Acute Psychological Trauma
The Acute Psychological effects of Trauma
When reading this article and thinking about “psychological trauma” and “traumatic events,” it is important to make a distinction between the common stresses of daily living and traumatic events that pose an immediate threat to life and bodily integrity.
Experiences such as a rape, physical assault, or exposure to a natural disaster or terrorist attack may overwhelm a person’s capacity to maintain a continued sense of safety and well-being.
Such psychological traumas can disrupt the victim’s basic assumptions about a world that, until now, had appeared safe and predictable. The victim is left struggling to make sense of a world that no longer feels as safe or predictable as it always had been.
Severe psychological trauma was first recognized after World War I when soldiers surviving gruesome battle scenes presented to mental health professionals with symptoms of confusion, dread, amnesia, and emotional detachment. Many of them were unable to return to battle.
Not all traumatic events lead to severe psychological trauma at all times in all people.
There are several “favorable circumstances” known to have an adverse influence on the outcome of any trauma. These fall into three general groups:
Pre-event factors:
- Previous exposure to adverse life events
- A history of childhood neglect or abuse
- A family history of dysfunction or domestic turbulence
- A history of early loss or separations
- A lack of external supports
Event Factors:
- The absence of any forewarning or opportunity to prepare psychologically
- The presence of physical injury
- Witnessing grotesque imagery or atrocities
- Continuous threat to personal safety
- Separation or disappearance of family members
- The disruption of access to basic necessities
- The nature of the relationship with the perpetrator
Post-event Factors:
- The absence of adequate rescue resources
- Personal resourcefulness in taking control of events
- Betrayal or negligence of caretakers
- The extent and duration of physiological arousal
- The severity of Post Traumatic Dissociation
One may be surprised how many victims survive unthinkable personal horrors and find a way to move on. Such survivors may know what went right in their lives to enable continued emotional survival following adversity.
Some individuals are able to maintain their sense of inner-cohesion and personal efficacy. They are action orientated and seek to communicate with potential rescuers; or they look to find meaning rather than despair; and they remain innovative with a sense of hopeful optimism (Tennen and Affleck. “Post Traumatic Therapy and Victims of Violence: Positive Changes in the Aftermath of Crises.” Post Traumatic Growth, 1998).
There is resurgence in our focus on early attachment experiences, the availability of empathic caretakers, and our ability to self-soothe.
I will devote separate articles to the subject of caretaking and its relevance to trauma.
This article describes some of the most serious symptoms that occur following acute (“Type I”) traumas, such as following natural disasters or terrorist attacks, as well as those.
Dissociation & Psychological Trauma
Dissociation is one of the cardinal symptoms of psychological trauma.
When an individual reacts this way to conditions of extreme stress, he becomes “disconnected” from the trauma by temporarily losing the ability to engage psychologically in the “present.”
When a high-intensity threat overwhelms the victim with fear or horror, his sense of awareness may “escape” him.
This is how a trauma patient described it: “It is as if my brain was telling me ‘I can’t deal with this’ and then, almost magically, my psyche ‘parked’ itself somewhere in metaspace or in a state of limbo.”
This disruption of the traumatized individual’s integrated awareness can vary significantly, in terms of both severity and duration.
The most common and benign example of dissociation is “amnesia,” which manifests by the trauma survivor showing an inability to recollect the details of what happened during the trauma. Sometimes the person with amnesia will retain only memory fragments of the traumatic event, insufficient to synthesize into a coherent trauma narrative.
A more serious form of dissociation is the “fugue state,” where the victim experiences total disorientation following a traumatic event. Well-documented cases abound in trauma literature of the survivors of catastrophic events found wandering around confused and unable to identify themselves. This form of severe dissociation, with temporary identity loss, is at the extreme end of the “dissociative spectrum” of disorders.
Among those with dissociative disorders of various types and degrees are survivors of prolonged interpersonal trauma, such as childhood or spousal abuse. These victims may emotionally “tune out” in such a way that others identify them as merely “distracted,” “detached,” or “emotionally absent.”
This phenomenon represents a form of “structural dissociation” according to Pierre Janet, a pioneer in the area of hypnosis research.
Janet’s explanation for this phenomenon is that the trauma has split the personality into separate compartments, which function independently.
One most often finds this in victims of chronic abuse, where victims compartmentalize their “emotional self” from their “apparent self” (Van der Hart, Onno, et al, “The Haunted Self”, 2006). According to Janet, this “defense” allows the individual to partially engage the world in an operational way (via the “apparent personality”) while remaining emotionally detached and disengaged.
While this form of emotional repression may be adaptive in some circumstances, “structural dissociation” represents a permanent structural split in the personality of these damaged trauma survivors.
The most serious manifestation of structural dissociation was formerly termed “Multiple Personality Disorder” and then renamed as “Dissociative Identity Disorder.” The essential feature of this disorder is the presence of two or more distinct identities that recurrently take control of the individual. Each personality has a distinct name, personal history, and identity.
While this condition is considered quite rare, there are some clearly documented cases. They all objectively confirm that these individuals had past histories involving physical or sexual abuse.
When trauma has produced this level of fragmentation, reintegrating the “split off” components into an “integrated whole” is one of the most arduous challenges in psychotherapy.
In summary:
- Dissociation is an automatic response to an overwhelming feeling.
- Dissociation is an experience where a person unconsciously feels “removed” from his present environment.
- This symptom is usually triggered by some fear-reminder, that signals the person to escape anticipated (conditioned) unbearable emotional pain.
- To an external observer, individuals appear emotionally “shut down” and disconnected.
- “Structural Dissociation” occurs when severe forms of early abuse assert a compartmentalizing effect on the structure of the personality.
Flashbacks
A flashback is a sudden, vivid recollection of a trauma experience.
The unwanted intrusion of trauma material into consciousness reflects fragments of a trauma that the brain was unable to synthesize into a meaningful narrative.
For some people, these intrusions take the form of visual trauma images.
While some trauma victims experience flashbacks visually, others “hear” them or even experience them as physical sensations, such as pain.
Flashback experiences are usually associated with intense negative emotions, fear in particular. They can also cause victims to feel shame, guilt, or anger.
Flashbacks can occur spontaneously when survivors are re-exposed to either internal trauma recollections or external trauma triggers. They can also be induced by hearing about the trauma event (that is, by exposure to trauma narratives) or by seeing visual imagery associated with the trauma.
Flashbacks may also take the form of nightmares. I have had Holocaust survivors as patients, for example, who had become sleep-phobic because they experienced predictable visitations of images, sounds, or smells of the crematoriums in the concentration camps.
Such experiences torment these survivors, particularly when perceived as if they were actually happening in the present.
During a simple flashback, the individual maintains a sense of cognitive cohesion.
When the victim has a flashback and dissociates, the consciousness is flooded with trauma material and the person feels as if they are at the scene and reliving it.
I would call this a dissociative flashback since the victim takes temporary leave of the present, revisits the past trauma, relives it, and even believes that the trauma is happening all over again.
In the immediate aftermath of a life-threatening event, flashbacks are frequent and are not indicative of PTSD.
There is much research implicating the role of the hippocampus gland, arching around the limbic brain, and responsible for downloading information into long-term memory in the temporal lobe.
In a state of super agitation, stress hormones and brain toxins have a “shutting down” effect on this delicate brain structure.
As soon as the state of heightened alarm is contained by good coping skills and appropriate external rescue functions, the sooner the victim can process the event and the less the chance of developing residual PTSD.
The school of Cognitive Behavior Therapy emphasizes the value of
“Self-soothing” and “anchoring” functions to allow the victim to “habituate” through repeated trauma exposure guided by the therapist.
If the victim continues to hold a significant reservoir of “split-off” (or unmetabolized) trauma material, this might always resurface as a flashback.
Once order and safety have been re-established, most individuals experience a gradual diminution of symptoms over time.
However, if the trauma remains, such as in victims of child or spousal abuse or following prolonged captivity (especially when there has been exposure to atrocities), flashbacks may become chronic.
Fear and Trauma
Fear is one of the most powerful primary negative emotions resulting from psychological trauma.
I will discuss some of the neurobiology of the “fear cascade” in a separate article.
Fear is a survival serving emotion, triggered by threat that activates a complex set of changes throughout the body via a domino-like effect. The most common term for this is the “fight or flight” response.
Fear can be a normal reaction to a life-threatening event.
I refer the reader to the articles covering “syndromes” in order to appreciate the spectrum of fear symptoms across the different trauma syndromes.
For instance, following a single traumatic incident such as an assault, or at a more global level, following the terrorist attacks on New York on 9/11, and subsequently on the Transit Systems in London and Madrid, a majority of the nation experienced elevation of stress levels, particularly “apprehension.” However, some victims experience persistent fear. There is good clinically based evidence that even the most severe fear symptoms will respond to treatment.
According to Edna B. Foa, a renowned international authority on post-traumatic stress disorder (PTSD), people who have been chronically traumatized victims live their lives in a constant state of fear and dread.
The “fear paradigm” is a useful term to describe victims who constantly experience the world as threatening.
While each school in neuro-behavior has a language to discuss fear as a symptom, the Behavioral school was perhaps the first to support its theory with preclinical and primate research data.
While other articles will address an array of perspectives, including an article on the protective role of early bonding with caretakers, the rest of this article will summarize the “Behavioral” theory of fear.
Traumatizing experiences have a tendency to “generalize” onto other aspects of life, and thus sensitize individuals to a widening array of new “threat cues.” Situations previously considered safe become danger signals. This increases the likelihood that traumatized individuals will constantly be scanning the world around them to identify threats to their safety and well-being. Their sympathetic nervous system (SNS) is constantly on the alert. In this state of activated threat arousal, there is a greater likelihood of interpreting ambiguous information as dangerous, by which they become constantly re-traumatized.
Research on “fear conditioning” shows that individuals subjected to horrific events react with both heightened emotions and avoidant behaviors when subsequently confronted by similar events. Once individuals become fear conditioned, a vast array of “triggers” becomes capable of exacerbating trauma recollections and autonomic over-arousal. “Stimulus generalization” is, therefore, integral to the so-called “fear cascade.” Exposure to these trauma triggers subsequently unleashes the full cascade of traumatic symptoms.
While living in a state of apprehension and perceived threat may be adaptive for most trauma sufferers (e.g. by helping victims of battery avoid potentially dangerous situations), this is not the case for victims of PTSD. They continue to function in a “survival mode,” even when the threat has been removed. These individuals show a narrowed attention focus, constantly scanning the world for threatening information.
At a biological level, excessive fear arousal in the brain results in the production of toxic neurotransmitters, which impair the functioning of the hippocampus.
This is the brain structure responsible for memory synthesis and recall.
The hippocampus stores information about fear relevant stimuli and functions as a reservoir for rapid recall of the individual’s adaptive response choices.
When healthy, this limbic brain-structure serves as the biological template for the victim to ultimately revisit and process traumatic memories in a constructive way.
This structure can only maintain its resilience when a particular traumatic event is of manageable intensity and duration.
Failing this, continued arousal and stimulation by stress-produced neurotoxins shuts down this integrative function, preventing adaptive responses and the consolidation of the trauma events into a coherent narrative.
The neurobiology and functional role of the hippocampus in fear and trauma is complex. This will be discussed in a future article, titled “What Happens to the Brain in PTSD?”
Suffice it at this point to mention that an activated state of threat arousal overwhelms the victim’s ability to “self-soothe” and remain “anchored” and “mindful.” This will prevent the victim from accessing and reprocessing traumatic material.
Avoidance
It is easy to understand why any person would flee from a direct threat or even a “threat association” for the sake of self-preservation.
Avoidance behaviors have the effect of terminating the unpleasant feeling of fear or dread, and represent the victim’s ways of learning how to escape unbearable emotional pain.
The school of Cognitive Behavioral Therapy often attributes this self-protecting response as an example of “instrumental learning.”
Trauma victims sometimes engage in behaviors that shield them from exposure to “trauma triggers,” thereby constricting their range of activities.
Victims of trauma are able to regulate their arousal levels through avoidance behaviors, exchanging “creative engagement” of the world, where they are “rewarded” by isolation instead of participation.
In other words, through the “avoidance defense” some trauma victims can continue their lives in a limited way by avoiding activities, thoughts, and emotions.
“Avoidance” allows the victim respite from painful memories by taking flight from all external trauma triggers.
People tend to avoid not only what they perceive as potential external threats, but also recoil from experiencing painful affects and memories, which are internal.
Paralleling this external/internal distinction of stimuli, the avoidance mechanism may have both unwanted external and internal consequences:
- Externally, it deprives the victim of experiencing the joy of “creative engagement” in the world.
- Internally, it narrows the victim’s full range of emotional experiences.
When stressful over-arousal persists, so does the avoidance response. This situation sets up a pathological dichotomy. On the one hand, if a person’s inhibitory control is not strong enough then “flashbacks” and “arousal” emerge. On the other hand, if inhibitory mechanisms over-assert themselves then avoidance symptoms dominate the victim’s handicap.
For patients with PTSD, psychiatric professionals now believe that to extinguish fear and over-arousal, the patients must fully recount their trauma story, i.e. they must communicate all components of their “trauma narrative” to themselves. The role of therapist is not only to help weave that narrative, but to provide both the empathic and didactic needs that are unique in each victim.
When the “avoidance defense” is active, it helps people ward off frightening memory fragments and painful affects, but at the same time allows “unprocessed” trauma-fragments and painful affects to simmer in the unconscious.
This process of “sealing-off” also contributes to a more chronic course PTSD if survivors live trapped within the narrow tunnel of hypervigilance and retreat.
The goals of trauma-recovery therefore have to include the return of personal sense of safety, as well as creative re-engagement of one`s social environment.
Trauma has a way of disconnecting victims from a previously safe holding-environment.
Attachment is a concept that arises not only in developmental psychology.
When there were attacks on the transit-systems in London and Madrid, cell-phone outages heightened stress-reactions.
Following natural disasters, the frequency of PTSD correlates with “displacement”.