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According to the DSM-IV, PTSD symptoms are divided into four clusters. The first cluster (A) requires the witnessing or experiencing of traumatic and life threatening events (direct or vicarious exposure), which stimulate in the individual anxiety, fright and helplessness. Past studies have shown that high magnitudes as well as low magnitude stressors contribute to the development of PTSD. The stressors are commonly external and deliberately inflicted. Vulnerability to PTSD does not lay in a specific type of trauma or in the gender of the survivor. It is the subjective perception and the interpretation of the traumatic event by the survivor, which increases the risk of PTSD development rather than the nature of the event (Yehuda, 1999).  The perception of unpredictability and/or uncontrollability is strongly associated with the emergence of PTSD symptoms (Kushner et al., 1993). Additionally, interpretation of feelings and behavior during the traumatic event as personal inadequacy also creates a greater risk for PTSD.

Cluster (B) of the PTSD symptoms is intrusion. It involves re-experiencing of the trauma in forms of nightmares, obsessive thoughts, reoccurring emotional and physical reactions, illusions, flashbacks, dissociative episodes and hallucination. These intrusions can be so vivid that the individual believes the trauma is reoccurring. There are also physical reactions to the intrusion such as sweating and heart pounding.  Vivid memories, thoughts, emotions, imagery and smells invade the individual’s consciousness; inhibit the survivor from carrying on with his daily activities. Individuals diagnosed with PTSD exhibit deficits in working memory, initial learning, concentration problems and slower processing speed (Vasterling et al., 2002; Twamley et al., 2009). It also disturbs sleep. Re-experiencing can occur suddenly and without intention. It is the result of exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event and it is typically accompanied by intense emotions, such as grief, guilt, fear or anger. Re-experiencing of the trauma may lead to helplessness, hopelessness and depression.

Cluster (C) is avoidance. It refers to the avoidance of thoughts, feelings, activities, places, people and any other stimuli, that are directly or symbolically connected to the traumatic experience and which may provoke undesirable reaction or remind the individual of the trauma. Avoidance involves social withdrawal, emotional numbing, denial of meaning and consequences, behavioral inhibitions, phobic activities and lack of interest to participate in activities. It causes alienation, loneliness, social isolation and inability to sustain relationships. As a result there is often a sense of detachment or estrangement from others.  Avoidance is an attempt to blunt the pain.

Avoidance may provide an initial relief but the price is high. Life is also not lived to the fullest. It also increases depressive symptoms and the presence of more acute life stressors (Holahan et al., 2005). It reduces the ability to cope with the trauma, recover and to function normally. Avoiding talking about the traumatic event is essentially hiding a part of the self from the outside world.  It costs a lot of energy and can be exhausting. The survivor is forced to keep up appearances. A gap is created between the real self and outside world self (Everly & Lating, 1995). Although in short term avoidance may give a sense of reduced anxiety and more control, in the long run it has disastrous consequences.

The paradox of avoidance is the more one tries not to think about something, the more one ends up thinking of it. The traumatic experiences are so extreme, atrocious and deviate from normal daily life that the brain cannot process it. The brain tries to make sense of the trauma, find meaning, search for answers and therefore it keeps repeating it in many forms (intrustion). By not avoiding anything that is connected to the trauma but by talking, thinking, confronting and even writing about the trauma and its effects, the individual can get control over the brains’ activity rather than letting it control him.

The last cluster (D) is characterized by hyperarousal. It is the body’s natural survivor system of fight or flight reaction in the face of danger. The individual is highly alert,  has exaggerated startle responses ( e.g. jumpiness), irritability, concentration problems, sleep problems, fright and anger outbursts. Individuals with PTSD are overly alert and are preoccupied with detection of the threatening sources in the environment. The constantly high arousal level impairs normal functioning. High physical arousal in combination with appraisal of a hostile environment can activate anger. Strong anger arousal challenges the individual’s already shaky self-regulation ability to inhibit anger expression. Anger is expressed in the form of aggression when inhibition abilities are too weak. In the individual’s mind the aggression is justified as it enables him to protect and defend his life.

The PTSD symptoms have survival values. Surviving the trauma is a great achievement, however, in order to fully recover from the trauma, one has to confront these symptoms head on.  PTSD is a normal reaction to abnormal and devastating event. It can nevertheless be efficiently treated. There are a few scientifically proven treatments for PTSD. CBT (cognitive restructuring and exposure) or EMDR are often used to treat PTSD and some clients also choose to combine medication. All these treatment are equally effective, though some may prefer one approach over the other.

Everley, G. S., & Lating, J. M. (1995). Psychotraumatology: key papers and core concepts in post traumatic stress. New York: Plenum press.

Holahan, C. J., Moos, R. H., Holahan, C. K., Brennan, P. L., & Schutte, K. K. (2005).Stress generation, avoidance coping, and depressive symptoms: A 10-year model.  Journal of Consulting and Clinical Psychology, 73, 658-666.

Twamley, E. W., Allard, C. B., Thorp, S. R., Norman, S. B., Cissell, S. H., Berardi, K. H., Grimes, E. M, & Stein, M. B. (2009). Cognitive impairment and functioning in PTSD related to intimate partner violence. Journal of the International Neuropsychological Society, 15, 6, 879-887.

Vasterling, J. J., Duke, L. M., Brailey, K., Constans, J. I., Allain, A. N., & Sutker, P. B. (2002). Attention, learning and memory performances and intellectual resources in Vietnam veterans: PTSD and no disorder comparisons. Neuropsychology, 16, 5-14.

Yehuda, R. (1999). Risk factors for PTSD. Washington DC: American psychiatric press.

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