Psychological Trauma and Post-traumatic Stress Disorder
Keywords trauma, PTSD, cognitive behavior therapy
Trauma means the experience of emotional shock which can cause significant damage to the psychological integrity of a person its effects can be lasting and can lead to further complications such as post-traumatic stress disorder, chronic depression, neurosis or addiction. As used in medical terminology, the word trauma refers to a serious injury or shock to the body, caused by a bodily abnormality or an accident or other types of violent incidents. Psychological trauma is the mental counterpart of physical trauma, though it may or may not have a physical basis (Schwarz, 2002). Psychological trauma can be triggered by extraordinarily stressful events that shatter an individuals ability to cope with reality. Feelings of insecurity, vulnerability, helplessness and loneliness take hold of the mind.
History
Historically, psychological trauma and the common symptoms of what we today consider as PTSD were often attributed to soldiers who could have gone through harrowing experiences in wars. In the late nineteenth century, Freud, taking a cue from his mentor Charcot, recognized childhood traumas to be the major causes of a variety of mental disturbances in the adult life (Webster 2003). Around this time, Pierre Janet too laid the foundations of our understanding of trauma. World Wars I and II brought a renewed focus on PTSD. Abram Kardiner did important work on trauma and published his seminal volume Traumatic Neuroses of War and War Stress and Neurotic Illness during the Second World War (Leys, 2000). In the 1960s and 70s soldiers returning from the Vietnam War frequently manifested PTSD symptoms. Robert J. Lifton, a psychiatrist at Yale University, contributed much to the field through his work on trauma patients, including Vietnam veterans (Bentley, 1991). In the 70s, womens movement attached the label of emotional trauma to the suffering experienced by physically and sexually abused women and children.
The medical establishment officially recognized PTSD only in the 1980s when the term post-traumatic stress disorder was included in the third edition of the Diagnostic and Statistical Manual of Mental Disorders DSM-III of the American Psychiatric Association (Wilson et al, 2004). Even so, there ensued much scientific debate as to the validity of categorizing PTSD as an illness. There was a great need for more research. Some of the key figures associated with path-breaking research on the subject of trauma are Harry S. Abram, John Henry Krystal, and Mardi J. Horowitz (Beall, 1997). Over the decades, the meaning and scope of psychological trauma expanded considerably as well as our understanding of its causes, consequences, and solutions. The decade of the nineties led to further enhancement and consolidation of our knowledge of psychological trauma and related disorders (Smith Segal, 2008). Recent research has continued to throw light upon the dark world of trauma.
Causes
Natural disasters, war experiences, serious accidents, physical, sexual or emotional abuse, violent or an unnatural death of a loved one, serious health problems, severely debilitating or life-threatening diseases, extreme poverty or other forms of physical deprivation, crime, terrorism all these can lead to trauma. Sometimes, traumas are divided into traumas with a big T and those with a small t one can be almost as damaging as the other. Small t traumas can occur repeatedly for long periods of time resulting in cumulative stress (Foa et al, 2009). These include being bullied or ridiculed, break in relationships, loss of source of income, betrayal, experiences of neglect, humiliation, shame, etc. For example, relatively milder forms of domestic abuse repeated over the years can lead to a mental breakdown in the victim. Trauma can be seen as stress that is gone out of hand, or as stress that has assumed a life of its own.
Traumatic experiences during childhood are particularly damaging in that they can radically alter an individuals personality for the worse. Children are highly sensitive and vulnerable to environmental impacts. Childhood traumas can be caused by any factor that can jeopardize a childs sense of safety and security. These include various kinds of abuse, physical, sexual and even verbal domestic violence, death of a parent, poverty, deprivation, neglect, bullying, separation from a parent, or serious illness, and so on (Perry, 2002).
Each individual has different susceptibilities to potentially traumatic incidents. The way in which a person reacts to an untoward event can significantly depend on various aspects of the persons character and worldview (Schwarz, 2002). With people who have a highly positive outlook of the world, even seriously adverse events such as the loss of a limb or a loved one may not have any noticeable impact on the other hand, people with a negative worldview may be seriously affected by even a relatively minor incident such as a job loss. Values, expectations and a variety of other mental factors play a considerable role in determining the damaging potential of a traumatic event or circumstances. For example, normally if a successful, young person were diagnosed with a life-threatening cancer, he or she is bound to go through great mental anguish that could border on trauma. However, Lance Armstrong, the legendary cyclist, took cancer in his stride, miraculously overcame the malady, and once again entered the marathon sport. In short, more than the event itself, it is the attitude we take to it that determines the future possibility of a trauma.
Etiology
Ford (2009) observes, Psychological trauma and PTSD involve profound impairments in the bodys stress response systems and the brains self-regulation systems (p.141). The human brain has three major parts, the cortex, the limbic system, and the brain stem. The cortex region of the brain, which includes frontal cortex that is the seat of higher thinking skills, is the outer area of the brain. It constitutes some of the most recently evolved portions of the brain which are unique to human beings. The limbic system is located at the center of the brain and is the region of emotions. The brain stem is the most primitive part of the brain, it handles certain basic survival functions at an unconscious level. It is also the seat of basic drives and instincts of an organism. Researches done on scanning the brains of trauma patients have revealed that the experience of trauma is accompanied by recognizable changes in the brain structure. The region of intersection of the frontal cortex, limbic system and the brain stem is most likely to be affected in a trauma patient (Smith Segal, 2008). It has also been found that people with a wide variety of psychological and behavioral problems show brain irregularities that are analogous to those seen in trauma patients. PTSD is a result of traumatic stress overloading and overwhelming the nervous system of a person. The resulting shock is likely to cause a dissociation between the three parts of the brain. As a consequence, the rational part of the mind can no longer oversee the emotional part of the brain (Gazley, 2007a).
From the point of view of neuro-chemistry, encountering the unexpected during times of emergency the brain releases the catecholamine neurotransmitters norepinephrine and epinephrine (noradrenaline and adrenaline). Studies have found that PTSD patients typically show catecholamine abnormalities, such as a high norepinephrine to cortisol ratio (Bayse 1998).
Studies have established that the overall physiological imprint of trauma and PTSD in the body is clearly distinct from the bodily responses associated with routine stresses and depression (Flannery, 1999).
Symptoms
Psychological trauma subjects an individual to great amounts of stress and distress. It can lead to ASD (Acute Stress Disorder), which in turn, if unchecked, can lead to PTSD. PTSD can be considered as an advanced or severe form of psychological trauma. Minor forms of trauma, on the other hand, lead to what is known as adjustment disorder which can be characterized by such symptoms as persistent anxiety, depression, behavioral disturbances or other maladaptive reactions (guidetopsychology.com, 2009).
Trauma can manifest itself through any of a wide variety of symptoms. On the physical level, it could manifest as listlessness, unusual physical fatigue, decrease of libido, insomnia, lack of appetite, and unexplained bodily pains. On a mental level the symptoms could be extreme depression, despair, hopelessness, feelings of helplessness, powerlessness, and lack of control, intense anxiety, panic attacks, outbursts of crying or anger, dread, compulsive and obsessive behaviors, increased irritability, proneness to anger, emotional numbness and withdrawal, loss of religious faith and resentment toward God or existence. Additionally, at a cognitive level, memory, decision-making skills, and the ability to concentrate can be affected (Smith Segal, 2008).
Intense forms of trauma, such as those precipitated by a natural disaster, battleground action, car or airplane accidents, can lead to PSTD and involve an even broader set of symptoms. Both milder and intense forms considerably overlap each other and there cannot be a clear demarcation. The symptoms of intense trauma are usually categorized as PTSD symptoms, and fall under three heads 1) re-experiencing the trauma compulsive thoughts, flashbacks and nightmares with associated physical manifestations, spontaneous flurry of images and emotions related to the traumatic event 2) emotional numbing and avoidance partial amnesia, avoidance of situations similar in character to the traumatic event (for example, avoiding driving after a car accident), loss of interest in activities which were previously enjoyed, intense aloofness, detachment, experiences of guilt, uncontrollable outbursts of grief, distorted perception of time 3) increased arousal edginess, jumpiness, restlessness, hyper-vigilance, obsession with death (NIMH 2009).
Re-experiencing and avoidance symptoms are usually triggered either by a persons own thoughts and feelings or by objects, situations, and persons around him or her these objects and person may or may not be associated with the traumatic event. Most of the hyperarousal symptoms, on the other hand, can be present constantly. The tendencies to manifest all these categories of symptoms take deep roots inside a persons mind and character, disrupting his or her routine and the capacity to handle simple daily tasks.
It may be noted that victims of trauma might present much more diffuse and subtle long-term psychological problems that are not usually labeled under PTSD. Such problems may include feeling of hollowness within, lack of a sense of personal agency, serious perceptual aberrations in regard to oneself and world, attention disorders etc. A significant proportion of these trauma victims who do not manifest overt trauma or PTSD symptoms may go undiagnosed (Trappler 2009).
Diagnosis
It is not uncommon for people to experience several seriously distressing situations in their lives. However, the stress we experience before or after an event tends to decrease over time and we return to normalcy. There need not be anything pathological about this type of stress. However, if we experience severe symptoms which last for weeks together, then we could be experiencing trauma. This condition would be more specifically known as Acute Stress Disorder. The symptoms might persist for more than a few weeks in some cases, and this could be a clear indication of PTSD. The symptoms of trauma in cases of PTSD sometimes may not manifest for weeks or even months after the original traumatic incident (Reyes Elhai, 2008).
A therapist diagnoses PTSD after having talks with the person and confirming that he or she has had all the following for a period of at least one month
One or more re-experiencing symptoms
Three or more avoidance symptoms
Two or more hyperarousal symptoms
Besides the above, the therapist also looks for any other recent behavioral changes that have been adversely affecting the normal workaday life. A range of newly acquired behavior patterns could serve as strong indications of trauma. These include
Alcohol and other psychoactive substance use
Suicidal thoughts and behaviors
Self injurious behaviors
Recklessness
Poor nutrition
Eating disorders
Anger and aggression including intimate partner violence
Victimization including intimate partner violence
Misinterpretation of benign andor helping situations as threatening and response to perceived need for self-protection
In addition, a number of physical ailments could result from the chronic levels of stress experienced in PTSD. The therapist may associate any of the following disorders with PTSD
Hypertension
Heart disease
Thyroid and Hormone functioning
Gastrointestinal disorders
Respiratory disorders
Susceptibility to infection and Immunological disorders
Pain perception and tolerance issues
Chronic pain conditions, e.g., Fibromyalgia
Treatment Interventions
Approaches to treatment of trauma and PTSD can fall under two broad categories psychological therapies (psychotherapycounselingcognitive therapy) and medication. Frequently, both these approaches go hand in hand. After examining studies on large numbers of PTSD patients, especially in the aftermath of natural disasters or acts of terrorism, findings that were obtained indicate that it would be reasonable to expect a natural recovery from PTSD, at the same time cases where the pathology persists are not uncommon (Kim 2006). In either case, it would be advisable to resort to treatment interventions as a means to expedite recovery.
The nature of trauma is complex, depending, as we have seen, on the interaction of external events and a persons response to them according to his or her worldview, belief-systems, and predominant dispositions of character. In such circumstances there cannot be any standardized form of therapy even in cases where symptoms appear alike what works for one person may not work for another. Unlike normal types of stress, which we expect a person to cope with and handle by himself or herself, situations of trauma and PTSD need medical attention persons with trauma and PTSD need to be treated by competent and experienced mental health care providers. Despite the expertise and experience of a therapist, sometimes different kinds of treatment need to be tried out in order to find the right one that clicks. PTSD can be sometimes accompanied by other associated problems such as depression, panic disorder, neurosis or other forms of mental instability, addiction to alcohol or drugs, and suicidal tendencies. Therefore, PTSD and other trauma-related problems need to be treated together. Foa et al. (2008) stress this point
More recently, there is an increased awareness among clinical researchers that the goals of treatment should include reduction of not only PTSD symptom severity but also associated symptoms, such as depression, general anxiety, anger, shame, and guilt, as well as improved quality of life. (p.8)
Special attention needs to be paid to cases where the source of trauma could be ongoing, such as domestic violence in such instances more efforts must be focused on bringing the trauma-inducing events to an end first (Dass-Brailsford, 2007). For a patient to undergo therapy while he or she continues to be subjected to high levels of stress could be an exercise in futility it could be like pressing one foot on the accelerator while the other foot is on the brake during driving.
A basic form of psychotherapy is talk therapy, which involves discussing extensively with a therapist on matters in any way related to trauma as well as life in general. Talk therapy can involve long periods of time, usually between 6 to 12 weeks or more, with a few sessions per week (NIMH 2009). It can be conducted either in one-on-one sessions or group sessions, both of which have their own advantages and disadvantages. Understandably, support from family and friends, normal and reassuring circumstances of life, can provide a boost to the effects of therapy.
Talk therapies also involve elements of counseling. During the counseling sessions the clients learn better ways to cope with their PTSD symptoms and the circumstances that trigger them. Counseling generally involves imparting a broad knowledge about trauma and its effects, as well as other more specific knowledge and skills. This knowledge could include tips and insights related to diet, sleep and exercise, relaxation and anger-control techniques, capability to better deal with negative emotions such as guilt and shame which may be associated with the trauma-inducing event (Dass-Brailsford, 2007). Talk therapy may also involve visiting people and or places in any way associated with the origin of trauma. It may be noted that though psychotherapy may appear simple, it needs to be provided only by formally trained therapists.
There are a wide variety of other therapies that deal with PTSD. A very popular approach which is increasingly becoming the treatment of choice for PTSD is called cognitive behavior therapy or CBT. CBT has a set of core components that include education, anxiety management, and exposure, all of these targeting PTSD symptoms from various directions.
Patient education is essentially counseling, it is a preliminary phase wherein there is a sharing of information about common symptoms that may appear after a trauma-inducing event. There is an effort to provide the client undergoing therapy with a fair idea as to how therapeutic work can mitigate the symptoms of trauma. A rationale for treatment is established.
In exposure therapy, people are encouraged to face and experience the trauma from safety, in any way that is possible. This could allay fear. For example, the client may be asked to vividly imagine the pictures and scenes related to trauma for prolonged periods of time. The patient would in effect be re-living the experience. While imagining and re-living the experience, the patient would also be required to provide a verbal narrative of the whole thing in the present tense. The patient understands the need to lay particular focus on the most distressing aspects of the trauma incident (Bryant 2006).
Prolonged exposure can last for 45 minutes in a session. Variants to this form of imagined exposure are repeatedly writing down the detailed descriptions of the incident and the experience of ones reactions, and exposure through computer-generated imagery and VR (virtual reality) where possible. Sometimes, these various forms of imagined exposure are complemented by graded, live, in vivo exposure to the trauma-related stimuli. Exposure therapy forms the cornerstone of CBT.
In cognitive restructuring, there is an effort to help people interpret things and events in a positive way. It helps people evaluate their beliefs about broad and general things such as the self, the world, and life. Often guilt and shame regarding the event of trauma can be resolved by learning to look at the event from a different perspective. Also, people tend to form wrong memories of how things occurred, and these would have to be corrected (Dass-Brailsford, 2007).
In stress inoculation training, the focus is on reducing the anxiety levels. Anxiety management approaches include breathing retraining, muscle relaxation and self-talk. These techniques aim to let the individual to take control of things again and achieve a sense of mastery over fear.
The above modes of CBT are generally used in combination, but they can be used independently too, depending on the circumstances. As a result of many studies, there is now enough evidence to show that CBT is an efficacious and possibly the most effective intervention for PTSD (Bryant 2006). After doing an extensive survey of empirical studies, Zayfert and Becker (2007) conclude that the literature offers convincing support for the efficacy of CBT based on exposure, cognitive therapy, or both. (p.5)
Although the other components of CBT are self-explanatory, the parts dealing with exposure therapy may appear paradoxical. Re-living is in fact the classic symptom of PTSD, how can it work as an aspect of therapy This question cannot be fully answered, but there is a fundamental difference between re-living as it is done in the experience of trauma, and re-living as it is done in therapy. In the former it is an involuntary occurrence, in the latter it is a voluntary and conscious experience. Although there is sufficient consensus pointing to the effectiveness of exposure therapy, the mechanisms that could explain its efficacy are still being worked out (Dass-Brailsford, 2007). It could be possible that consciously re-living the experience provides a distance between the observer and the observed, the experiencer and the experienced, thereby breaking a persons identification with the traumatic experience and creating a distance or a perspective from which to look at it.
Forms of psychotherapy and cognitive therapy are often used in conjunction with medication. There are two FDA-approved drugs for treating PTSD in adults, sertraline (Zoloft) and paroxetine (Paxil). These drugs are classified as serotonin reuptake inhibitors (SSRIs) (Kim, 2006). Both these drugs are also used to treat depression. Feelings such as sadness, worry, anxiety, mental numbness in the context of trauma can have a marked neuro-chemical basis and are hence susceptible to the action of drugs. However, these drugs can have side-effects and have to be used with caution. In addition to the above-mentioned drugs, the therapist may prescribe some regular drugs which fall under the categories of tranquilizers, antipsychotics, and anti-depressants (NIMH, 2009). These drugs are used especially in conditions where PTSD is accompanied by other mental problems which can be considered as issues in themselves. For example, depression can be regarded as a component of PTSD or as a separate problem in itself accompanying PTSD, depending upon its intensity and other factors in which case use of certain drugs to allay it may be warranted.
In the recent years some novel approaches have emerged to deal with trauma in more effective ways than the more traditional forms of therapy. However, since they are based on alternative modalities, their use remains controversial.
The first approach is a rediscovery of the oldest technique that was used to deal with the unconscious mind, and an application of it in the modern clinical context. Hypnosis can be quite effective in altering many subconscious mechanisms that play out inside a traumatized mind. After the process of induction, the hypnotherapist asks the client to live the painful experiences of the past again, but in an attitude of detached calmness. Re-experiencing under hypnosis can be a much more vivid and realistic experience than doing so in a state of normal consciousness. Such re-living can change the perception of the original experience. Hypnosis, however, works only with more sensitive type of people, who make up only 20 to 30 percent of the general population (Schwarz, 2002).
EMDR (Eye-movement desensitization and re-processing) is becoming a popular method in treating trauma. It could be fast, painless and effective. It is based on the principle of REM or rapid eye movements, which occur during dreaming. The brain uses REM to consolidate short-term memory into long-term memory short-term memories have much more emotional content than long-term memories. Through inducing REM in the client while he or she consciously holds the memory of the traumatic event, the therapist helps the client to do away with the emotional immediacy of the traumatic event, while the memory of it can be retained.
NET (Neuro-Emotional Technique) and TFT (Though Field Therapy) can be considered as twin alternative therapy techniques that are slowly gaining acceptance, although practitioners who are adept at these techniques are still rare. These techniques are based on the principle that cells of the body can store memories, and the entire body has a role in preserving the memories of the past. They are also based on the traditional Chinese medicine and concept of the Meridian systems. In these methods, the therapist taps on certain crucial areas of the body in order to release toxic memories associated with past ordeals (Gazley, 2007b).
The prognosis in the context of PTSD is highly variable from individual to individual. It depends on a host of personal and circumstantial factors. However, with the intervention of proper treatment in right time, one can expect to recover to normalcy within six months from the onset of the illness (NIMH, 2009).
Current research
Terence M. Keane, Director of the Behavioral Science Division of the National Center for Post-traumatic Stress Disorder, has noted the following regarding the strides current research in this field has been making
Recent advances in the psychological treatment of PTSD, with veterans and the broader population, indicate that there are now multiple treatments available with great promise and demonstrated efficacy. In particular, there are more than a dozen clinical trials examining the effectiveness of cognitive-behavioral treatments for PTSD. (2010)
The focus of much of the ongoing research in PTSD is on the effectiveness of CBT and medications, while that of EMDR is also being studied (DeAngelis, 2008). Recent studies are also focusing on the study of effects of PTSD on the brain. A part of the brain that is of particular interest to the researchers is the hippocampus, a component of the limbic brain system usually considered as the seat of memory (Tull, 2009).
The current research efforts are a continuation of the research that has been going on since the 1990s. In the last two decades, there has been much research in areas related to fear, stress, depression and PTSD. Insights gained about how people form memories have been of great use in developing new treatments for PTSD. Besides, advanced brain-scanning technologies and progress in such fields as genetics, molecular biology, and neuroscience are paving the way for a deeper understanding of PTSD. At present, there are efforts underway seeking ways to improve methods of screening and diagnosis of PTSD and its early treatment, especially in circumstances of mass trauma. A greater understanding of why some people are more susceptible to trauma and others less can go a long way in evolving more effective methods of treatment, and as such is a focus of considerable research in this field (NIMH. 2009). Another important initiative that has been going on in the past few years is the study of psychological trauma and PTSD in the context of various non-Western cultures (Wilson et al, 2007). Dramatic improvements in the technology of virtual reality could facilitate more effective treatment interventions for PTSD. The understanding of the nature of psychological trauma and the search for better forms of treatment would remain major medical challenges in the years and decades to come.
Conclusion
Although the affliction could have been as old as humanity itself, the pathological nature of PTSD has been formally recognized only three decades ago. At the same time, it is possible that the accelerating pace of modernity during the second half of the twentieth century has brought about greater levels of stress and strain to many people across the world. Certainly, people feel more lonely and insecure living in the modern-day concrete jungles than if they lived in small emotionally-nurturing family-oriented communities. Also, millions of years of gradual evolution has simply not prepared the human mind to cope with the constant barrage of stimuli and the incessant onslaught of change that we experience in the modern world. There seems to be a growing awareness as well as an increased incidence of PTSD in the recent times. Although the nature of PTSDs multifarious aspects are well understood, thanks to the amount of research that has gone into this field particularly in the past two decades, the type of treatment interventions we have generally take a long time and do not seem to offer robust outcomes. Incidentally, this is the case with many other mental afflictions, even common ones such as chronic depression. Notwithstanding the rapid advances being made in field of trauma and PTSD, perhaps what we really need is a revolution of sorts which can help us tackle the apparently increasing stress and trauma problems of our times head-on.
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