Note: I am only in partial agreement with the official viewpoints on this matter, but present them in the name of completeness. To be balanced, I have included both the professional views and the view from where I stand as someone who lived with what professionals consider severe PTSD for a long time.
Official views on PTSD
Post-traumatic stress disorder (PTSD) is the current psychiatric term for a specific set of long-term responses to a traumatic situation: Involuntary re-experiencing of the events, avoidance of anything related to the events, numbing of emotions, and an increase in physical arousal. It is still not known why this occurs in some people and not others.
First documented in soldiers during wars, these reactions used to be known by such names as combat fatigue, shell shock, combat neurosis, traumatic neurosis, and post-Vietnam syndrome. In combat situations, it used to be erroneously considered a form of defection. The same reactions were later connected to other traumatic events, such as rape, torture, domestic violence, natural disasters, child abuse, and car accidents.
The extremeness of the event and the level of participation in the event necessary to evoke this response have been controversial since the concept of PTSD was introduced. At one end of things, some professionals have held that only a life-threatening event experienced directly by the individual in question can truly provoke this response. Others have argued that it is the perceived level of threat that is important, and that a person can develop PTSD from witnessing an event. Current criteria allow for both possibilities.
Re-experiencing the events in question can take the form of anything from the inability to get ideas out of one's head, to full-immersion flashbacks that make a person feel exactly as if it is still happening. These things often happen more in response to a trigger -- something that reminds a person of some aspect of the event. For instance, a combat veteran may hear fireworks and react as if the noises come from shooting or bombing. They can also be more intense around the anniversary of the event. Flashbacks are probably the most famous aspect of PTSD, but reactions can be much more subtle or take the form of panic attacks or nightmares.
The unpleasantness and intensity of re-experiencing the events can cause a person to avoid anything they perceive as related to the event. A rape survivor may avoid the street or building in which he or she was raped, as well as any thoughts or emotions that seem remotely connected to it. The person can also become so disconnected from their emotions that they become fairly numb while not re-experiencing the event.
A person with PTSD can be wary, aroused, or jumpy. They may always be on alert, and may overreact to what would otherwise be insignificant stimuli. A honking car horn, while not necessarily arousing memories of the event, may cause a previously sedate person to visibly jump and scream.
These things are codified in the DSM-IV-TR criteria, as follows:
A. The person has been exposed to a traumatic event in which both of the following have been present:
- the person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others.
- the person's response involved intense fear, helplessness, or horror. Note: in children, it may be expressed instead by disorganized or agitated behavior.
B. The traumatic event is persistently re-experienced in at least one of the following ways:
- recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: in young children, repetitive play may occur in which themes or aspects of the trauma are expressed.
- recurrent distressing dreams of the event. Note: in children, there may be frightening dreams without recognizable content
- acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur upon awakening or when intoxicated). Note: in children, trauma-specific reenactment may occur.
- intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
- physiologic reactivity upon exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by at least three of the following:
- efforts to avoid thoughts, feelings, or conversations associated with the trauma
- efforts to avoid activities, places, or people that arouse recollections of the trauma
- inability to recall an important aspect of the trauma
- markedly diminished interest or participation in significant activities
- feeling of detachment or estrangement from others
- restricted range of affect (e.g., unable to have loving feelings)
- sense of foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)
D. Persistent symptoms of increasing arousal (not present before the trauma), indicated by at least two of the following:
- difficulty falling or staying asleep
- irritability or outbursts of anger
- difficulty concentrating
- hyper-vigilance
- exaggerated startle response
E. Duration of the disturbance (symptoms in B, C, and D) is more than one month.
F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The ICD-10 contains a similar description, but only requires the presence of a traumatic event and intrusive recollections for diagnosis. The rest of the symptoms, while described, are viewed as nonessential.
People with PTSD have a higher rate of substance abuse, depression, and anxiety. They also have a higher rate of physical health problems, although the exact cause for that higher rate is not known. Health problems could be caused by behavior like substance abuse, by the physiological strain of remaining hypervigilant for years on end, by stress-related chemicals in the body, or various other factors that have not yet been uncovered.
Official views on Complex PTSD
Some professionals have noticed an apparent difference in the way people react to prolonged trauma, especially in situations where the person's entire life is being controlled by another person. Examples might include prisoners of war, people who have been institutionalized, people in long-term abusive relationships, concentration camp survivors, and members of destructive cults. While the idea of a separate diagnosis remains controversial, it has been described alternately as DES-NOS (Disorder of Extreme Stress, Not Otherwise Specified), Chronic Trauma Syndrome, Personality Change from Catastrophic Experience, Post-Traumatic Character Disorder, and Complex PTSD. Some professionals prefer to diagnose PTSD and tack on other diagnostic labels (such as personality or somatization disorders) as necessary.
The essential difference, according to those who believe in it, is that complex PTSD produces deeper, broader, and longer-lasting changes in a person's personality, relationships with other people, and ways of reacting to their surroundings. For instance, a person with complex PTSD might develop a strong attachment to the perpetrator of abuse toward them.
If the most stereotypical example of PTSD is the Vietnam veteran who thinks the war is still going on, the most stereotypical example of complex PTSD might be the battered wife who returns to her husband no matter how much he beats her and seems to almost seek out abusive relationships. People who don't understand may ridicule her as stupid and weak, but internally she is reacting to a view of herself and the world that has been completely remolded by the abuse and control over here life that has been going on for so long.
Dr. Judith Herman, who popularized the term complex PTSD in her book Trauma and Recovery, describes a set of working criteria:
1. A history of subjection to totalitarian control over a prolonged period (months to years). Examples include hostages, prisoners of war, concentration-camp survivors, and survivors of some religious cults. Examples also include those subjected to totalitarian systems in sexual and domestic life, including survivors of domestic battering, childhood physical or sexual abuse, and organized sexual exploitation.
2. Alterations in affect regulation, including
- persistent dysphoria
- chronic suicidal preoccupation
- self-injury
- explosive or extremely inhibited anger (may alternate)
- compulsive or extremely inhibited sexuality (may alternate)
3. Alterations in consciousness, including
- amnesia or hypermnesia for traumatic events
- transient dissociative episodes
- depersonalization/derealization
- reliving experiences, either in the form of intrusive post-traumatic stress disorder symptoms or in the form of ruminative preoccupation
4. Alterations in self-perception, including
- sense of helplessness or paralysis of initiative
- shame, guilt, and self-blame
- sense of defilement or stigma
- sense of complete difference from others (may include sense of specialness, utter aloneness, belief no other person can understand, or nonhuman identity)
5. Alterations in perception of perpetrator, including
- preoccupation with relationship with perpetrator (includes preoccupation with revenge)
- unrealistic attribution of total power to perpetrator (caution: victim's assessment of power realities may be more realistic than clinician's)
- idealization or paradoxical gratitude
- sense of special or supernatural relationship
- acceptance of belief system or rationalizations of perpetrator
6. Alterations in relations with others, including
- isolation and withdrawal
- disruption in intimate relationships
- repeated search for rescuer (may alternate with isolation and withdrawal)
- persistent distrust
- repeated failures of self-protection
7. Alterations in systems of meaning
- loss of sustaining faith
- sense of hopelessness and despair
Dr. Herman's belief is that this diagnosis will prevent excessive use of other diagnoses (such as borderline personality disorder) and a "blaming the victim" attitude, toward people who have been subjected to long-term trauma. She acknowledges, however, that professionals have not worked out to what extent these criteria, or a separate diagnosis at all, apply.
Official views on treatment
Professional treatment practices vary with the trends in psychiatry, but the most common are medications, individual therapy, and group therapy.
Medications, when used, tend to be antidepressants and sedatives, for the purpose of helping with depression and anxiety. Some research is going into drugs that deal with stress-related chemicals in the body directly.
Individual therapy can take many forms. Cognitive behavioral therapy aims to teach the patient new ways of viewing and approaching life and problems, rather than the old ways, which are presumed to be dysfunctional. Hypnotherapy may be used to uncover memories, although this is highly controversial because of the unreliability of the memories that do get recovered. Another somewhat controversial technique, known as EMDR (Eye Movement Desensitization and Reprocessing), has the patient focus on specific disturbing memories while moving his eyes back and forth, purportedly helping him "reprocess" the memory. Other forms of individual therapy may follow the usual conventions of various forms of psychoanalysis, and may help patients to air their emotions or learn to trust people again.
Some professionals believe that it is imperative to remember and relive the traumatic experience in order to recover. Others disagree, believing that it may even be damaging for people to remember things before they are ready. A recent study has shown that the debriefings given to some people immediately after traumatic events can force a person to think about the event more intensely than otherwise, increasing the risk of long-term reactions.
Group therapy lets the person meet other people who have been through similar things. This can allow him to learn ways of dealing with the world from people who have been there, and to find out how he might look from the outside. It can also be a source of emotional support. There are also numerous self-help and support groups for people with PTSD on the Internet and in real life.
The physiological changes resulting from strain on the body can result in a variety of physical illnesses, which are real and should be treated.
Most people who treat PTSD through therapy will use some combination of the above techniques, rather than just one.
My unofficial, personal, biased views
These views are entangled with me and my past, because that is the nature of how these things work.
I have a piece of paper from my psychiatrist that says I have PTSD, and where most of it came from. To me, the piece of paper is not that important. It gives me insurance against things that could compound the problem, and that is most of its use: to keep me out of the psychiatric system, and to explain the more incomprehensible side of my behavior to professionals.
Post-traumatic stress disorder is, to me, a set of words that describe the ways in which I have contorted myself to adapt to an unremittingly hostile environment that happens to now be in the past. It does not have a life of its own. There is no disease called PTSD in my brain that can be ripped out with the proper therapy. There are only lots of mental and physical survival mechanisms, some of them more useful than others. My only wish is to keep the useful ones and to not need the harmful ones.
Once the situation that brought all of this on was over, I didn't notice it was over. Until recently, talking about flashbacks was an interesting exercise in semantics. It would have been more accurate to say that I had rare and intermittent flashes of the present. I wrote the wrong decade on my personal cheques, and my degree of immersion in the past varied only in how hallucinatory it became: If I physically perceived objects from the past, I called it a flashback, and the rest of the time my thoughts and emotions were in the past while my senses were in the present. I called people in the present by the names of people from the past, and even when I didn't do that I reacted to them as if they were different people. Even since I learned what PTSD was, it hasn't meant I can always tell by logic which sensory perceptions are the past and which are the present. It's that vivid.
I reenacted situations from the past, even when I didn't know I was doing it. Every February, like clockwork, I had an overwhelming urge to kill myself by strangulation or suffocation. It took time to remember that February was the month I had nearly suffocated to death. I'm told I had a habit of embarking on incongruous monologues that seemed to be lifted straight out of a years-dead conversation, and, more worryingly, getting into fights with people that seemed to mirror prior events in which my life was endangered. It's sobering to find yourself on top of your best friend staring them in the face while they hold your fists away from them and ask you, "Do you know who I am?" Especially when you've always been against most violence on principle, and you start wondering if your exception for self-defense applies to hallucinations.
I refused to go to parts of my house that had been deemed off-limits in other settings. I didn't bother going outside because I thought the door was locked. I was afraid of doctors. I heard screaming in my head all the time. I had the same nightmares every night, and often couldn't get out of bed in the morning because I thought I was strapped to it: Someone else had to tell me the straps were being let off one by one, as protocol had been, or else convince me they were not there at all. The world I was living in was like a surreal and constant form of time travel, the present mixing with various parts of the past. They were so entangled that I often looked around for the past in the present, thinking I must be missing something.
I oscillated between feeling nothing at all, and feeling things I had not felt at the time the events I was reacting to were occurring. I had strings of panic attacks so frequently that at times I seemed to run out of whatever chemicals fueled them, but my body kept trying to panic anyway. To top it all off, when I did notice I was not there anymore, I felt guilty for being alive. I'd end up banging my head on a wall just to try to get it to stop, and at one point I contemplated gouging my brain out but couldn't seem to find the tools to do it.
I was fortunate. There were people around me who were willing to patiently show me that the world today was not like the world yesterday. They protected me from the system, while reinforcing the better world I was living in here and now. They did not, as many people did, claim that I was deliberately living in the past, and they did not, as many therapists do, force me to relive it. I was already reliving it every day. The people who helped me the most were ordinary everyday friends who helped show me that this had happened to other people too, I was not going to be judged for it, I did not need to protect myself from the past anymore, and that it was safe and possible to deal with the present.
Without them, I would have been a classic revolving door chronic patient: Entering the system, being traumatized there, leaving, showing I was too crazy to be let out, getting back in, and being traumatized again until the layers were so thick there would be little chance of escape and I would have kept the psychosis label I'd been given for life instead of having it rescinded. That is essentially what had been happening to me until I gained the social resources to avoid the system altogether.
Nonetheless, it took four and a half years before I was able to say I had flashbacks rather than glimpses of the present, and that I was starting to respond to things in ways that made sense more often than not. I went through a February with no flashbacks, and I knew that my life was getting better. Since then, I have come to the conclusion that there is probably no end to this. These events will stick with me forever, as similar events do for anyone. I remember, I always will. But the longer I live my life without all of this, the better I feel, and the less likely my mind is to try to jump back in time. I can sometimes forget for a whole day that these things happened at all. The present is a very nice place.
At the same time, it's not simple. The medical models of PTSD fall short of the reality. This is not a disease that I acquired and am healing from. This is what happens when a person's survival instincts turn against them in a situation they were not built for in the first place. A situation that often has a political and social context. The person this happens to belongs to a society.
In my case, I belong to a society that tends to range from ignorant to openly condoning what happened to me. It is hard not to walk down the street, watch television, read books, or use the Internet without finding people who honestly believe that what happened to me and countless others was help. Especially when the way I have ended up as a result is considered a form of insanity, taking my credibility away even on things I am competent to judge. It makes me doubt myself and wonder sometimes if I'm still as out of it as I sometimes used to be, but whenever I check with people, our perceptions seem to match.
Rather than viewing myself as recovering from a disease, therefore, I work politically to build a world in which it is safe for me and others like me to remain in the present. I don't do this for therapy. I do it because it seems like the right thing to do. People's reactions, however bizarre they may become, cannot be separated neatly from our surroundings in the form of a disorder, and the diagnosis of PTSD is one of the clearest examples of this. Both we and our circumstances need to change.
Main References:
National Center for Post-Traumatic Stress Disorder. http://www.ncptsd.org/. NCPTSD. Accessed 2003, 2004.
Herman, Judith. Trauma and Recovery: The Aftermath of Violence -- From Domestic Abuse to Political Terror. New York: Basic Books, 1992.
Chamberlin, Judi. On Our Own: Patient-Controlled Alternatives to the Mental Health System. New York: Hawthorn Books, 1978
Coghlan, Andy. "Counselling Can Add to Post-Disaster Trauma". New Scientist. Accessed 2003, 2004.
Diagnostic and Statistical Manual of Mental Disorders 4th Edition, Text Revision (DSM-IV-TR) Washington, DC: American Psychiatric Association, 2000.