PTSD - History and Terminology

August 31st, 2010

Post Traumatic Stress Disorder (PTSD)

In the early versions of psychiatric classifications, trauma literature was dominated by combat trauma reported in World War II. Many of the symptoms that we today would call “PTSD” were captured by terms such as “combat neurosis” or “war neurosis.”

In fact, the DSM-II reflected the model proposed by Kardiner and Spiegel in their manuscript “War, Stress, and Neurotic Illness.” The manuscript was later revised and published under the title “The Traumatic Neurosis of War” (New York: Hoeber, 1947).

In the middle of the 1970’s, “Post Traumatic Stress Disorder” (otherwise referred to as “PTSD”) was first proposed for inclusion in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III).

By the time DSM-III was first publicized in 1980, sufficient data was available to justify the PTSD construct and thereby replace the “Traumatic Neurosis” construct of DSM-II.

Since then, the lay community as well as physicians tended to conform to a reductionist terminology, attempting to lump all traumatic conditions into the PTSD construct.

Despite the attempts of experts to widen the enduring effects of trauma beyond the narrow construct of post-traumatic stress disorder, “PTSD” remains as the only construct for persistent, unresolved trauma and is categorized in the DSM IV as an “Anxiety Disorder.”

Several factors will influence the outcome of a particular trauma:

The trauma itself varies in duration and intensity.

Survivors vary in age, temperament, and coping skills.

When someone is the victim of a serious, usually unexpected, trauma, external rescue responses need to be rapid and robust. This is very important for psychological damage control.

In contrast, external rescue resources sometimes fail as a result of negligence, indifference or even collusion by appointed caretakers.

There are social, legal, and political factors that can either deter or facilitate the likelihood of the occurrence of a traumatic event.

There are numerous reports of domestic and political terrorism where allocated “caretakers” ignored clear warning signs. These include mandated reporters such as physicians, nurses, social workers, school teachers, judges, and intelligence agencies.

There is an abundance of case studies illustrating instances of both domestic and political violence that could have been prevented by diligent “caretaking.”

Examples of caretaker negligence would include the 9/11 attacks and the shootings at Fort Hood.

In both instances, while suspicious behavior was reported by the terrorists and intelligence reports were on file, the definitive interventions needed to be taken by law enforcement to protect its citizens were not.

The most benign responses reported by trauma survivors would fall under the umbrella of “Trauma Related Symptoms.”

In such cases, victims may experience worry, apprehension, and sleep disturbance. But when these victims receive or actively pursue rescue resources, even in the form of simple social bonding and “ventilation,” these symptoms (despite appearing quite disruptive) tend to be benign and self-limiting.

When the trauma is of higher intensity and duration, and rescue services fail, victims are much more likely to develop the more serious trauma induced condition of “Acute Stress Disorder,” viewed by experts as a harbinger of PTSD.

This explains how victims of life-altering traumatic events may show little recollection of certain details of the traumatic event. Some victims have no recollection of the entire event.

Because of the brain’s inability to successfully “process” or “resolve” a serious psychological trauma, elements of the trauma are left to fester or “ferment.”

According to Donald Kalsched from the Carl Jung Institute, if left unchecked this “trauma complex” becomes autonomous and “self-traumatizing” (The Inner World of Trauma. Brunner-Routledge, 1996).

Neurobiologists explain this phenomenon as “limbic kindling.”

When a trauma is not “put to rest,” stress circuits in the limbic brain, sympathetic nervous system, and adrenal glands remain “primed” to be reactivated as “alert-systems” to further trauma triggers.

Patients with PTSD are constantly vigilant to the perception of threat   (McNally, et al. “Selective Processing of Threat Cues.” J Abnormal Psych, 1990).

Trauma generated failure of synthetic brain function leads to the “over-memorization” of fragmented trauma recollections in the form of vivid “unprocessed” images and sensations.

In contrast, victims who cope better with trauma are more able to formulate a coherent, less emotional representational abstract of the event (Foa. 1995).

This is because PTSD victims have slowing and inhibition of verbal coding.

At a biological level, neurotransmitters generated from overwhelming stress exert a toxic effect on the hippocampus. This inhibits the “processing” function that is required to transform sensory-dominated trauma recollections into a rational coherent trauma narrative (Sapolsky. Science, 1996).

Put differently, one could say that in PTSD, the “emotional brain” assumes dominance over the “rational brain.”

The reason appears to be the failure of the hippocampus to create abstract verbal representations that inhibit the brain’s access to sensory perceptual recollections of the traumatic event (Conway and Pearce. Psychological Review, 2000).

Because of fear sensitization, heightened threat sensation, and failed verbal encoding, PTSD victims continue to live their lives within a narrow “fear paradigm” (Brewin. 1996).

Avoidance” refers to a victim’s flight from any thoughts or feelings that could serve as trauma reminders. The “avoidance defense” also shelters the victim from engaging in a world dominated by external trauma triggers.

Activation of “negative feedback loops” and other “brake systems” drives avoidance behaviors and serves a defensive function, but comes at a price.

Victims with dominant avoidance symptoms cannot creatively reengage socially or into the workplace (Goleman, 1995).

Over-arousal” is the result of persistent over-activation of central stress circuits such as the “sympathetic nervous system.” Once this occurs, the individual will continuously scan the environment to identify danger signals which subsequently reinforce the perception of danger, hence maintaining the state of “alert.”

Persistence of the three aforementioned domains of symptoms for a month or longer constitute the core elements of PTSD.

Further downstream effects of unremitting stress include a multitude of somatic systems including chronic pain, immune function, and chronic wear and tear of the cardiovascular system (Uno, et al. J. Neurosci, 1989).

Victims exposed to extreme or constant danger without adequate respite continue to live as if they are still in a “war zone.”

This refers to the “over-arousal” domain of PTSD, in which even seemingly harmless triggers lead to apprehension, fright, and the wish to flee.

These survivors are stuck in the trauma of the past, unable to engage the present in a spontaneous or gratifying way.

Since the original trauma usually occurred while the victim was unprepared and vulnerable, the goal of therapeutic “unlearning” fear is to enable the victim to establish a safe haven.

From this safe haven (which might be limited to the therapist’s room or the trauma group), he or she can revisit the recollection of the trauma with the support of a “coach” (such as a professional therapist).

It is that “caretaking” function, together with emotional support, strategic advice, and immediate rescue functions from which true healing flows.

The therapeutic components involved in unlearning fear include the following:

  • Recognizing the nature of the fear responses in one’s body
  • Accepting the symptoms as an opportunity to heal
  • Identifying environmental triggers of one’s fear response
  • Knowing how to anchor oneself in the face of fear
  • Confronting one’s inaccurate perceptions of danger
  • Convincing oneself that one is safe in the present and that the trauma occurred in the past

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