Symptoms of Psychological Trauma

October 21st, 2010

“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 following chronic traumas, such as extended captivity or child abuse (which we call “Type II” traumas). 

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:

1. Dissociation is an automatic response to an overwhelming feeling.

2. Dissociation is an experience where a person becomes unconsciously removed from the present environment.

3. Dissociation is usually triggered by fear and allows the person to escape unbearable emotional pain.

4. To an external observer, individuals appear emotionally “shut down” and disconnected.

5. 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 reestablished following a trauma, 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 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. 

It is the memory structure that 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 trauma 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 of the role of the hippocampus in fear and trauma will further be discussed in an 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. 

For this reason, victims of chronic trauma (such as deprivation and abuse) may appear to others as being emotionally distant, restricted, or absent.

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 the therapist. 

When the “avoidance defense” is active, it helps people ward off frightening memory fragments and painful affects, but at the same time, it allows these fragments and painful affects to simmer in the unconscious.

This process contributes to the chronic nature of PTSD.

Issues With Power Failure or Submission?

Predatory behavior is played out both interpersonally and in the global arena.

True predators are easily able to outwit both the victim-to-be, as well as the negligent caretaker.

Throughout life, if most of your relationships were abusive, then your ability to relate to others would be within a narrow range of expected outcomes. All new relationships would likely follow a narrow focus of appeasement and obedience. You may become confined in relationships to giving up all of your rights and self-dignity in order to remain attached.

In fact, your abuse generated survival tactics may be maladaptive in the larger world. You may not feel entitled to self-regard, respect, and affection. You may continue to be abused by authority figures, and lack the skills to identify or free yourself from this negative attachment to others. If you are a woman, for example, you may find men to be sexually exploitative or degrading, yet you cannot be assertive or disrupt your participation in such relationships. The notion of escape overwhelms you with fear. You cannot express your personal rights for fear of retaliation.

You cannot perceive an alternative way to move beyond this narrow script.

In general, you may feel that your relationships lack spontaneity and fluidity. You cannot articulate your goals or make life choices until you transcend your recurring trauma narrative. You have been robbed of the opportunity to enjoy the full landscape of social freedom.

Confronting these maladaptive self-schemas and reclaiming self-agency is a vital component in the recovery of complex trauma, and will be published in an article discussing the treatment of complex trauma.

Negative Interpersonal Schemas

As we grow up from infancy, each of us forms mental pictures, “templates,” or “models” of relationships with others, which I refer to as an “interpersonal schemas.” 

They are built primarily by our early relationships with parents or other caretakers, and these interpersonal memory templates will influence the dynamics of our future relationships with others.

Victims of interpersonal abuse usually have negative interpersonal schemas that they carry over into their lives as they grow older, and tend to reenact. 

Eventually those individuals, abused during childhood, tend to relive the traumatic events in their adult lives.

According to the school of “Cognitive Therapy,” abuse schemas subsequently sabotage all interpersonal relationships. 

The victim’s schemas will later translate into miserable or dysfunctional relationships, and such individuals live in a world where to be “attached” means to be “abused.”

The basic elements of the abuse-generated schema are the following:

  • Children have a normal instinct to seek attachment and comfort, even from bad caregivers.
  • Models learned within the context of traumatic relationships become programmed into the brain and are called “interpersonal schemas.”
  • These schemas guide subsequent expectations and behaviors in future interpersonal situations.
  • Childhood abuse distorts and disrupts the formation of healthy schemas.
  • Abused or neglected children carry these distorted schemas into adulthood.
  • These schemas might continue to influence your experiences and feelings about relationships and events throughout your life.
  • They can inadvertently result in patterns of repeated negative relationships.
  • You may be easily exploited or feel helpless to stand up against predators.
  • Such schemas have to be reshaped in recovery.

Identifying and changing unhealthy relationship patterns are central to the reversal and disruption of these abusive patterns.

Such patterns have to be replaced by the victim’s capacity to feel safe, confident, and empowered in all relationships. 

The achievement of this goal frees the individual from the compulsion to “act out” past traumas in the present.

Prolonged Trauma and Cognition

During the Cold War, individuals living under Soviet rule would have to be on constant guard against “thought police.”

Children were indoctrinated in school to inform authorities if their parents spoke critically or questioningly against “the State,” even within the privacy of their home.

In political tyranny, rulers routinely use propaganda and intimidation to “dumb down” the masses. In order to keep group members obedient, political tyrants and even cult leaders prefer to project the image of “being right” and, hence, in charge.

A common methodology of creating a culture of obedience and capitulation is via the fabrication of simplistic ideologies.

This form of interpersonal abuse would fall under the title of “political terrorism.” It is more likely to thrive under conditions of fear and confusion.

The scourge of modern terrorism is built on a paradigm of creating fear and confusion, constellating archetypal sentiments, and offering ideological remedies.

The Stockholm Syndrome

The concept of the “Stockholm syndrome” began on August 23, 1973, when Jan Olsson began a bank robbery that would forever transform the spectrum of how the world would view the outcome of hostage situations. 

It started with the storming of a local Kredit Bank in downtown Stockholm, Sweden, and the shooting of the police officers who had gone in after Olsson. 

With this action, a six-day ordeal and hostage situation known as the Norrmalmstorg Robbery began. 

Three women and one man were confined to a small room, fighting to survive.

The four hostages were taken into the bank’s vault. Dynamite was strapped to them, and they were rigged to traps that would kill the hostages regardless of any rescue attempts. 

Yet when these captives were released, they had more sympathy for their captors than the police who had rescued them – and went so far as to publicly decry their own rescue. 

Two of the hostages became friends with the captors, establishing a fund to help pay for their defense fees accrued through the trial. They continue to support their captors against the police even today. 

The psychologist Nils Bejerot named the captives’ attachment towards their abusers the "Stockholm Syndrome."

While the phenomenon of “emotional bonding" between hostages and their captors had been familiar in psychological circles, the use of the term "Stockholm syndrome" became popularized following the publicity of two more high profile hostage cases: Patricia Hearst and Elizabeth Smart. Both cases involve the kidnapping of a woman to pursue the ideals of their captors. 

In the case of Elizabeth Smart, at the young age of fourteen, Smart’s instincts of survival and protection produced the development of a strong bond between Brian Mitchell and herself, resulting in intense Stockholm syndrome. 

This paradoxical sense of loyalty is exemplified by her behavior in the willful obstruction of rescue attempts by family and law enforcement.

Only three days after her kidnapping, Smart had heard her uncle searching and calling for her, not far from her hidden location, but did not call out or attempt to draw attention to herself. 

The pervasive resistance to be rescued dominated the entire nine months during which she was kept hostage. 

During her captivity, and living under constant threat, Smart’s personal will broke down. This allowed a relationship of affection to develop towards her captor to the point where she even adopted, as her own, the propaganda presented to her by her captor. 

Unlike Hearst, Smart did not speak out against her captor once she returned to regular life. 

Despite her family’s anger and disbelief, she remained silent about her relationship with Brian Mitchell during the nine months in which she remained his hostage, and was never defensive about her choice to avoid seeking rescue.   

The Stockholm syndrome refers to the unique bond of loyalty established between a hostage and his or her captor occurring within the dynamic of the victim’s absolute dependence upon the predator.

This unique attachment established between the victim and captor evolves from the exclusive dependence by the former on the latter.

In exchange for the restricted life granted by the captor, these victims are willing to adopt a false reality in which no harm can come to them.

In this apparent act of self-deception, victims of Stockholm syndrome believe that their irrational empathy for their captors and their ideologies will protect them. 

While the psychological dynamics dominating subservient bonding patterns have been previously conducted among abused children and women, victims of incest, cult members, mistreated prisoners of war, and criminal hostage situations, on a more global scale it has also occurred under Socialist dictatorships such as the Soviet Union, North Korea and Iran. 

In this fashion (through a combination of threat, isolation, and propaganda), a political tyranny has been asserted over the collective consciousness of large populations inducted into the mythical ideologies of their masters.

When entire communities lose their power of critical thinking, there is nothing to protect them from the exploitations of their leaders.

Trauma and Emotional Dysregulation

Emotional regulation refers to our capacity to tolerate all kinds of emotional states while feeling comfortable in one’s own skin and positively engaged in life. 

This requires the capacity to soothe oneself, while staying connected with one’s environment.

Victims of severe or prolonged psychological trauma, however, are more likely to feel they are living in a world dominated by internal emotional turbulence or dysregulation.

Abused children are more likely to feel constantly negative, and are more easily upset by trivial events. 

Since abuse victims lack the capacity to neutralize unpleasant feelings or “self-soothe,” they are prone to erupt in the form of angry outbursts. 

When triggered, anger or rage can be displaced towards oneself or others who may have set off a “trigger.”

Alternatively, victims may escape overwhelming distress by numbing themselves with alcohol or illicit drugs, or engaging in other self-injurious behaviors such as binging or self-mutilating.

Effective emotional regulation contributes to more fulfilling relationships, work-effectiveness, and parenting. 

Strategies for regulating emotions are learned throughout development, but are primarily embedded in early development by our parents or other caretakers.

Abused children often report parents being unable to respond effectively to their needs, as well as being unable to regulate their own emotions.

Good parenting involves a parent correctly identifying and validating a child’s experience. This is sometimes referred to as a “mirroring response.” When children feel protected, they are more successfully able to learn effective coping strategies, both cognitively (“everything will be all right”) and behaviorally (such as eliciting social support).

Healthy maturation allows one to face negative emotions in relationships by holding onto good internalized objects (such as parents) which have a soothing and containing effect.

When this capacity is lacking because of early neglect or abuse, victims are more likely to continuously re-experience and reenact their early abuses without any emotional safety buffers.

The neurobiological underpinning of mood dysregulation appears to be driven by the loss of hippocampal volume, particularly in the left-brain, during prolonged trauma. This results in the accumulation of cytotoxic levels of glucocorticoids and glutamate.

The hippocampus and amygdala are structures in the limbic brain that are respectively responsible for the restraint or activation of the Hypothalamic-Pituitary-Adrenal Axis.

Through using Magnetic Resonance Spectroscopy and other functional imaging techniques, it is now thought that the right hippocampus mediates unpleasant moods and subjective experiences, which include feeling endangered and becoming hypergilant.

The left hippocampus, in contrast, mediates a sense of comfort and well-being.

The fact that trauma appears to cause more shrinkage on the left has a compounding result of more unpleasant feelings, as well as excessive emotional arousal.

Somatic Symptoms of Trauma

Rothschild describes how the body remembers psychological trauma.

She explains that while one experiences trauma emotionally, it is interpreted cognitively, and experienced physically (The Body Remembers: The Psychophysiology of Trauma. W.W. Norton, 2000).

The central nervous system (CNS) stores trauma memories somatically.

In other words, the emotions connected to a trauma may be carried in somatic memory storage. Therefore, the body can remember a trauma that the conscious mind does not.

It is interesting to note the early association between trauma and physical ailments by Freud and Janet.

The early psychoanalysts often identified victims of childhood abuse (sexual molestation in particular) as presenting frequently with symptoms of chronic pain, digestive symptoms, and sexual symptoms.

Other common symptoms associated with an overestimated autonomic nervous system include insomnia, fatigue, fibromyalgia, headaches, and irritable bowel syndrome.

Sometimes psychogenic-induced symptoms are referred to as “conversion symptoms.” The theory behind this phenomenon is dissociation, whereby unbearable psychological pain is “split off” from consciousness and “parks itself” in the victim’s body organs.

Trauma recollections can then function as triggers to elicit pain, allergic hives, or menstrual pain or irregularities, depending on the nature of the trauma and corresponding trigger.

In addition, since PTSD causes prolonged activation of stress systems, PTSD patients may be at risk for cardiovascular disease resulting from increased platelet stickiness and hypercoagulability.”

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