Self-Study Unit 1: Journalism & Trauma

In recent years, thanks to a number of researchers, educators and organizations, the role of traumatic stress and journalism has come under closer scrutiny. One of the pioneers of this work is Dr. Frank Ochberg, a Michigan-based psychiatrist who was a director of the National Institute for Mental Health and former head of the Michigan Mental Health Department. Over the years, Dr. Ochberg and the organizations that he is affiliated with, has helped increase public awareness of journalism and trauma issues — specifically what journalists should know about victims and survivors of trauma and their families, and what journalists should know about the effects (on themselves) of covering traumatic stress stories such as homicides, sexual assaults, criminal violence, natural disasters, plane crashes, and so forth.

An expert on posttraumatic stress disorder, Dr. Ochberg helped many journalists and journalism educators understand what PTSD is and what are its effects. "Whenever a reporter meets a survivor of traumatic events," he has written, "there is a chance that the journalist will witness - and may even precipitate - posttraumatic stress disorder. Therefore it is important that working journalists (including grizzled veterans) anticipate PTSD, recognize it and report it, while earning the respect of the public and those interviewed. The recognition of PTSD and related conditions enhances not only a reporter's professionalism, but also the reporter's humanitarianism."

Of course Dr. Ochberg is not suggesting that journalists "diagnose" PTSD in their interviewees but rather recognize that victims or survivors of trauma may display a wide range of responses and emotions related to the traumatic experience.

 

NORMAL REACTIONS
There are a number of possible reactions to a traumatic situation which are considered within the "norm" for individuals experiencing traumatic stress:

Emotional Effects

  • shock
  • terror
  • irritability
  • blame
  • anger
  • guilt
  • grief or sadness
  • emotional numbing
  • helplessness
  • loss of pleasure derived from familiar activities
  • difficulty feeling happy
  • difficulty feeling loved

Cognitive Effects

  • impaired concentration
  • impaired decision-making ability
  • memory impairment
  • disbelief
  • confusion
  • nightmares
  • decreased self-esteem
  • decreased self-efficacy
  • self-blame
  • intrusive thoughts, memories
  • dissociation (e.g., tunnel vision, dreamlike or "spacey" feeling)

Physical Effects

  • fatigue, exhaustion
  • insomnia
  • cardiovascular strain
  • startle response
  • hyperarousal
  • increased physical pain
  • reduced immune response
  • headaches
  • gastrointestinal upset
  • decreased appetite
  • decreased libido
  • vulnerability to illness

Interpersonal Effects

  • increased relational conflict
  • social withdrawal
  • reduced relational intimac
  • alienation
  • impaired work performance
  • impaired school performance
  • decreased satisfaction
  • distrust
  • externalization of blame
  • externalization of vulnerability
  • feeling abandoned, rejected
  • overprotectiveness

Problematic Stress Responses
The following responses are less common, and indicate the likelihood of the individual's need for assistance from a medical or mental health professional:

  • Severe Dissociation (feeling as if you or the world is "unreal," not feeling connected to one's own body, losing one's sense of identity or taking on a new identity, amnesia)
  • Severe Intrusive Re-experiencing (flashbacks, terrifying screen memories or nightmares repetitive automatic re-enactment)
  • Extreme Avoidance (agoraphobic-like social or vocational withdrawal, compulsive avoidance)
  • Severe Hyperarousal (panic episodes, terrifying nightmares, difficulty controlling violent impulses, inability to concentrate)
  • Debilitating Anxiety (ruminative worry, severe phobias, unshakeable obsessions, paralyzing nervousness, fear of losing control/going crazy)
  • Severe Depression (lack of pleasure in life, worthlessness, self-blame, dependency, early wakenings)
  • Problematic Substance Use (abuse or dependency, self-medication)
  • Psychotic Symptoms (delusions, hallucinations, bizarre thoughts or images)

Some people will be more affected by a traumatic event for a longer period of time than others, depending on the nature of the event and the nature of the individual who experienced the event. One of the most debilitating effects of traumatic stress is a condition known as posttraumatic stress disorder (PTSD). The current trauma literature suggests that many factors are related to increased or decreased risk for PTSD. The likelihood of developing PTSD and the severity and chronicity of symptoms experienced, are functions of many variables, the most important being exposure to a traumatic event. It is therefore important to bear in mind that, even among vulnerable individuals, PTSD would not exist without exposure to a traumatic event.

With traumatic exposure as the foundation, other risk factors which have been shown to contribute to the development of PTSD include magnitude, duration, and type of traumatic exposure. Variables such as earlier age of onset and lower education are also associated with increased risk for developing PTSD. Additional factors related to vulnerability for developing PTSD include: severity of initial reaction, peritraumatic dissociation (i.e., feeling numb and a sense of "unreality" during and shortly following a trauma), early conduct problems, childhood adversity, family history of psychiatric disorder, education level, poor social support after a trauma, and personality traits such as hypersensitivity, pessimism, and negative reaction to stressors. Women are more likely to develop PTSD than men, independent of exposure type and level of stressor, and a history of depression in women increases the vulnerability for developing PTSD (Kessler et al., 1995; Breslau, 1990; Kulka, 1990).

SYMPTOMS OF PTSD
Posttraumatic stress disorder (PTSD) is a mental disorder resulting from exposure to an extreme traumatic stressor. PTSD has a number of unique defining features and diagnostic criteria, as published in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV, 1994). These criteria include:

Exposure to a traumatic stressor
To be diagnosed with PTSD, the person must have 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; and (2) the person's response to the trauma involved intense fear, helplessness, or horror. (In children, this may be expressed instead by disorganized or agitated behavior.)

Stressful events of daily life that do not meet these criteria include divorce and financial crises, which may lead to adjustment problems, but are not sufficient to meet Criterion A for PTSD.

Qualifying stressors must induce an intense emotional response. According to DSM-IV, a qualifying stressor must not only be threatening, but it must also induce a response involving intense fear, helplessness, or horror. Some severely traumatized individuals may dissociate during a stressor or have a blunted response, due to defensive avoidance and numbing. Often, the intense emotional response to the stressor may not occur until considerable time has elapsed after the incident has terminated.

Re-experiencing symptoms
One set of PTSD symptoms involves persistent and distressing re-experiencing of the traumatic event in one or more ways. In these symptoms, the trauma comes back to the PTSD sufferer in some way, through memories, dreams, or distress in response to reminders of the trauma. A more extreme example of this is "flashbacks," where the individual feels as if he or she are reliving the traumatic experience. This is more extreme, but less common as a re-experiencing symptom. PTSD is distinguished from "normal" remembering of past events by the fact that re-experiencing memories of the trauma(s) are unwanted, occur involuntarily, elicit distressing emotions, and disrupt the functioning and quality of life of the individual.

Avoidance and numbing symptoms
A second set of PTSD symptoms involves persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness. These symptoms involve avoiding reminders of the trauma. These reminders can be internal cues, such as thoughts or feelings about the trauma, and/or external stimuli in the environment that spark unpleasant memories and feelings. To this limited extent, PTSD is not unlike a phobia, where the individual goes to considerable length to avoid stimuli that provoke emotional distress. These symptoms also involve more general symptoms of impairment, such as pervasive emotional numbness, feeling "out of sync" with others, or a lack of expectation for future goals being met, due to their trauma experiences.

Symptoms of increased arousal
This set of symptoms is represented by persistent symptoms of increased arousal not present before the trauma. These symptoms can be apparent in difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, a hypervigililant watchfulness, and an exaggerated startle response. Individuals suffering from PTSD experience heightened physiological activation, which may occur in a general way, even while at rest. More typically, this activation is evident as excessive reaction to specific stressors that are directly or symbolically reminiscent of the trauma. This set of symptoms is often, but not always, linked to reliving of the traumatic event. For example, sleep disturbance may be caused by nightmares, intrusive memories may interfere with concentration, and excessive watchfulness may reflect concerns about preventing recurrence of a traumatic event that may be similar to that previously endured.

 

REQUIRED DURATION OF SYMPTOMS
For a diagnosis of PTSD to be made, the symptoms must endure for at least one month.

PTSD symptoms must be clinically significant.

PTSD symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Some individuals may experience a great deal of subjective discomfort and suffering owing to their PTSD symptoms, without conspicuous impairment in their day-to-day functional status. Other individuals show clear impairment in one or more spheres of functioning, such as social relating, work efficiency, or ability to engage in and enjoy recreational or leisure activities.

Acute Traumatic Stress Reactions
Many individuals experience acute stress reactions as a result of having experienced a life-threatening event or some other sudden, uncontrollable, and frightening experience such as sexual assault, motor vehicle accident, fire, natural or man-made disaster, or domestic violence. Receiving a serious, life-threatening diagnosis (e.g., cancer or HIV) can also lead to acute stress reactions. For some trauma survivors, acute stress reactions are severe enough to meet DSM-IV criteria for Acute Stress Disorder (ASD). In addition to symptoms of reexperiencing, avoidance, and arousal, individuals with ASD show multiple symptoms of dissociation (e.g., subjective sense of numbing, reduced awareness of surroundings, depersonalization); to be so diagnosed, specific exposure, symptom, and functional impairment criteria must be met, and the disturbance must occur within 4 weeks of the trauma and last for a minimum of 2 days and a maximum of 4 weeks.

Complex PTSD
Clinicians and researchers have found that the current PTSD diagnosis often does not capture the severe psychological harm that occurs with such prolonged, repeated trauma (e.g., concentration camp and prisoner of war experiences, domestic violence, child abuse). For example, an ordinary, healthy person can experience changes in their self-concept and the way they adapt to stressful events. While not an official DSM-IV diagnosis, the term "complex PTSD," has been coined by clinicians to define the symptoms unique to long-term trauma, including:

  • Alterations in emotional regulation, which may include symptoms such as persistent sadness, suicidal thoughts, explosive anger, or inhibited anger.
  • Alterations in consciousness, such as forgetting traumatic events, reliving traumatic events, or having episodes in which one feels detached from one's mental processes or body.
  • Alterations in self perception, which may include a sense of helplessness, shame, guilt, stigma, as well as a sense of complete differences from other human beings.
  • Alterations in perception of perpetrator, such as attributing total power to the perpetrator or becoming preoccupied with the relationship to the perpetrator, including preoccupation with revenge.
  • Alterations in relations with others, including isolation, distrust, or repeated search for a rescuer.
  • Alterations in system of meanings, which may include a loss of sustaining faith or a sense of hopelessness and despair.

ASSOCIATED DISORDERS
In addition to PTSD and ASD, individuals who have experienced trauma are at heightened risk for developing other psychiatric disorders, including:

  • Depression
  • Substance abuse
  • Panic disorder
  • Obsessive-compulsive disorder
  • Sexual dysfunction
  • Eating disorders

Other Problems Individuals with a Trauma History Report
In addition to the problems listed above, patients with a trauma history are also at a heightened risk for the following problems:

  • Depression, despair and hopelessness
  • Difficulty trusting others
  • Irritability and anger
  • Intense emotions when reminded of their trauma
  • Suicidal ideation
  • Feeling unsafe and remaining "on guard" for possible threats in the environment
  • Difficulty experiencing positive emotions such as love or happiness
  • Difficulty controlling their trauma memories
  • Inability to feel sadness or to cry, even with death of a family member
  • "Workaholism" and/or alcohol/substance use
  • Homelessness
  • Revictimization (increased risk of subsequent exposure to trauma)
  • Loss of important beliefs
  • Aggressive behavior toward oneself, self-blame, guilt, and shame
  • Problems with identity or sense of self
  • Feeling permanently damaged
  • Problems with self-esteem
  • Physical health symptoms and problems
  • Alcohol and/or drug use
  • Problems in relationships with people, such as feeling detached or disconnected from others, social isolation, or getting into arguments and fights with people

For some individuals, some of the symptoms of PTSD (such as numbing, irritability, hypervigilance, or avoidance) are so ingrained as to be perceived as "part of their personality." These individuals may not appear to have any PTSD symptoms that are distressing or interfering with functioning. For some, avoidance is so ingrained that they "manage" PTSD simply by restricting their lifestyle to the degree that they have no contact with any reminders of the trauma, and therefore may appear to have relatively few symptoms. For some individuals, symptoms have been effectively managed for years by over-immersion in work or family; for others, substance abuse suppresses many of their symptoms. When such individuals retire, or stop using alcohol or drugs, they often find that their PTSD symptoms re-emerge and compromise their level of functioning in one way or another.

The Physiological Basis for Stress Responses
There is an important underlying physiological dimension to traumatic stress. In his book, Why Zebras Don't Get Ulcers: An Updated Guide to Stress, Stress-Related Diseases, and Coping, stress expert Robert M. Sapolsky, professor of biological sciences and neuroscience at Stanford University, explains in meticulous but lucid detail how the human body responds to an external threat of death or serious injury. First, two classes of hormones are released by the body's sympathetic nervous system. One class of hormones includes epinephrine (more commonly known as adrenaline) and a related hormone, norepinephrine. Another class of hormones is the glucocorticoids, which, like the others mentioned, are secreted from the adrenal gland. These hormones and others kick into action when the body is under stress and cause physiological changes in the body that could be life-saving.

Among the changes that occur are:

  • "rapid mobilization of energy from storage sites and the inhibition of further storage"
  • "glucose and the simplest forms of proteins and fast come pouring out of your fat cells, liver, and muscles, all to stoke whichever muscles are struggling to save your neck"
  • "heart rate, blood pressure, and breathing rate increase, all to transport nutrients and oxygen at greater rates"
  • "digestion is inhibited"
  • "growth is inhibited"
  • "reproduction.is curtailed"
  • "sexual drive decreases in both sexes"
  • "immunity is inhibited"
  • "perception of pain can become blunted"
  • "shifts occur in cognitive and sensory skills"

These changes occur to increase the organism's chance for survival when threatened and are helpful to humans when confronted by acute physical or psychological stressors. Once the danger passes, the body's physiological processes should return back to normal. A problem develops, however, when stressors are chronic, and that is largely the focus of Dr. Sapolsky's book. (More on this in section 6, "Journalists: A Self-Care Primer.")