moment when he threw her to the floor. Even though no shots were fired and the robber was eventually apprehended, her sensations of terror, her feelings of impending doom, still return with sudden images of that unforgettable night.
There are important distinctions among traumatic memories. Some are clearly memories. The beholder knows this is a recollection, painful but not terrifying. Through time and (often) through telling and retelling of the trauma story, the memory is muted, modulated and mastered. It no longer has a powerful, disruptive presence. It is a piece of personal history. On the other hand, that personal history may burst forth into awareness, and a trauma survivor may feel and act as though bombs are falling, a rapist is ready to strike or the death of a loved one is witnessed again.
Incidentally, the loss of a loved one and the consequent bereavement is not, by definition, a source of PTSD, unless the death evoked images of terror or horror. Tragic loss is often an aspect of PTSD, but shocking imagery is not usually part of natural death. Therefore, as painful as the loss of a spouse or child may be, the diagnosis of PTSD is reserved for only those losses accompanied by haunting death imagery.
Some repetitive recollections include regrettable acts by the person with PTSD. A patient of mine killed a boy in Viet Nam. It was self defense, in combat, but indelible and inexcusable in my patient's overactive conscience. Guilt - crushing guilt - was a major component of his intrusive recollection.
When the trauma reappears in the mind, some individuals experience an altered state of consciousness. They enter a trance, a dissociative disorder that can be dangerous to themselves or others.
The war veteran confuses his wife with a Viet Cong woman who tried to kill him many years ago, and he smothers her with a pillow. Or he leaps from the window. Or he runs from the room with a weapon and is shot by police. These are relatively rare situations and, according to most experts, beyond the boundaries of PTSD.
PTSD may include flashbacks and hallucinations, but neither is necessary for the diagnosis. When prolonged flashbacks and prolonged hallucinations, particularly auditory hallucinations that command violent activity, occur, other diagnoses may be involved, such as Dissociative Disorder and Brief Psychotic Disorder. These may coexist with PTSD. They will be discussed later, when considering consequences of trauma that are not PTSD.
Remember, PTSD is more than a repetitive traumatic memory. It also is a form of emotional anesthesia and of generalized anxious arousal.
Emotional numbing and constriction of life activity
The emotional anesthesia, or numbing, may protect a person from overwhelming distress between memories, but it also robs a person of joy and love and hope. While participating in a national PTSD research effort, I interviewed dozens of soldiers, decades after their service in Viet Nam. The presence of this second of the three PTSD diagnostic criteria, this loss of emotional tone, struck me as the most tragic legacy. Marriages suffered, child raising was impaired, life was hollow. To these veterans, "survivor" meant being no more than a survivor and considerably less than a fully functioning human being. Painful memories might have subsided. Anxiety attacks were tolerable. But the capacity for feeling pleasure was gone.
These PTSD victims were anhedonic, meaning not necessarily sad or morose, just incapable of delight. And they no longer participated in activities that used to be fulfilling. Why bowl or ride horses or climb mountains when the feeling of fun is gone? Some marriages survived, dutiful contracts of cohabitation, but devoid of intimacy and without the shared pride of watching children flourish - even when the children were flourishing.
These negative symptoms of PTSD, numbing and avoidance, are less prominent, less visible and less frequent than the more dramatic memories and anxieties. Early on, most survivors of trauma will consciously avoid reminders and change familiar patterns to prevent an unwanted recollection. For example, some ex-hostages from a notorious train hijacking in the north of Holland avoided all trains for weeks. Some only avoided the particular train on which the hostage incident had occurred. Others took that train, but changed to the bus for the few miles near the site of the trauma.
This aspect of PTSD, numbing and avoidance, is adaptive to a point, then becomes a serious impediment to recovery. It can also mislead an interviewer of a survivor into seriously underestimating the severity of a traumatic event. There is a popular belief that victims of rape, kidnapping and other violent crimes should be full of feeling, tearful, shuddering, even hysterical, after the assailant leaves. When feelings are muted, frozen or numb, the survivor may not be believed. When testimony in court is mechanical and unembroidered, jurors may assume that damages were minimal or never incurred. I have testified as an expert for the prosecution (or for the plaintiff in a civil suit) on several occasions to explain this phenomenon. The victims were numb or avoidant or both, and therefore did not come forward immediately. When they did come forward, they appeared, to untrained observers, to be indifferent, unconcerned and unharmed, when, in fact, they were in a state of profound post-traumatic stress.
This dimension of PTSD includes psychogenic amnesia. Along with loss of emotional tone and limited life pursuits are holes in the fiber of recollection. For example, an opera singer, battered by her husband, could not recall the most serious beatings. She was finally ready to divorce him and she needed to testify in court at a settlement hearing. After several supportive sessions, including hypnosis, she remembered him choking, almost strangling, her. Eventually, all of the memories returned, and she could joke, "He not only threatened my life but my livelihood! No wonder I put that out of my mind."
A female police officer shot and killed a man who threatened her and her partner with a gun. She could remember everything vividly except for the sound of her pistol firing. Obviously, the gun went off and the sound was audible. She repressed that piece of memory for many years, eventually recalling it as her PTSD subsided.
The final dimension of PTSD is a lowered threshold for anxious arousal. This is physiological. Unexpected noises cause the person to shudder or jump. The response is automatic and not necessarily related to stimuli associated with the original trauma.
A patient of mine, a bank teller who was robbed, held hostage, then kidnapped, was not exposed to gunfire or loud sounds during her ordeal. But six months later, she was visibly startled and upset by the rumble of a train near my office. It is as though the alarm mechanism that warns us of danger is on a hair trigger, easily and erroneously set off. A person lives with so many false alarms that he or she cannot concentrate, cannot sleep restfully and becomes irritable or reclusive. A normal sex life is difficult with such apprehension. PTSD therefore impairs the enjoyment of intimacy, and this, in turn, isolates the sufferer from loved ones - the ideal human source of reassurance and respect.
Often, the anxiety takes familiar shape: panic and agoraphobia. Panic is a sudden, intense state of fear, frequently with no obvious trigger, in which the heart beats rapidly, respirations are quick and shallow, and fingertips tingle. There is lightheadedness, there may be sensations of choking or smothering, and the person feels he or she is dying or going crazy or both. It is a seizure of the autonomic nervous system. It mimics a heart attack. Panic lasts a few minutes but is so debilitating that one is upset for several hours. After experiencing a few panic attacks, a person will often avoid places where an attack would be particularly embarrassing, such as shopping malls and supermarkets.
The term agoraphobia, from the Greek words for market (agora) and fear (phobia), literally means fear of the marketplace. But it applies to many similar settings that are shunned by those with a particular pattern of anxiety. Extreme agoraphobia causes self-imprisonment in one's house or even a single room within a home.
Few PTSD sufferers reach this condition, but many of my patients have imposed dramatic restrictions on their social activity, not out of fear of a traumatic reminder, but out of embarrassment in anticipation of a panic attack that would be witnessed by others.
By now it should be evident that PTSD has not only a variety of dimensions and components, but vastly different effects and implications. Some trauma survivors are continually reminded of their victimization and experience relief when they tell the details to others. Some survivors are humiliated by their dehumanization or laden with guilt for harming another person. They refuse to discuss details. Some are dazed, moving in and out of trance-like states. Some are full of fear, hypervigilant, easily startled, unable to concentrate, wary of strangers. The syndrome may be evident soon after the trauma or may emerge years later.
Acute Stress Disorder
In 1994, a variant of PTSD was added to the official list of diagnoses: Acute Stress Disorder. This term is used to describe early effects lasting more than two days but no more than four weeks. To qualify for ASD, a trauma survivor must have the PTSD triad of intrusive recollections, avoidance and anxiety, and also must have several dissociative symptoms - at least three of the following five:
A sense of numbing, detachment, and absence of emotional responses.
A reduction in awareness of surroundings, being in a daze.
De-realization. (The immediate environment seems unreal, as though it were a movie or a play.)
Depersonalization. (The self is experienced as altered, unreal, an actor, a fictional character.)
Dissociative amnesia. (There are gaps in memory that cannot be explain by head injury, drug use or other physical causes.)
The distinction between Acute Stress Disorder and Post-Traumatic Stress Disorder is important for clinical research and therapy: Why do some people have persistent symptoms while others have only short-term effects? What treatments effectively reduce the immediate and the chronic disabilities? For journalists, however, it is enough to know that Acute Stress Disorder and Post-Traumatic Stress Disorder are closely related conditions, almost indistinguishable, except for timing. ASD refers to debilitating recollections, numbing, avoidance and anxiety up to a month after a traumatic episode, and PTSD refers to the continuation of those symptoms thereafter.
Who gets PTSD?
What do we know about vulnerability to PTSD? Long before there was a PTSD diagnosis, there was a body of theory and research regarding coping. Scientists described copers as those who faced major life transitions and major life disruptions while still achieving four goals:
they successfully accomplished necessary tasks;
they maintained relationships with significant others;
they preserved self-esteem;
they kept anxiety within tolerable limits.
Populations of copers and non-copers were studied among students adapting to out-of-town colleges, children entering puberty, soldiers with extensive third-degree burns at an Army hospital, and many other populations. The coping mechanisms that enabled some to thrive while others failed or suffered (or, in the case of the badly burned soldiers, lost their lives) included denial, role rehearsal, information gathering, positive use of fantasy or imagination and the ability to anticipate and devalue failure. For example, soldiers with 50 percent body burns who denied - who kept from conscious awareness - the realization that they would be disfigured and that their recovery would be painful, had a better rate of survival than those who, early on, recognized grim reality. Of course, there comes a time when unfortunate consequences must be accepted. Copers delayed such acceptance until their electrolytes had stabilized and physical healing had begun.
Two employees of the US Information Agency were captured and held in isolation near Lebanon for 18 months by terrorists of the PFLP (Popular Front of the Liberation of Palestine). I interview both men six month later in Washington, D.C.. The one who coped well occupied his mind while in captivity by visualizing the designs for a house, down to the last detail. He categorized favorite restaurants (including the one in which our interview took place), anticipating future menus. He exercised and kept his spirits up. I recall our conversation in 1978 as pleasant for both of us.
The second interview, with his associate, was far less comfortable. This man spoke guardedly, fearing foreign agents would overhear. He had no sense of humor and smoked nervously. During captivity, he counted bricks in his cell and paced. He had no way of occupying his mind.
The men were treated equally in confinement and released the same week. One celebrated freedom. The other was disabled and diminished. I do not recall that either had flashbacks, nightmares or intrusive recollections. Probably neither would have therefore qualified for the diagnosis of PTSD, (which was defined two years later). But one was a coper and the other was not. One had conscious and unconscious coping mechanisms: denial of danger, use of fantasy, positive thinking. The other, literally a plodder, failed to cope.
Most current research shows that the intensity and duration of traumatic events correlates positively with the occurrence of PTSD. But individuals exposed to the same extreme stress will vary in their responses. Heredity could play an important role. Just as some children are born shy and others exhibit a bolder temperament, some of us are born with the brain pattern that keeps horror alive, while others quickly recover. As a varied, interdependent human species, we benefit from our differences. Those with daring fight the tigers. Those with PTSD preserve the impact of cruelty for the rest of us.
An interesting experiential (rather than hereditary) theory posits that minor traumas, successfully resolved in childhood, protect against major psychological stressors later on, much as an attenuated virus creates immunity to full-blown infection. Other theories emphasize the presence or absence of social supports, sustaining religious and spiritual beliefs, use of drugs and alcohol, coexisting medical and emotional disorders and the age of the trauma survivor.
When children are traumatized, they often regress. A preschooler will wet the bed, even though he or she has been toilet-trained for a year. A verbal child may not speak. Severe childhood traumas will disrupt personality development and therefore pose major lifelong challenges. Reviewing the relatively high incidence of PTSD in Viet Nam compared to other conflicts, researchers noted the younger age of the soldier, the public disapproval of the war, and the fact that rotations were individual and not by unit. This meant that veterans were forced to cope with the demands of adolescence as well as those of war. Their identities were not complete; they lacked adult experience. They may have faced ridicule by war protesters back home. There were no comrades-in-arms to offer support. None of these factors cause PTSD. But each makes coping with it more difficult and compounds the impact of the disorder.
I tell patients with PTSD that there is nothing abnormal about those who suffer. It is a normal reaction of abnormal events. Anyone could have PTSD, given enough trauma.
Frank Ochberg, M.D. is a founding board member of the International Society for Traumatic Stress Studies and recipient of their highest honor, the Lifetime Achievement Award. He edited the first text on treatment of post-traumatic stress disorder (PTSD), and served on the committee that defined PTSD. Ochberg founded and secured the funding for the Dart Center for Journalism and Trauma, served as its first chairman and now is chairman emeritus of the Center. He helps journalists understand traumatic stress and he helps traumatic stress experts understand journalists.