Download Understanding Post Traumatic Stress Disorder (PTSD)

Understanding
Post Traumatic Stress Disorder
(PTSD)
A Guide for Individuals
Who Have Experienced Traumatic Events
Eldon Richey, M.A., MFCC
POST TRAUMATIC STRESS DISORDER
Understanding
Post Traumatic Stress Disorder
(PTSD)
A Guide for Individuals
Who Have Experienced Traumatic Events
Eldon Richey, M.A., MFCC
Family Therapy Service
ε
Haven Psychological Associates
9140 Haven Ave., Suite 120
Rancho Cucamonga, CA 91730
(909) 987-1997
© Copyright Eldon Richey, M.A., MFCC
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POST TRAUMATIC STRESS DISORDER
TABLE OF CONTENTS
Introduction ...........................................................4
Questions And Answers Regarding PTSD ........5
Diagnostic Criteria For
Post Traumatic Stress Disorder (PTSD) .........6
The Traumatic Event ............................................7
Symptom Constellation #1
Psychic Numbing, Denial, Or Avoidance .....7
Symptom Constellation #2
Reexperiencing The Trauma, Intrusion,
Or Flashbacks ....................................................8
Avoidance and Triggers.......................................9
Symptom Constellation #3
Hyperarousal Symptoms...............................10
Damage Resulting from Trauma.......................12
Physiological Responses To Trauma ................12
Community Response to Trauma Victims.......14
PTSD Is A Treatable Disorder ...........................15
About the Author................................................17
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INTRODUCTION
Over the years I have had the opportunity to assist many
individuals who have had the unfortunate occasion to be
involved in traumatic incidents. Some of these individuals
suffered from years of childhood abuse while others were
involved in a single incident such as a violent attack or
natural disaster. Whatever the cause, the response of the
body and mind to traumatic events is the same all over the
world.
Trauma causes the same physiological response among
animals as it does in humans. The deer in the woods
during hunting season is acutely aware of every noise,
movement and smell. The deer is hypervigilant due to the
damage it has witnessed that hunters inflict on animals. It’s
body is in a state of hyperarousal. It dare not relax less it
could be shot. When hunting season is over, the deer
remains hypervigilant because it does not understand that
it is suppose to be safe now. And then there is the fear of
poachers. Humans react to trauma very much like this
deer.
This booklet is designed to assist individuals suffering
from PTSD to understand the reactions that they are
having. It is also my hope that this booklet will help the
family and friends of individuals suffering from PTSD to
have an increased awareness of this problem and thus be
able to provide appropriate support.
Eldon Richey, M.A., MFCC
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QUESTIONS AND ANSWERS REGARDING PTSD
Q. Is Post Traumatic Stress a mental illness?
A. No. Post Traumatic Stress is a normal emotional and
psychological response to an abnormal or traumatic event.
Q. Who is likely to develop PTSD?
A. Anyone who is either a victim or witness to a
traumatic event can develop Post Traumatic Stress.
Individuals who have previously suffered from traumatic
events or who have poor support systems are more likely
to suffer from PTSD.
Q. Can PTSD be treated?
A. Yes! PTSD is a treatable disorder. Research has shown
that the earlier an individual reaches out for treatment the
less likely the symptoms of PTSD will linger.
Q. What can family and friends do?
A. Family and friends can be a tremendous help.
Research and common sense tells us that individuals who
have supportive and sympathetic family or friends respond
better to traumatic events. Conversely, individuals who are
without support or who refuse to open up or reach out are
at greater risk to suffer. Sometimes individuals are
ashamed to talk about incidents such as rape or incest
because they feel like they have done something to deserve
the attack. Support is critical at times like this.
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DIAGNOSTIC CRITERIA FOR
POST TRAUMATIC STRESS DISORDER (PTSD)
We think in terms of PTSD as a triad of symptoms. These
include:
1. Psychic numbing, denial, or avoidance
2. Reexperiencing the trauma, intrusion, or flashbacks
and
3. Hyperarousal symptoms.
There are however, many variations and sub-themes of
PTSD of which I shall refer to only a few.
THE TRAUMATIC EVENT
Before one can be diagnosed with PTSD there has to be a
traumatic event(s). Trauma means severe wounding. The
question of what constitutes trauma in the context of PTSD
requires cautious consideration. In medicine, trauma has
two meanings. The first is that an organ of the body has
been suddenly damaged by a force so great that the body’s
natural protections (skin, skull, and so on) were unable to
prevent injury. The second meaning refers to injuries in
which the body’s natural healing abilities are insufficient to
mend the wound without assistance. Trauma goes beyond
the ordinary bumps and bruises of everyday living.
At the psychological level, trauma refers to the severe
wounding of the emotions, damage to beliefs about one’s
self and the world, one's dignity, and one's sense of
security. The assault on one's psyche is so profound that
normal ways of thinking and feeling and the usual ways
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the individual has of warding off stress in the past are now
inadequate.
SYMPTOM CONSTELLATION #1
Psychic Numbing, Denial, Or Avoidance
What happens when a person enters a state of psychic
numbing is similar to what transpires when the human
body is injured. The body is able to discharge a natural
anesthetic which allows people to take care of their
wounds and to do whatever is necessary to protect
themselves from further injury. For example, due to this
natural anesthetic, severely wounded soldiers have been
able to continue fighting to protect themselves. Similarly,
abused women and battered children sometimes report
experiencing minimal pain from their injuries during or
immediately after being attacked.
In a similar way the psyche in self-protection can numb
itself against the onslaughts of unbearable emotional pain.
During the traumatic event it is often essential for the
victim to put aside his or her feelings since at the time
those emotions could have been overwhelming. For
example, if a rape victim began to connect with her feelings
while being assaulted, she would be less able to estimate
the dangerousness of the situation or figure out how to
escape or minimize the damage that was happening at the
time. This deadening, or shutting off of emotions is called
“psychic numbing.” It is a central feature of PTSD.
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SYMPTOM CONSTELLATION #2
Reexperiencing The Trauma, Intrusion, Or Flashbacks
Another fundamental dynamic of PTSD is a cycle of
reexperiencing the trauma, followed by attempts to bury
the memories and associated feelings, followed by another
round of intrusive memories. This cycle of intrusive recall
followed by avoidance has a biological component which I
shall refer to later. We refer to this part of the triad of
symptoms as intrusion because the intrusive thoughts are
exactly that, they are intrusive. The thoughts invade the
mind and they are truly outside of the individual’s ability
to control them. The thoughts and associated feelings are
not wanted because they are so painful. It is similar to
when one drives past a horrific auto accident and sees a
bloody mangled body. One will immediately try to put
that image out of their mind and not think about it, only to
have the image pop back into there memory a few miles
down the road.
A flashback is very similar to the above example. It is a
sudden vivid recollection or reexperiencing of the
traumatic event, followed by a strong emotion. Individuals
who are having flashbacks are often reluctant to
acknowledge them to other people because they are afraid
of sounding crazy. Flashbacks are not indications that the
individual is psychotic or on the verge of a psychotic break.
It merely means that the individual is allowing the
traumatic event(s) to come into consciousness. The
therapeutic hope is that the individual will be able to
process the event(s) so that they will come under conscious
control.
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Avoidance and Triggers
During the times the trauma is re-experienced, individuals
often have some of the feelings associated with the original
trauma(s) that were not felt, or only partially felt, due to
the psychic numbing which attended the original trauma.
These feelings of sadness, fear, sorrow, anger, and guilt or
sense of shame may shake the individual to the core. In
response to the power of these feelings the victim may shut
down, just as he or she did during the traumatic event.
Shutting down serves as a means of reducing the intensity
of the affect generated by the trauma.
Having flashbacks, being in a state of hyper-alertness,
while experiencing the opposite feelings of being in a state
of psychic numbing, are extremely painful. These are also
conditions that can be easily misunderstood and
misinterpreted by the individual’s family members,
friends, associates, co-workers, medical personnel, social
workers, clergy and the legal system. In order to avoid
possible social rejection, PTSD-afflicted individuals often
begin to avoid situations that they have found bring forth
(or that they fear will bring forth) either symptoms of
numbing or hyper-alertness. This avoidance may lead to
various degrees of withdrawal from society. For example,
rape survivors may stay inside their homes at night. Flood
survivors may avoid water-related activities, and car or
airplane accident survivors may limit their travel.
Similarly, crime victims may avoid the site of the crime or
places that remind them of the crime. Things such as a
siren may bring back painful memories and images which
are sudden and overwhelming at the time.
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Every trauma survivor has his or her own set of triggers.
The triggers can be anything that can bring back memories
of the trauma. Avoiding trigger situations makes perfect
sense to individuals who are trying to prevent a resurgence
of their PTSD symptoms. However, this avoidance can
generate yet another set of problems. For this reason, as
with flashbacks PTSD sufferers need to be educated as to
the purpose of their numbing states. Otherwise, they may
begin to feel "out of control" of themselves and
subsequently either berate themselves, lash out at others, or
isolate from others.
SYMPTOM CONSTELLATION #3
Hyperarousal Symptoms
Trauma victims experience symptoms of increased
arousal which were not present before the trauma. These
hyperarousal symptoms include:
1. difficulty falling or staying asleep,
2. irritability or outbursts of anger,
3. difficulty concentrating,
4. hypervigilance,
5. exaggerated startle response and
6. Physical complaints such as abdominal distress, hot
flashes or chills, frequent urination and trouble
swallowing.
Trauma involves life-threatening situations, which
naturally gives rise to feelings of terror and anxiety. There
may also be anger at the circumstances causing the
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devastation. All of these trauma generated emotions, fear,
anxiety, and anger are emotions that have strong
physiological components and can actually change the
body’s chemistry.
In a dangerous situation, the adrenal glands begin to
pump either adrenaline or noradrenaline into the body.
Adrenaline causes a state of hyper-alertness in which the
heart rate, blood pressure, muscle tension, and blood sugar
levels increase. The pupils dilate and the blood flow to the
arms and legs decreases. A little known fact is that even the
hair on the back of one’s neck will stand up on end during
periods of fear and stress.
Alternatively, if the adrenals push noradrenaline into the
system, the individual may have a freeze reaction. Some
PTSD sufferers have described their freeze reactions as
moving or thinking in slow motion. Others find themselves
temporarily unable to move at all. Even if a person freezes,
he or she will most likely be experiencing some of the other
symptoms of Hyperarousal.
The persistent or continuous Hyperarousal symptoms
experienced by those with Chronic PTSD are caused by
continuous adrenaline surges analogous to the one they
experienced during the original traumatic event(s). This
continuous surge is most likely to occur when the
individual is continuously exposed to trigger events, or
constant reminders of the original traumatic event(s).
The pain of being a trauma survivor is not limited to
coping with the traumatic incident or series of incidents.
The major challenge is understanding and coping with
those current life situations that, consciously or
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unconsciously, remind them of the trauma. Almost
automatically, survivors may find themselves either overreacting or under-reacting to these situations. Either way,
their responses are usually socially inappropriate and
personally problematic. Indeed, many trauma survivors
come to therapy because they want to change some of their
reaction patterns.
Damage Resulting from Trauma
Trauma causes damage. In my workshops on Disaster
Psychology I talk about the various things that individual’s
are robbed of. These things vary form individual to
individual. They, however are vital to understanding the
trauma victim and hold the keys to recovery. For example,
one can be robbed of a sense of safety, a belief that one can
trust others or trust in one’s own judgment.
The self-esteem of many trauma survivors is damaged not
only because they have been stigmatized by society,
friends, or family, but because they greatly fear and
misunderstand their own trauma-related responses to
current events. When these people do not understand the
causes of their reactions, they may feel not only like
failures but like social lepers or as if they are emotionally
abnormal.
Physiological Responses To Trauma
According to Dr. Bessel van der Kolk, a doctor who has
written several articles on the physiological responses to
trauma, when individuals come under conditions of severe
stress there is an initial massive secretion of certain
neurotransmitters. However, if the stress is prolonged,
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there is a depletion of these neurotransmitters, which
occurs presumably because utilization exceeds synthesis.
Some of the major neurotransmitters that tend to be
depleted as a result of continuous, intense and traumatic
stress are norepinephrine (noradrenaline), dopamine,
serotonin, endogenous opioids, and catecholamines. These
neurotransmitters are significant because they serve as
emotional buffers and help individuals regulate the
intensity of their feelings. Thus when these
neurotransmitters are depleted, the trauma survivor is
subject not only to clinical depression, but to difficulties in
modulating emotions, leading to mood swings, explosive
outbursts, startle response, and hyperactivity to subsequent
stress. Another possible effect is the development of
"learned helplessness" syndrome: diminished motivation,
clinical depression, and a decline in optimal functioning.
According to Dr. van der Kolk depletion of some
neurotransmitters can result in over-dependence on other
people, feelings of "I can't make it without you," or in the
opposite, an unrealistically independent or counterdependent stance of "I don't need anyone; I can make it on
my own".
Repetitive trauma appears to amplify and generalize the
physiologic symptoms of PTSD. Chronically traumatized
people are hypervigilant, anxious and agitated, without
any recognizable baseline state of calm or comfort. Over
time, they begin to complain, not only of insomnia, startle
reactions and agitation, but also of numerous other somatic
symptoms. Tension headaches, gastrointestinal
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disturbances, and abdominal, back, or pelvic pain are
extremely common.
Animal research has demonstrated that there is a
physiological link to PTSD and has confirmed observations
by clinicians of some of the basic characteristics of PTSD.
For example; the tendency to react to relatively minor
stimuli as if the trauma were happening all over again as
well as the startle response that is prevalent for victims of
war, crime and natural disasters such as earthquakes. We
do not fault these victims for jumping when a door slams.
The jump occurs before the person has any conscious
understanding that it is only a door. If they had time to
think about it they would not have jumped. The reaction
proceeds conscious thought. It is outside of the individuals
ability to control it at the moment. It takes time and
desensitization to regain control over exaggerated startle
response.
COMMUNITY RESPONSE TO TRAUMA VICTIMS
Much has been said lately in the news and on talk shows
about traumatic events. It appears that everybody is a self
appointed expert and there is no shortage of people willing
to cathart about traumatic events on national TV talk
shows. In spite of this sudden awareness of abuse and
trauma, I am not convinced that the media attention has
brought about an appropriate understanding of PTSD.
Neither am I convinced that in spite of our new found
fascination with abuse and trauma that our society is ready
to deal with trauma when confronted with it personally.
Victims are still being blamed for the abuse that occurred
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to them. This reversal of blame placing is common and is
unfortunate.
PTSD, especially Chronic PTSD is a disorder which is
often misunderstood by inexperienced clinicians and other
professionals. It is not uncommon for patients with
Chronic PTSD to be misdiagnosed because PTSD can
mimic all of the personality disorders and can appear as a
psychotic disintegration during periods of high stress.
Victims of traumatic events often find themselves in a
downward spiral of re-victimization as they confront new
events in there lives. There difficulty in assessing stressful
situations brings about ether over-reactions or withdrawal.
This makes it difficult for these trauma victims to respond
appropriately. These reactions can pull further
misunderstandings and rejection from those who are in a
position to help. As I pointed out earlier, it is often the case,
that it is not the past traumatic event(s) that is most
difficult for trauma victims; it is “coping” with the current
day to day triggers of the traumatic memories.
PTSD IS A TREATABLE DISORDER
Treatment needs to be individualized. For many a few
sessions may be all that is required. For others it may take
longer for the healing process to take place. Treatment can
come in the form of:
1. INDIVIDUAL THERAPY: Survivors resolve
problems with the help of a trained therapist. Ideally
the treatment includes training in desensitization
techniques, and coping skills. Learning to cope with
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the current day to day triggers of the traumatic event
is essential for recovery.
2. FAMILY THERAPY: Members of the family join in
the process of recovery. Guidance is given to family
members about the recovery process so that they
may provide appropriate support.
3. GROUP THERAPY: Individuals join a group of
individuals either in Group Therapy or in a Critical
Incident Stress Debriefing Group. Understanding
how other people are coping who have gone
through the same or similar traumatic event(s) can
provide a great sense of relief for many people.
4. DRUG THERAPY: Some symptoms of PTSD can be
treated with prescription drugs. This should be done
under the guidance of a Psychiatrist knowledgeable
of the symptoms of PTSD. Pharmacological (drug)
therapy can assist in the return of the body to its
normal state prior to the traumatic event(s).
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ABOUT THE AUTHOR
ELDON RICHEY, M.A. has been a Licensed Marriage,
Family and Child Counselor since 1976. He has been in
private practice in Rancho Cucamonga, California since
1978 where he is director of Family Therapy Service.
Mr. Richey is responsible for the formation of the Disaster
Response Team, a volunteer organization of clinicians who
respond to traumatic events on short notice. He is coauthor of “The Disaster Response Team Manual: A Manual for
Clinicians”. He has led numerous seminars on Post
Traumatic Stress and Disaster Psychology and has trained
hundreds of clinicians in Southern California as well as
chaplains and psychologists prior to their departure for
Desert Storm in Iraq. He has also presented at the
International Society of Traumatic Stress Studies, an
international organization of scholars and clinicians
pursuing the study of trauma and its effects on human
beings.
As director of the Disaster Response Team he was
responsible for triage and disaster response for several
disasters including the 1991 Palm Springs Girl Scout Bus
Tragedy. He recieved a letter of commendation from
Mayor Tom Bradley for “... providing comprehensive and
innovative programs dealing with emergency
psychological services for people traumatized by violent
acts and natural disasters.”
Mr. Richey specializes in working with both Acute and
Chronic Post Traumatic Stress Disorder. He is adept in the
use of desensitization techniques to deal with dissociative
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episodes, intrusive memories, flashbacks, and nightmares
associated with psychic trauma. He has extensive
experience using desensitization techniques to decrease
present anxieties and phobias. Mr. Richey has used
desensitization procedures in thousands of treatment
sessions with patients having suffered rape, sexual
molestation, severe child abuse, physical assault and with
Vietnam Veterans dealing with Chronic PTSD.
Mr. Richey has extensive experience in working with
addiction and with the family members of individuals who
are addicted. He has conducted group therapy at various
psychiatric hospitals, on both the adolescent and adult
units from 1979 to 1995.
Mr. Richey authored the “Weekend Family Program”
which has been held at psychiatirc hospitals. Mr. Richey
wrote the “Weekend Family Program Parenting Manual”
which is aimed at the special needs of parents who have
children or adolescents with serious problems.
Mr. Richey works in tandem with his wife Enid Richey,
Ph.D. who is a Licensed Psychologist and Licensed
Marriage, Family and Child Counselor. With this team
approach Mr. Richey believes that they can preserve the
integrity of patients who need a female therapist with
which to discuss sexual abuse issues.
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