PTSD & Politics

What is Shellshock?

Post-traumatic stress is a disorder, that automatically implies a chaotic state of being.  The experiences that tend to induce PTSD include combat trauma, crimes, rape, grief, kidnapping, natural disasters, accidents, torture, and imprisonment.  Predisposition to dissociation can arise in violent family environments. 

Those with PTSD become hypervigilant and hyperreactive to environmental threat, real or imagined.  The frozen traumatic syndrome is ever present and unchanging.  Emotionally, it is as if it keeps on happenING.  State-related learning and memory encoding help maintain the trance-like steady state.  Depression, shame, anxiety, substance abuse, over-medication and survivor guilt are complications.

The nucleus of the disorder is a physioneurosis, somatization, depersonalization, and dissociation.  Psychosomatic symptoms are expressions of the dissociation.  Therapy proceeds by facilitating information transduction between them. Sufferers exhibit poor impulse control and explosive aggressive reactions.  There are persistent and profound alterations in stress hormone secretions and immune function. 

Therefore, PTSD is a toxic biochemical cascade that prevents homeostasis or recalibration of the whole person. They cannot “stand down.” Integration of traumatic memories proceeds by verbal and nonverbal means in therapy.  However, time does not heal all wounds. 

Different treatments are needed at different stages of posttraumatic adaptation.  Consciousness restructuring offers a way of restructuring the frozen structure of this disorder at the most fundamental level, in the sensory terms in which it is encoded. The healing processing and imagery must come from within the individual, not be imposed or mandated from without.

PART II: WHAT IS POSTTRAUMATIC STRESS DISORDER?

The development of a chronic trauma-based disorder is qualitatively different from simple exaggeration of the normal stress response.  In those affected, a cascade of biobehavioral changes leads far beyond simple conditioning.  Symptoms are intrusive and lead to hyperarousal and/or avoidant behavior.  Frightening and vivid flashbacks are the most striking phenomenon.   Prime victimization comes from memories of the event, rather than simply the event itself.  Development of PTSD depends on personality and genetic make up, and on whether or not the trauma was expected.  Prolonged exposure to severe trauma may cause permanent psychological scars.

Dissociation at the moment of the trauma has been shown to be an important factor in developing full-blown PTSD.  Therefore, adults with a predisposition from childhood in chaotic, threatening, sexually abusive or violent families are at greater risk.  Dissociation is characterized by feelings of detachment, estrangement, depersonalization, an unusual sense of one’s own reality, being an outside observer of one’s own actions and body, feeling like an automaton, or as if in a dream.  Ability to feel emotions of any type, (especially those associated with intimacy, tenderness, sexuality), is markedly decreased, as is ability to express angry feelings.  Attacks appear like a psychological seige, therefore “bunkering” mentality prevails.

Flashbacks can be triggered by overreactions to sounds, smells, feelings, or images.  During the flashback, the person relives the traumatic event and may completely lose touch with reality, suffering through the trauma for minutes or hours at a time, believing that it is actually happening all over again.  There is activation of sensory areas of the brain during flashbacks, right-hemispheric activation, and limbic-system activation.

The psychological function of emotions is to alert us to pay attention to what is happening, so that we can take adaptive action.  Generally, we stop having an emotional response when we have realigned our expectations of what is supposed to happen with what is actually happening.  We either take action that adjusts the given situation to our expectations, or change our expectations to fit better with what is actually going on. 

But in PTSD, emotional arousal and goal-directed action are disconnected from one another because of emotional numbing.  Arousal is no longer a cue to pay attention to incoming information.  There is no gap between stimulus and response with fight-flight reactions.  They either freeze or overreact.  The emotions of fear, terror, and helplessness characterize any traumatic event, and avoidance of these feelings would seem to be the result, but chronic reenactment of the damaging event is compulsive.

Those with PTSD are more sensitive to sound intensities than average.  They are “reducers” in whom inhibitory feedback loops are activated to dampen a tonic state of hyperarousal.  They have difficulty neutralizing stimuli in the environment in order to attend to relevant tasks.  To compensate, they tend to shut down, which of course means decreased involvement in ordinary, everyday life.  Rather than reacting to the daily environment flexibly, they react to internal stimuli that are irrelevant to current demands.

Trauma effects the hormones of both brain and body creating more psychophysical stress.

Intense distress is accompanied by release of stress-responsive neurohormones which seek to mobilize the energy required to deal with the stress.  Chronic and persistent stress inhibits the effectiveness of the stress response and produces desensitization and sleep disturbances combined with hypervigilance.

Time does not heal all wounds.  Therapy allows an inner search for healing alternatives within the “deeper” state-dependent psychobiological levels until the sought-for structure is transduced into the verbal level and emerges as a new psychophysical form.  The recursive process which manifests in flashbacks and immersive rumination is facilitated, unblocked, and allowed to flow to its healing conclusion.  This creates a shift in recurrent intrusive recollections and in recurrent distressing dreams and nightmares.

CRP helps probe into the state-dependent patterns of physiology, memory, and learning that have been encoded during circumstances of stress-released epinephrine by the autonomic nervous system and related responses by the endocrine and neuropeptide systems, and their related existential meanings and sensory images.  It provides a healthier means of dissociation and reiteration leading to creative self-organization.

DIAGNOSIS OF POSTTRAUMATIC STRESS DISORDER

The diagnostic criteria for PTSD are listed in the DSM IV:

A.  The person has been exposed to a traumatic event in which both of the following were present:

    (1)  The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.

     (2)  The person’s response involved intense fear, helplessness, or horror.  Note:  In children, this may be expressed instead by disorganized or agitated behavior.

B.  The traumatic event is persistently reexperienced in one or more of these ways:

    (1)  Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions.  Note: in children, repetitive play may occur in which themes or aspects of the trauma are expressed.

     (2)  Recurrent distressing dreams of the event.  Note: in children, there may be frightening dreams without recognizable content.

     (3)  Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated).  Note: in children trauma-specific reenactment may occur.

     (4)  Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

     (5)  Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspects of the traumatic event.

C.  Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:

    (1)  Efforts to avoid thoughts, feelings, or conversations associated with the trauma.
    (2)  Efforts to avoid activities, places, or people that arouse recollections of the trauma.
    (3)  Inability to recall an important aspect of the trauma.
    (4)  Markedly diminished interest or participation in significant activities.
    (5)  Feeling of detachment or estrangement from others.
    (6)  Restricted range of affect (e.g. unable to have loving feelings).
    (7)  Sense of foreshortened future (e.g. does not expect to have a career, marriage, children, or normal life span).

D.  Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:

     (1)  Difficulty falling or staying asleep.
     (2)  Irritability or outbursts of anger.
     (3)  Difficulty concentrating.
     (4)  Hypervigilance.
     (5)  Exaggerated startle response.

WHAT CAUSES POSTTRAUMATIC STRESS DISORDER?

Any overwhelmingly stressful life situation (surgery, war, natural disaster, robbery, traumatic bereavement, torture, physical battery, accident, rape, malnutrition, etc.) that stimulates excessive arousal by the autonomic and endocrine systems can lead to the symptomology of post-traumatic stress.  State-dependent memory, learning, and behavior (SDMLB) is the essential feature of posttraumatic stress syndrome, and the many more subtle dysfunctions associated with it.  Fear-conditioning and parasynaptic cellular modulation mediates SDMLB, (Rossi, 1986).

PTSD seems to be the basic process underlying Freud’s original concept of the “traumatic neurosis” as the organic basis of psychopathology.  Therefore, the entire history of depth psychology and psychotherapy can now be understood as a prolonged clinical observation of how dissociated or state-dependent memories remain active at unconscious levels, giving rise to “complexes.”  These complexes are the source of psychological and psychosomatic problems. 

Trauma affects our capacity to regulate bodily homeostatsis.  Even years after the trauma has ceased, memories continue to dominate people’s perceptions, and affect capacity to think and make sense out of current experience.  Psychological interventions can only effect the degree of reversal of a disorder with such strong biological underpinnings.

Healing those who develop PTSD in the aftermath of overwhelming experience is a complex process, whose dynamics cannot be described like a cookbook recipe--it requires tremendous sensitivity and intuition.  Reestablishing a sense of personal safety and equilibrium is a primary goal of all treatment, and this happens within the therapeutic alliance. 

Recognition of each person’s unique situation and reactions is paramount.  It is critical that the therapist continue to take stock of the safety of the relationship and progress in achieving therapeutic goals.  Participants are encouraged to make meaning of their life experiences when they feel personally supported by their therapists.  A primary goal is to not retraumatize the person with therapies that force them to relive the original trauma in historical, rather than metaphorical or sensory terms, or compound the episodes with fallacious material.

Because traumatic memories are stored in state-dependent fashion, they are often rendered inaccessible to verbal recall for prolonged periods of time.  Because memories are dissociated, they are stored outside of ordinary awareness, and expressed in incomprehensible symptoms as physical ailments, behavioral reenactments, and vivid sensory reliving experiences.  Reenactment of the trauma in personal and social relationships is a major source of shame for the victims and is a source of ongoing tragedy.

Constricted ego functioning is a feature of all traumatized individuals.  It is even more complex when traumatization comes in childhood, because trauma early in the life cycle fundamentally affects maturation of systems in charge of regulating psychological and biological processes.  It can result in lack of emotional control, destructuve behavior against self and others (or animals), brutality (victim/victimizer), learning disabilities, somatization, dissociative problems, and distortions in concepts about self and others.

Reaction to trauma is a process of adaptation over time.  In Chaos Theory, attractors describe the characteristic behavior of a dynamical system changing over time.  Traumatic events, especially chronic events, act as “strange attractors” in consciousness which keep everything in their orbit, cycling wildly, unpredictably, but within the parameters of the attractor, reiterating the same cues over and over. Memories are embedded in all layers of psychophysical self in, what is known in Chaos Theory, as infinite nesting. 

Psychological siege describes the dominance of trauma in memory and its crucial maintenance over time.  The feeling of being constantly beseiged or barraged leads to a bunkering mentality which may be acted out, particularly in combat veterans.  Over time some people’s PTSD may become subclinical, and yet it may continue to influence their level of functioning.

PTSD is the result of complex interrelationships among psychological, biological, and social processes--one that varies depending on the maturational level of the victim, as well as the length of time for which the person was exposed to the trauma, and the source of the trauma.  Central to understanding these processes is awareness of the nature of traumatic memory and its biological substrates that lead to the dominance of the trauma in memory and to its maintenance over time.

Social cues are important for recovery -- whether people are encouraged to attend to their pain and learn from the past or cultivate a “stiff upper lip,” suppressing the profound meaning of their experience.  There is often resistance to acknowledging the trauma or depth of its impact.  Reality can profoundly and permanently alter people’s psychology and biology.  Individuals make a choice whether to examine their reactions to the trauma in order to overcome it, or ignore it and try to go on with their lives.  There is a range of reactions from acute trauma to long-term outcome.

The inner structure of the disorder overlaps catagories of dissociative disorder and stress responses.  Adjustment disorder, grief reactions, and a variety of characterological adaptations are germaine.  The interaction between external events and subjective response can vary widely, even among victims of the same trauma, based on internal processing and approach to life in general. 

Predisposition and vulnerability reflect on recovery from acute symptomology and long-term resilience.  Critical issues include the emergence of chronic patterns of adaptation, in which lack of involvement in current reality, rather than preoccupation with the past are the most pathological features.

The ways people view themselves and their world can be compounded by a host of self-destructive behaviors (e.g. suicide attempts, self-multilation, and eating disorders).  Complexity of adaptation includes both hormonal and autonomic nervous system dimensions.  This includes unusual patterns of cortisol, norepinepherine, and dopamine metabolite excretion; the role of serotonergic and opioid systems (arousal and numbing); receptor modification by processes such as kindling; and involvement of central pathways involved in the integration of perception, memory and arousal.

Traumatic memories are qualitatively different from memories of ordinary events, in that amnesia co-exists with vivid recollections.  Information processing and dissociation affect a person’s ability to perceive and integrate overwhelming experiences.  Dissociative fragmentation of the self is common, leading to shattered psyches and lives.

Trauma is particularly devastating in childhood, including traumatic bereavement.  Because of their dependence on caregivers, their incomplete biological development, and immature self-concepts and concepts of surroundings, children have unique patterns of reaction and needs for intervention.  Although they may suffer from subclinical PTSD in middle age, memories recur and come to dominate their lives as seniors.  There is generally greater lack of flexibility or capacity to repair damage with increasing age.

CONVENTIONAL TREATMENT OF PTSD

In actual practice, most clinicians use an eclectic approach, in which we must constantly reevaluate what is being accomplished.  The core symptoms of PTSD (including paranoia, intrusions, numbing, and hyperarousal), occupational disabilities, dissociative phenomena, and interpersonal problems and alienation may all need widely different approaches.  Treatment, therefore, depends in large part on clinical judgement. 

In order to respond to current life and reach their fullest potential, people need to regain control over their emotional responses. It helps to place the trauma in the larger perspective of their lives--as a historical event (or series of events), that occurred at a particular time in a particular place, and that can be expected not to recur if the traumatized individuals take charge of their lives.

The key element is integration of the alien, the unacceptable, the terrifying, and the incomprehensible; the trauma must come to be “personalized” as an integrated aspect of one’s personal history.  The therapeutic relationship is the cornerstone of effective treatment.

Critical incident stress debriefing has been proposed as a way of modifying the stress reactions of emergency service workers.  Acute stress reactions, with the absence of stable symptom patterns and extreme degrees of physiological hyperarousal at this stage mean that there are unique problems in the treatment of this group. 

Traumatized people with high levels of avoidance are often most reluctant to expose themselves to their traumatic memories, even when they seek help.  Systematic desensitization and Eye Movement Desensitization and Reprocessing (EMDR) have been applied with limited results.  Any positive results with EMDR probably come from mimicing the REM state.

Representations of trauma are more complex than roles like “perpetrator,” and “victim”.  They are embedded in numerous affect states, defenses, object relations, and deep meaning configurations.   Pertinent to these are subjective decision points in which critical self-judgements are embedded.

They include insufficient anticipation of danger, naive trust, impossible choices, guilt and shame, and terror at revealing the content of the traumatic experience to someone new.  Other elements include temporally continguous ego states, such as splitting, denial, and dissociation, coupled with temporally contiguous fantasy states, such as murderous vengeance and wishes to die.  Intrusions can also remind the person of moments of fantasied safety within the trauma.

The conventional view is that hyperarousal, sleep disturbances, and embeddedness of the trauma makes effective pharmacological treatment essential.  Whether antidepressant, antianxiety, or sleeping medications are prescribed or not, dealing with traumatized people requires a staged process of treatment that is responsive to how much the victim can tolerate.  Here again, the specific nature of the therapeutic relationship is a critical variable in outcome.

PTSD plays a role in the dysregulation of neurohormones and their roles in the stress response.  Intense stress is accompanied by the release of endogenous, stress-responsive neurohormones, such as the catecholamines (including epinephrine and norepinephrine), serotonin, hormones of the hypothalamic-pituitary-adrenal (HPA) axis (including cortisol and other glucocorticoids, vasopressin, oxytocin), and endogenos opioids.  These stress hormones help us mobilize energy required to deal with emergency stress by increasing glucose release for quick energy and enhancing immune function.  Chronic stress inhibits their effectively and induces desensitization.

Drug therapy for PTSD is based on several biological models and has a few different purposes, (which also can be met with CRP’s intregrative approach).  (1).  Noradrenergic dysregulation is treated with MAO inhibitors, tricyclic antidepressants, beta-adrenergic blockers and benzodiazepines to calm the body’s alarm center.  (2).  Serotonergic dysfunction is treated with antidepressant SSRIs to regulate stress resilience, sleep, and for impulse control.  (3).  Anti-kindling drugs, such as carbamazepine, allegedly regulate an excitability threshold that has been lowered.  (4).  Anxiolytic drugs, such as clonazepam and buspirone are given in an attempt to reduce the startle response, which is one of the most persistent symptoms of PTSD.

The principle goals of using medication in PTSD are as follows:

1.  Reduction of frequency and/or severity of intrusive symptoms.
2.  Reduction in the tendency to interpret incoming stimuli as recurrences of the trauma.
3.  Reduction in conditioned hyperarousal to stimuli reminiscent of the trauma, as well as in generalized hyperarousal.
4.  Reduction in avoidant behavior.
5.  Improvement in depressed mood and numbing.
6.  Reduction in psychotic or dissociative symptoms.
7.  Reduction of impulsive aggression against self and others. (Davidson, van der Kolk).

Intrusion is the active force creating anxiety.