WK3CISCH-7

CHAPTER 7: Posttraumatic Stress Disorder Part II’s discussion of the more common types of crises that you, as a mental health worker or consumer of mental health care, are likely to encounter opens with posttraumatic stress disorder (PTSD). The reason for beginning here is that many other crises reviewed in this book may be rooted in PTSD. For example, suicide (Chu, 1999; Kramer et al., 1994) and substance abuse (Ouimette, Read, & Brown, 2005; Read, Bollinger, & Sharansky, 2003) may be the end products of attempting to cope with trauma. In contrast, rape, sexual abuse, battering, loss, physical violence, hostage situations, and large-scale natural and human-made disasters may precipitate the disorder (Ackerman et al., 1998; Bigot & Ferrand, 1998; Darves-Bornoz et al., 1998; Davis et al., 2003; Elklit & Brink, 2004; King et al., 2003; Lang et al., 2004; Melhem et al., 2004; North, 2004; Pivar & Field, 2004). Finally, PTSD-like symptoms may appear in the very people who attempt to alleviate the mental and physical suffering of people in crisis (Figley, 2002; Halpern & Tramontin, 2007; Pearlman & Saakvitne, 1995). While acute distress and acute stress disorder will be dealt with in other parts of this book, this chapter will deal specifically with the long-term residual effects of trauma on survivors. We know this is a long chapter and you might need to take a nap or a snack break to get through it. Try as we might to prune it down, we felt that “all this stuff” was critical to giving you the background for understanding not only what PTSD is about, but what occurs in treating the other crisis and transcrisis topics in this book. What we knew about PTSD in the first edition of this book in 1987 and what we know about it now—particularly the neurobiology and just how complex that is in manifesting the various traumatic responses that occur in humans—is like the difference between writing with a goose quill, inkwell, and papyrus scroll and word processing with an Apple Thunderbolt, OSX Lion operating system, and high-speed printer/scanner/fax. So bear with us! If you nail this chapter down, the other chapters will make a whole lot more sense as to how “all this stuff” goes together. Background Psychic trauma is a process initiated by an event that confronts an individual with an acute, overwhelming threat (Freud, 1917/1963). When the event occurs, the inner agency of the mind loses its ability to control the disorganizing effects of the experience, and disequilibrium occurs. The trauma tears up the individual’s psychological anchors, which are fixed in a secure sense of what has been in the past and what should be in the present (Erikson, 1968). When a traumatic event occurs that represents nothing like the person’s experience of past events, and the individual’s mind is unable to effectively answer basic questions of how and why it occurred and what it means, a crisis ensues. The traumatic wake of a crisis event typically includes immediate and vivid reexperiencing, hyperarousal, and avoidance reactions, which are all common to PTSD. The event propels the individual into a traumatic state that lasts as long as the mind needs to reorganize, classify, and make sense of the traumatic event. Then, and only then, does psychic equilibrium return (Furst, 1978). The typical kinds of responses that occur immediately after the crisis may give rise to what are called peritraumatic (around, or like, trauma) symptoms. These are common responses as the mind attempts to reorganize itself and cope with a horrific event. For many people, these responses will slowly disappear after a few days. Most people are amazingly resilient in the aftermath of a crisis and quickly return to mental and physical homeo-stasis, but if the symptoms continue for a minimum of 2 days and a maximum of 4 weeks and occur within 1 month of the traumatic event, then those time frames will meet the criteria of acute stress disorder (American Psychiatric Association, 2000, p. 469). If acute stress disorder symptoms develop, they will typically drop off in 1 to 3 months for most people (Brewin, 2003). If the person can effectively integrate the trauma into conscious awareness and organize it as a part of the past (as unpleasant as the event may be), then homeostasis returns, the problem is coped with, and the individual continues to travel life’s rocky road. If the event is not effectively integrated and is submerged from awareness, then the probability is high that the initiating stressor will continue to assail the person and become chronic PTSD. It may also disappear from conscious awareness and reemerge in a variety of symptomatic forms months or years after the event. When such crisis events are caused by the reemergence of the original unresolved stressor, they fall into the category of delayed PTSD (American Psychiatric Association, 2000, p. 468). PTSD is a newborn compared with the other crises we will examine, at least in regard to achieving official designation. In 1980, PTSD found its way into the third edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-III) as a classifiable and valid mental disorder. However, the antecedents of what has been designated as PTSD first came to the attention of the medical establishment in the late 19th and early 20th centuries. Two events serve as benchmarks. First, with the advent of rail transportation and subsequent train wrecks, physicians and early psychiatrists began to encounter in accident survivors trauma with no identifiable physical basis. Railway accident survivors of this type became so numerous that a medical term, railway spine, became an accepted diagnosis. In psychological parlance, the synonymous term compensation neurosis came into use for invalidism suffered and compensated by insurers as a result of such accidents (Trimble, 1985, pp. 7–10). Concomitantly, Sigmund Freud formulated the concept of hysterical neurosis to describe trauma cases of young Victorian women with whom he was working. He documented symptoms of warded-off ideas, denial, repression, emotional avoidance, compulsive repetition of trauma-related behavior, and recurrent attacks of trauma-related emotional sensations (Breuer & Freud, 1895/1955). However, what Freud found and reported on the pervasive childhood sexual abuse of these women as the traumatic root of their hysteria was anathema to a puritanical Victorian society, and he was forced to disavow and then reject his findings (Herman, 1997, pp. 13–17). Second, the advent of modern warfare in World Wars I and II, with powerful artillery and aerial bombardment, generated terms such as shell shock and combat fatigue to explain the condition of traumatized soldiers who had no apparent physical wounds. As early as the American Civil War, soldiers were diagnosed with “neurasathenia,” a state of mental and physical exhaustion. This malady was also termed “soldier’s heart” because of the belief that nerves at the base of the heart were somehow affected by combat. The term nostalgia, which would be seen as a stress disorder in current terms, was also coined. The thought was that soldiers became nostalgic for home and thus started to manifest a variety of physical symptoms that would relieve them from combat and allow them to go home (Kinzie & Goetz, 1996). Various hypotheses such as the foregoing were proposed to account for such strange maladies (Trimble, 1985, p. 8), but Freud (1919/1959) believed that the term war neurosis more aptly characterized what was an emotional disorder that had nothing to do with the prevailing medical notion of neurology-based “shell shock” in World War I. The U.S. Medical Service Corps came to recognize “combat fatigue” in World War II and the Korean War as a treatable psychological disturbance. The treatment approach was that combat fatigue was invariably acute and that treatment was best conducted as quickly and as close to the battle lines as possible. The idea was to facilitate a quick return to active duty. The prevailing thought was that time heals all wounds and that little concern needed to be given to long-term effects of traumatic stress. Such has not been the case (Archibald et al., 1962). Indeed, a notable proponent of establishing the Vietnam Veterans Centers, Arthur Blank, ruefully commented that when he was an army psychiatrist in Vietnam, he believed there would be no long-term difficulties for veterans (MacPherson, 1984, p. 237). Although PTSD can and does occur in response to the entire range of natural and human-made catastrophes, it was the Vietnam War that clearly brought PTSD to the awareness of both the human services professions and the public. Through a combination of events and circumstances unparalleled in the military history of the United States, veterans who returned from that conflict began to develop a variety of mental health problems that had little basis for analysis and treatment in the prevailing psychological literature. This combination of events and circumstances had insidious and long-term consequences that were not readily apparent either to the individuals affected or to human services professionals who attempted to treat them. Misdiagnosed, mistreated, and misunderstood, military service personnel became known to a variety of social services agencies that included the police, mental health facilities, and unemployment offices (MacPherson, 1984, pp. 207–330, 651–690). As the war continued to grind on, more and more veterans started having psychological problems. Rebuffed by the Veterans Administration, these veterans formed self-help groups to try to come to terms with their psychological issues. These “rap” groups rapidly coalesced and became a political force that pushed the federal government to come to grips with their problems. One major result of their lobbying efforts was the establishment of the Vietnam Veterans Centers, where alienated veterans could seek help for a variety of readjustment problems. An informal network of mental health professionals became interested in the veterans and started to classify their symptoms and compare them to the work Kardiner (1941) had done on war neurosis. Their review of clinical records led them to generate 27 of the most common symptoms of the Vietnam veterans’ “traumatic neurosis” (van der Kolk, Weisaeth, & van der Hart, 1996, p. 61). Interestingly, many of the physical or somatic complaints resemble those of a large retrospective archival study on the medical records of American Civil War Union veterans (Pizarro, Silver, & Prause, 2006)! At the same time, researchers in the growing women’s movement were looking at psychological problems after domestic violence, rape, and child abuse. What they were finding in the individuals who had suffered from these civilian assaults closely paralleled the problems that Vietnam veterans were experiencing. Their research rediscovered what Freud had found 80 years before and had dismissed: that victims of physical and sexual assault suffered long-term effects of the psychological trauma (Herman, 1997, p. 32). These different research avenues culminated in combining the “Vietnam veterans syndrome,” the “rape trauma syndrome,” the “abused child syndrome,” and the “battered woman syndrome” into one diagnostic category—posttraumatic stress disorder—in the third edition of the American Psychiatric Association’s Diagnostic and Statistical Manual in 1980 (van der Kolk, Weisaeth, & van der Hart, 1996, p. 61). Although the Vietnam War may be no more to you than a reference in a high school history book, the wall memorial in Washington, D.C., or your “crazy old Uncle Harold” who continues to wear combat fatigues and a headband with a ponytail, the war’s effects are a crucial history lesson in mental health provision (or the lack thereof) that any aspiring mental health worker should learn. For that reason, the psychological lessons learned from the Vietnam War continue to play a major role in the discussion of PTSD in the seventh edition of this book and play a large part of the armed services and Veterans Administration’s current treatment programs for it. It should be clearly understood that, even 40 or 50 years after the fact, the events that caused the trauma in many of these approximately 1 million veterans who suffered and suffer from PTSD are as alive for them today as they were then (Price, 2011). What is perhaps even more ominous in regard to the Vietnam veterans is their “graying.” Mounting evidence indicates that World War II and Korean War veterans have manifested delayed onset or worsening of posttraumatic complaints as they have grown older. Aging, with its subsequent loss of social supports through death, increased health problems, declining physical and mental capabilities, and economic hardship, appears to put older veterans at increased risk (Aarts & Op den Velde, 1996, pp. 359–374; Hamilton & Workman, 1998). Thus, it would appear that as this population ages, the mental health professions are a long way from being done with the legacy of Vietnam. Perhaps even more ominous, the current wars in Iraq and Afghanistan have eerily similar parallels to Vietnam. There are no front lines, the enemy fades into the population, everyone in the theater of operations is essentially in combat. As a result, vigilance must be constant, 24/7, throughout one’s entire rotation. Degree of combat exposure has been found to be one of the major predictors of PTSD (Miller et al., 2008; Smith et al., 2008). There are two major differences in these conflicts. So far there is general public support for the troops, whereas in Vietnam there was not. A support group is critical in any crisis, and this is particularly true of troops in an increasingly unpopular war. Lack of support and outright hatred of returning troops was a major contributing factor for PTSD in Vietnam veterans. However, while the armed forces in the current conflicts are all volunteers and not 18-year-old draftees, there are a tremendous number of reserve units in combat action, and there are also huge differences in the number of women involved in direct combat action. Preliminary reports from the Gulf War indicate that British reservists might not be as resilient as regular combat veterans (Hotopf et al., 2006). The question then becomes what the use of reservists and women in combat portends for the onset of PTSD. Preliminary results regarding mental health problems in veterans returning from Iraq and Afghanistan have ranged from 19 to 44 percent of the samples examined (Hoge, Auchterlonie, & Milliken, 2006; Lapierre, Schweigler, & LaBauve, 2007). Dynamics of PTSD Diagnostic Categorization PTSD is a complex and diagnostically troublesome disorder. To be identified as having PTSD, a person must meet the following conditions and symptoms as specified in the DSM-IV-TR (American Psychiatric Association, 2000, pp. 463–468). First, the person must have been exposed to a trauma in which he or she was confronted with an event that involved actual or threatened death or serious injury, or a threat to self or others’ physical well-being. Examples include but are certainly not limited to military combat, physical or sexual assault, kidnapping, being held hostage, severe vehicle accidents, earthquakes and tornadoes, being a refugee from a war zone, concentration camp detention, and life-threatening illness. The person’s response to the trauma was intense fear, helplessness, or horror. As a result, he or she has persistent symptoms of anxiety or arousal that were not evident before the traumatic event. Second, the person persistently reexperiences the traumatic event in at least one of the following ways: 1. Recurrent and intrusive distressing recollections of the event 2. Recurrent nightmares of the event 3. Flashback episodes, including those that occur on awakening or when intoxicated, that may include all types of sensory hallucinations or illusions that cause the individual to dissociate from the present reality and act or feel as if the event were recurring 4. Intense psychological distress on exposure to interedi or erences in symbolize or resemble someas aspect of the traumatic event 5. Physiologic reactivity on exposure to events that symbolize or resemble some aspect of the trauma, such as a person who was in a tornado starting to shake violently at every approaching storm Third, the person persistently avoids such stimuli in at least three of the following ways: 1. Attempts to avoid thoughts, dialogues, or feelings associated with the trauma 2. Tries to avoid activities, people, or situations that arouse recollections of the trauma 3. Has an inability to recall important aspects of the trauma 4. Has markedly diminished interest in significant activities 5. Feels detached and removed emotionally and socially from others 6. Has a restricted range of affect by numbing feelings 7. Has a sense of a foreshortened future, such as no career, marriage, children, or normal life span Fourth, the person has persistent symptoms of increased nervous system arousal that were not present before the trauma, as indicated by at least two of the following problems: 1. Difficulty falling or staying asleep 2. Irritability or outbursts of anger 3. Difficulty concentrating on tasks 4. Constantly being on watch for real or imagined threats that have no basis in reality (hypervigilance) 5. Exaggerated startle reactions to minimal or nonthreatening stimuli Fifth, the disturbance causes clinically significant distress or impairment in social, occupational, or other critical areas of living. Examples include not being able to keep a job, having a failed marriage, or becoming a substance abuser. The duration of the foregoing symptoms must be for more than one month. PTSD is not confined to adults. Children also experience PTSD and manifest symptoms that closely parallel those of adults, with the following notable differences. First, children must experience disorganized or agitated behavior. Children usually do not have a sense they are reliving the past, but rather relive the trauma through repetitive play. Their nightmares of the traumatic event may change to more generalized nightmares of monsters or of rescuing others. A foreshortened future for a child generally involves a belief that they will never reach adulthood. Children may believe they can see into the future and can forecast ominous events. Physical symptoms may appear that include headaches and stomachaches that were not present before the event (American Psychiatric Association, 2000, p. 466). Complex PTSD If “catching” PTSD isn’t bad enough, the dramatic personality changes that may occur with long-term, intensive trauma have led many respected researchers and practitioners to call for a diagnostic category of “complex PTSD” or “disorders of extreme stress not otherwise specified” (DESNOS) (Briere & Scott, 2006; Courtois & Ford, 2009; Herman, 1997, p. 121; van der Kolk, 1996b, pp. 202–204). The lobbying effort for this diagnostic category has so far fallen short of achieving official recognition, but the three cardinal symptoms are somatization (physical problems, associated pain, and functional limitations), dissociation (division of the personality into one component that attempts to function in the everyday world and another that regresses and is fixed in the trauma), and affect dysreg ulation (alterations in impulse control, attention and consciousness, self-perception, perception of perpetrators, relationships to significant others, and systems of meaning) (Courtois, Ford, & Cloitre, 2009, pp. 85–86), all of which go beyond the diagnostic criteria of “simple” PTSD. The DESNOS classification opens a Pandora’s box of psychological evils that include the inability to regulate feelings, suicidal and other self-destructive behaviors, impulsive and dangerous risk-taking behaviors, anger management problems, amnesia and dissociation from reality, somatic complaints that take a variety of physical forms, chronic character changes that range from consuming guilt to permanent ineffectiveness in coping with life, adopting distorted and idealized views of perpetrators of the trauma, an inability to trust others, a tendency to victimize or be revictimized, and despair and hopelessness that previously held beliefs about a “fair and just” world are no longer valid. Typical inhabitants of a DESNOS world are persons with long-term exposure to combat service, adult survivors of chronic childhood sexual and physical abuse, and concentration camp survivors. Whether simple or complex, it should be readily apparent that PTSD is an extremely serious condition and that the DSM-IV-TR criteria do not begin to depict all the consequences and effects of the disorder that assail the individual and ripple out to significant others in the individual’s life. Conflicting Diagnoses Given the wide variety of maladaptive behaviors that characterize the disorder, it is not uncommon for those who suffer from PTSD to have companion diagnoses of anxiety, depressive, organic mental, and substance use disorders (American Psychiatric Association, 2000, p. 427). In fact, it is probably more common to have comorbidity (the presence of two diagnosable disorders such as major depression and substance abuse) (Spinazzola, Blaustein, & van der Kolk, 2005). Further, because of presenting symptoms, PTSD may be confused with adjustment, paranoid, somatic, and personality disorders (Herman, 1997, pp. 116–117; Zanarini et al., 1998; Zlotnick et al., 1999). One of the hallmarks of PTSD is that it is often comorbid—particularly with alcohol abuse (Reynolds et al., 2005; Thaller et al., 2003). That is, the person will have another preliminary mental illness diagnosed in the course of treatment. There are few “pure” cases, and few symptoms are unique to the disorder (Atkinson, Sparr, & Sheff, 1984). Thus, no matter what the diagnosis, assessment in crisis intervention should always attempt to determine if there has been exposure to prior trauma, particularly when the crisis seems to have occurred spontaneously, with no clear, immediate, precipitating stimulus. The Question of Preexisting Psychopathology For a variety of political and social reasons, society does not perceive (and has not perceived) being a victim of war, domestic violence, or other types of human cruelty as the equivalent of being mentally ill. Vietnam veterans who early on sought help from Veterans Administration (VA) hospitals were misdiagnosed or thought to have some preexisting psychopathology or character disorder. As a result, they were revictimized by a bureaucratic and rigidly conservative mental health system that added psychic insult to psychic injury (Ochberg, 1988, p. 4). Victims of domestic violence fared no better and were often seen to have a “masochistic” personality that subconsciously enjoyed physical assaults (Herman, 1997, p. 117). Such revictimization and discounting by supposedly “caring” professionals exacerbate the trauma survivor’s problems exponentially. There is evidence of a heritable component to the transmission of PTSD (American Psychiatric Association, 2000, p. 466), and undoubtedly some people, because of a previous psychiatric history, are more predisposed to breaking down under stress than are others (Norris et al., 2002; Ullman & Siegel, 1994). Furthermore, the number and magnitude of the trauma will predict higher potential for PTSD (Norris et al., 2002; Shalev, 1996, p. 86). Exposure to multiple rapes, being held in a concentration camp, extended child abuse, the loss of loved ones, or prolonged frontline combat typically puts the individual at far greater risk for PTSD than a onetime physical assault by a parent or an auto accident in which no one was killed. Additionally, lack of education, low economic status, increased number in family, gender (females are seen as at greater risk), age (younger age at time of event), marital status (not married), and lack of family support systems have all been seen as contributing factors for developing PTSD (Jovanovic et al., 2004; Myers & Wee, 2005; Norris et al., 2002; Suar & Khuntia, 2004; Wilson, Friedman, & Lindy, 2001). However, no absolute factors guarantee that one person as opposed to another will develop PTSD. Brewin (2005) found that although there are a number of risk factors for PTSD, their effect sizes tend to be small and vary according to the nature of the trauma. Given the right conditions, it appears anyone can be a candidate. Several years ago, the collapse of a concrete walkway in a crowded hotel gave us a prime example of how one event may suddenly produce PTSD symptoms. Biographical data gathered following the Kansas City Hyatt Regency skywalk disaster revealed that few survivors had character disorders before the event. Yet 6 months after the event, many were suffering from a variety of presenting symptoms (Wilkinson, 1983). White (1989) found the same result in a study of burn victims suffering PTSD symptoms. The overwhelming majority of these individuals had no previous psychiatric history. Probably the best summing statement about who will and who will not manifest PTSD was made by Grinker and Spiegel (1945) in their study of World War II veterans. They concluded that no matter how strong, normal, or stable a person might be, if the stress were sufficient to cross that particular individual’s threshold, a “war neurosis” would develop. It should also be clearly understood that PTSD is not culture bound. While there are variations on the theme cross-culturally, there is a great deal of evidence that PTSD is a cross-cultural phenomenon common to all people (Brewin, 2003; Marsella et al., 1996). In summary, susceptibility to PTSD is a function of several factors: genetic predisposition, ecological factors, constitution, personality makeup, previous life experiences, state of mind, cultural artifacts, phase of maturational development at onset, spiritual beliefs, social support system before and after the trauma, and content and intensity of the event (Brewin, 2003, 2005; DeVries, 1996; Furst, 1967; Green & Berlin, 1987; Halpern & Tramontin, 2007; Kaniasty & Norris, 1999; Norris et al., 2002; Shalev, 1996; Wilson, Friedman, & Lindy, 2001). Physiological Responses In the last 15 years a tremendous number of psychobiological studies have conclusively demonstrated that trauma affects the individual in a variety of physical ways. Researchers have discovered that neurotransmit ters, hormones, cortical areas of the brain, and the nervous system play a much greater role in PTSD than was previously suspected (Bremner et al., 1995; Copeland, 2000; Malizia & Nutt, 2000; Rothschild, 2000; van der Kolk, 1996a; Vasterling & Brewin, 2005; Yehuda, 2000). The underlying thesis is that the brain is much more like a “wet” hormonal gland than a “dry” cybernetic computer (Berglund, 1985). When a person is exposed to severe stress, neu rotransmitters, neuromodulators, hormones, endogenous opioids, and specific cortical functions designed to deal with the emergency are activated (Grinker & Speigel, 1945; Santa Ana et al., 2006; Selye, 1976; Siegel, 1995; van der Kolk, 1996a, pp. 215–234; Vermetten & Bremner, 2002). Although cessation of the traumatic event may remove the person from danger and no longer require the body’s system to function on an emergency basis, if the stress is prolonged, the nervous system may continue to function in an elevated and energized state as if the emergency were still continuing (Burgess-Watson, Hoffman, & Wilson, 1988; van der Kolk, 1996a, pp. 214–234). Furthermore, there is evidence that intense and continuous stress can cause permanent physical changes in the brain (Copeland, 2000; Malizia & Nutt, 2000; Vermetten & Bremner, 2002). These changed physiological states are important because they not only cause individuals extreme physical and psychological duress long after the traumatic event but also help explain why people do not “get over” PTSD. In their study and review of the neuroanatomical correlates of the effects of stress on memory, Bremner and associates (1995, 1997) and Gurvitz, Shenton, and Pittman (1995) found in combat veterans significant decreases in the hippocampal area of the brain where explicit memory encoding, memory consolidation, and organization take place, as did Stein and associates (1994) in women who had experienced severe child sexual abuse. Whether the smaller hippocampus is a causal factor for PTSD or PTSD causes the hippocampus to become smaller is not known. However, Astur and associates’ (2006) study of identified PTSD experimental subjects versus non-PTSD controls supports these findings of decreased hippocampal activity. A great deal of psychophysiological assessment evidence indicates that stimulus presentation to PTSD sufferers of sights, sounds, and smells associated with the long-past traumatic event will immediately send the neuroendocrine system into overdrive and cause physiological responses such as increased heart rate, blood pressure, and triglyceride and cholesterol levels, along with decreased blood flow to the skin and gastrointestinal and renal areas. These psychophysiological responses are not evinced in control subjects who are presented with the same stimuli (Lating & Everly, 1995). Affective-State-Dependent Retention There is now very clear evidence that physiological changes occur in the presence of trauma (Briere & Scott, 2006) and are exacerbated when the trauma becomes ongoing and complex (Ford, 2009). Changed physiological functioning due to traumatic stimuli is important as a building block in Bower’s (1981) hypothesis of affective-state-dependent retention. Bower has proposed that because the traumatic event was stored in memory under completely different physiological (increased heart rate, higher adrenal output) and psychological (extreme fright, shock) circumstances, different mood states markedly interfere with recollecting specific cues of the event. Karl, Malta, and Maercker’s (2006) meta-analysis supports the hypothesis that changes in memory processing accompany PTSD. Therefore, the important elements of the memory that need exposure in order to reduce anxiety are not accessible in the unaroused state (Keane et al., 1985, p. 266) and can be remembered only when that approximate state of arousal is reintroduced by cues in the environment (Keane, 1976). Indeed, there is evidence that release of neuromodulators such as norepineph rine when an individual is in a stressful situation leads to pathological response to recall of previous traumatic events for which the individual has no previous memory (Bremner et al., 1995). To the contrary, the classic dissociative, numbing response and “forgetting” of the traumatic event may be caused by excessive endogenous opioids secreted during prolonged stress (van der Kolk, 1996a, p. 227). Thus the notion that a victim of PTSD can “just forget” or adopt a “better, more positive attitude” does little to effect change in the individual (Keane et al., 1985, p. 266). This proposal has important implications for treatment, particularly with respect to returning the person to as close an approximation of the event as possible. These neurological issues are even more omilikeli hood for children Children and Neuropathology There is a high likelihood for children who experience traumatic events in early childhood to develop neuropathology (Lewis, 2005). If the trauma occurs during early developmental stages, there is a dramatic shift in the brain’s functioning from an inquisitive, exploring, learning mode to a reactive, defensive, surviving mode. When the stress response survival systems of the child’s brain are operating in overdrive, the learning systems take a back seat. As a result, a wide array of normal developmental activities are placed on hold, with potentially catastrophic consequences across social and educational environments. In plain language, operating systems in the child’s brain get damaged. Damage occurs in three areas: emotional dysregulation, which may be characterized by emotional emptiness or constant distress; dissociation, which manifests as mental disorientation and confusion; and hyper arousal, which physically drains the body to the point of exhaustion. The potential for these devastating outcomes to occur is particularly enhanced if the trauma comes at the hands of a caregiver who is supposed to be nourishing the learning brain of the child rather than activating the survival system (Ford, 2009). You will meet some of the characteristics of these neurological train wrecks later in this chapter and in Chapter 9, Sexual Assault. The foregoing paragraphs should give you a fair idea of why treating childhood PTSD and survivors of extended childhood trauma is so difficult and why transcrisis states are so common with these individuals. Incidence Impact, and Trauma Type Incidence If PTSD has been with us for so long, what made it finally surface with such profound impact? Epidemio-logical studies indicate that a lifetime rate of about 8 percent can be expected in the general civilian population of the United States (American Psychiatric Association, 2000, p. 466). So, in the common course of events, the chances of “catching” PTSD are fairly small. The average “catch it” rate for PTSD appears to be about 20 percent after a trauma is experienced (Norris et al., 2002). However, when studies target particular at-risk groups such as adolescents and young adults, people in hazardous occupations, sexual assault victims, severe burn cases, psychiatric cases, and refugees, the incidence of PTSD in these populations is much greater (McFarlane & de Girolamo, 1996, pp. 129–154). The classic at-risk example is the Vietnam veteran. The numbers of returning Vietnam veterans who were having some kind of personality disorder far exceeded what statistics would predict. It is estimated that 26 percent, or 960,000 Vietnam veterans, have had episodes of PTSD (Kukla et al., 1990). This massive number of veterans in severe psychological trouble was simply too large to ignore. Residual Impact People’s basic assumptions about their belief in the world as a meaningful and comprehensible place, their own personal invulnerability, and their view of themselves in a positive light account to a great extent for their individual manifestations of PTSD (Figley, 1985b, pp. 401–402; Kaniasty & Norris, 1999). Even in the most well-integrated people, who have excellent coping abilities, good rational and cognitive behavior patterns, and positive social support systems, residual effects of traumatizing events may linger. An outstanding example of such residual effects is the experience of a retired Marine captain who had seen extensive field duty as a combat infantryman in Vietnam in 1968. The anecdote he relates typifies the residual effects in an individual who is psychologically well integrated, is securely employed in a professional job, has a tightly knit, extended family support system, and on the whole enjoys life and has a positive outlook on it. Chris: I had just gotten home from work late one summer evening. The kids had decided to camp out in the woods down by the creek. A thunderstorm was rolling in and I decided I’d better go down and check on them to see if they were packed in for the night. It had started to rain pretty heavily, and there was a lot of thunder and lightning. I pulled on a poncho and got a flashlight, crossed the road, and went into the woods. I don’t suppose it was 200 yards to where the kids were camped. Now, I’d grown up running those woods, so I knew it like the back of my hand. However, once I got into the woods things kinda went haywire. I immediately thought, “Get off the trail, or you’ll get the whole platoon zapped.” I slipped off the path and became a part of the scenery. Every sense in my body went up to full alert. I was back in Nam again operating with my platoon, and I was on a natural, adrenaline high. Time and place kinda went into suspended animation, and I eased through the woods, kinda like standing off and watching myself do this, knowing it was me, but yet not me too. The last thing I remember before walking into the clearing where the kids had their tent set up was that we could have ambushed the hell out of that place. I don’t harp and brood on Nam, put it behind me after I got out of the Corps, but that night sure put me in a different place than central Indiana, July 1984. I just couldn’t believe that would ever happen. It’s a bit unnerving. Importance of Trauma Type Catastrophes, when viewed by the public, tend to fall into one category: bad. However, one of the interesting phenomena around PTSD is that there is a marked distinction between natural and human-made catastrophes. Acts of God create far fewer instances of PTSD than do human-made ones. As an example, the volcanic eruption of Mount St. Helen’s incident rate of PTSD was a very low 3 to 4 percent (Shore, Tatum, & Vollmer, 1986). Human-made acts of trauma create even more instances of PTSD when the trauma directly affects the social support system of the family. Holocaust survivors, hostages, rape victims, children of murdered parents, and victims of incest are all strong potential candidates for PTSD. Survivors of both uncommissioned human-made disasters such as the breaking of the Buffalo Creek dam and commissioned trauma such as the Chowchilla bus kidnapping carry high potential for PTSD. (The Buffalo Creek disaster occurred in 1972 when a coal company retainer dam broke during a series of heavy rainstorms; the resulting flood wiped out the residents of the Buffalo Creek valley in West Virginia. The bus kidnapping occurred in 1976 when a Chowchilla, California, school bus carrying elementary and secondary school children was hijacked at gunpoint. The children were taken from the bus and forced into a truck buried underground; eventually they were able to tunnel out.) What makes these events so particularly terrible is that they seem to be tragedies that should not have happened, responsibility for them can be readily assigned, and they clearly violate accepted standards of moral conduct (Figley, 1985a, pp. 400–401). As a result, there exists in any human-made catastrophe the likelihood of more severe posttraumatic psychological problems as compared to natural disasters. The problem is that the line between the two is becoming less clear. More and more people look at technology as a means of controlling nature. Thus, for example, Mother Nature makes the rain, but the Army Corps of Engineers builds dikes and opens floodgates (Kaniasty & Norris, 1999), and when things go wrong individuals (and lawyers) start looking for culprits. Vietnam: The Archetype In a comparative analysis of PTSD among various trauma survivor groups, Wilson, Smith, and Johnson (1985) isolated 10 variables that were hypothesized as predisposing to PTSD: degree of life threat; degree of bereavement; speed of onset; duration of the trauma; degree of displacement in home continuity; potential for recurrence; degree of exposure to death, dying, and destruction; degree of moral conflict inherent in the situation; role of the person in the trauma; and the proportion of the community affected. They compared these variables in a variety of trauma survivor groups: Vietnam combat veterans as well as victims of rape, auto accident, armed robbery, natural disasters, divorce, life-threatening illness of a loved one, family trauma, death of a significant other, multiple traumas, and a control group. Veterans were significantly affected in 7 of the 10 dimensions, with rape victims a distant second in terms of number of predisposing variables present. When the data were transformed to fit precise PTSD criteria, all trauma groups were significantly different from the control group (pp. 142–172). In plain words, the data suggest that one could not experience a catastrophic event more likely to produce “complex” PTSD than Vietnam—with one exception. With the advent of women in combat, if sexual assault and combat are combined, such as has occurred in Iraq and Afghanistan, then either women or men who have been in combat and have also been sexually assaulted are one-and-a-half more times likely to be diagnosed with a mental health condition than those who have not been assaulted (Munsey, 2009). Why did Vietnam mark the birth of what was to become PTSD? Although any war could be construed to produce many PTSD symptoms, the rules of war changed in Vietnam. First, the average age of the soldier in Vietnam was 19.2, compared with 26.0 in World War II (Brende & Parson, 1985, p. 19). A psychologically immature 19-year-old soldier was not mentally prepared for the psychic trauma that awaited him in Vietnam (MacPherson, 1984, pp. 62–63). Hypervigilance. In Vietnam, there was no front line and no relief from constant vigilance. A 365-day combat tour was exactly that. In comparison to World War II troops, who might be in acute combat situations for a few days or weeks and then be pulled off the line, Vietnam “grunts” spent extended periods of time in the field, and even when they were in a base camp, they had to be alert for rocket attacks and combat assaults on their position. Hypervigilance became an ironclad rule of survival. Listen to Billie Mac, a composite character of many combat veterans I have interviewed. Billie Mac: I was 18 when the plane set down at Da Nang. The crew chief told us to hit the ground running because Da Nang was under a rocket attack. I was scared stiff. Well, Da Nang was heaven, rockets and all, to what later happened. It got a lot, lot worse than that. Lack of Goals. No territory was ever “won,” so there was no concrete feeling of accomplishment. Combat troops felt betrayed by U.S. politics over a war for which there were no fixed goals for winning and a command structure that was waging a war of attrition, with “body counts” being the primary way of judging whether a mission was successful (Lifton, 1974; MacPherson, 1984, p. 58). Billie Mac: We swept that one village at least a half dozen times. Sometimes we’d dig in and dare the NVA to hit us, and they did. We lost a half dozen guys in that pesthole. For what? For nothin’. We gave it up, and they moved right back in. Victim/Victimizer. It further compounded the virulent psychological milieu of Vietnam that veterans, unlike most individuals who suffer from PTSD, played two roles—victim and victimizer. Because both enemies and allies were Vietnamese, a soldier could not distinguish friend from foe, nor could vigilance be relaxed around women or children because of their potential lethality. Also, because the enemy was Asian and had extremely different cultural values from Americans, it was relatively simple to dehumanize killing or maiming them, particularly when troops saw such things done to their comrades. The nasty way guerrilla war is fought brought out brutality on both sides (Lifton, 1974). Shifts of role from victim to aggressor could occur in seconds (Brende & Parson, 1985, p. 96). Billie Mac: I couldn’t imagine killing a kid or woman. That was true until our medic tried to take care of a kid covered with blood. We all thought he was wounded. When John went over to the dink, he opened up his arms and had a grenade. Blew him and the medic away. Kill them after thats? You bet! Bonding, Debriefing, and Guilt. The way the armed services filled units had much to do with lack of a support system within the service itself. Personnel replacements were parceled piecemeal into units, which is a bad idea if you are trying to avoid PTSD. Current research indicates that unit cohesion is a critical buffer against PTSD (Armistead-Jehle et al., 2011). Although this method put rookies with veterans, it was not the best way to bond a unit together. The rotation system also took its psychological toll. Each person did a 365-day tour. The stress of being “short” caused men to become very self-preservative and immobilized. Units as a whole were never moved out of combat, and a man who entered combat singly returned singly without benefit of debriefing time. The war was essentially fought in patrol and platoon actions. It was a loner’s war, and the soldier who fought alone went home alone (MacPherson, 1984, pp. 64–65). A man might be sweating out an ambush in the jungle one day, and two days later be sitting on his front porch back home. It is no great surprise that returning soldiers who had no transition period from Vietnam to the United States were viewed as “different” and “changed” by their relatives (Brende & Parson, 1985, pp. 48–49). Such rapid transitions out of life-threatening situations left many with survivor’s guilt (Spiegel, 1981). They were glad to be out of Vietnam, but felt guilty of betrayal for leaving comrades behind; or they took responsibility when they were away from their units and friends were hurt or killed (MacPherson, 1984, p. 237). Billie Mac: It was inside of a week from jungle to home. My folks thought it was pretty weird because I put my fatigues on and slept in the woods. I just couldn’t take being confined in that house. I kept thinking about the guy who took my place as squad leader, Johnson. I knew he was gonna get somebody wasted. I needed to be there, but I sure didn’t want to be. I immediately got drunk and stayed that way for a long time. Civilian Adjustment. The rapid change from intense alertness in order to preserve one’s life to trying to readjust to a humdrum society made many question where the “real world” was. Furthermore, the returnee’s basic belief system would be quickly jarred when, on his arrival home, he was greeted with insensitivity and hostility for having risked his life for his country (Brende & Parson, 1985, p. 72). Veterans quickly found that for all the ability they had shown in making command decisions of life-or-death importance and the authority they had exercised over expensive equipment in Vietnam, the onus of having been there relegated them to civilian jobs far below their capabilities (MacPherson, 1984, p. 65). Billie Mac: Any job I could get stunk. They were all menial, and they acted like they were doing me a favor. Hell! I’d made a lot bigger and smarter decisions than anybody I ever had as a boss. Substance Abuse. The ease with which soldiers could obtain alcohol and drugs to numb themselves and escape mentally from the reality of Vietnam had severe consequences, both in addiction on return and in the public’s growing misconception that veterans were all “drug-crazed baby killers,” to be shunned as erratic and undependable (Brende & Parson, 1985, p. 72; MacPherson, 1984, pp. 64–65, 221–222). Billie Mac: Yeah, I drank. Yeah, I shot kids. I drank mainly to try to forget about shooting kids. Anybody who hadn’t been there could never understand. Attitude. The time period during which a vet served in Vietnam seems to be highly correlated with PTSD. Historically the war can be divided into trimesters. Anyone serving in Vietnam during the last two trimesters, from the time of the Tet offensive in 1968 to the U.S. withdrawal in 1973, would have, from a psychological standpoint, a much greater reason to question the purpose of being there than those who had served early on. The prevailing attitude of “Nobody can win, so just concentrate on surviving” cynicism was in direct opposition to the “Save a democracy from the perils of communism” idealism of the first trimester (Laufer, Yager, & Grey-Wouters, 1981). Antiwar Sentiment. The impact of the antiwar sentiment that veterans met on their return home cannot be minimized. It is unique to the Vietnam War and found its focal point in returnees. Veterans were spurned immediately on their arrival in the United States, suffered prejudice on college campuses as they came back to school, were left out of jobs because of antiwar sentiments, and were disenfranchised from government programs through meager GI Bill benefits and government disavowal of physical problems associated with exposure to the chemical defoliant Agent Orange. Perhaps worst of all were the comparisons their fathers made—men who had fought the “honorable” fight of World War II and could not understand the problems their sons suffered in a war that was not black and-white but a dirty shade of gray (MacPherson, 1984, pp. 54–58). It is interesting to note that Vietnam combat veterans diagnosed with PTSD whose fathers were also combat veterans are likely to have more severe problems than those Vietnam veterans whose fathers had not seen combat (Rosenheck & Fontana, 1998). Billie Mac: I tried to talk to my old man about it. He’d been in World War II on Okinawa. Hell, he might as well have been in the Revolutionary War for all he could understand about Nam. He finally got so mad that he told me I was nuts and no damn good. He didn’t mean that, but I’ll never forget it. All these factors came together in a sort of witch’s brew for veterans trying to make meaning out of a situation that was life-threatening and generally considered pointless (Williams, 1983). To survive such a situation called for imposing psychological defense mechanisms that made a fertile breeding ground for PTSD. When these psychological defense mechanisms go awry, symptoms are typically seen in the three major PTSD diagnostic categories of intrusive thoughts, avoidance, and increased nervous system arousal. Intrusive-Repetitive Ideation Intrusive-repetitive thoughts become so problematic for the individual that these thoughts begin to dominate existence. Intrusive thoughts generally take the form of visual images that are sparked by sights, sounds, smells, or tactile reminders that bring the repressed images to awareness (Donaldson & Gardner, 1985, pp. 371–372). Billie Mac: That day at the village when Al got it keeps coming back. I don’t go fishing in the bayou anymore. It smells and looks like Nam, and every time I’d go I’d start thinking about that village, and I’d get the shakes. Over time, triggers for intrusive thoughts may become associated with subtle and more generalized stimuli that are seemingly irrelevant to the trauma (van der Kolk & McFarlane, 1996, p. 10). These thoughts occur not only in conscious contact with reality but also in the form of flashbacks and nightmares. Billie Mac: The reason that got me to the vets center is real simple. I was having these awful nightmares about being in a firefight while on a long-range reconnaissance patrol near Laos. The next thing I know, I’m dug into a bunker watching an enemy truck convoy’s headlights come down the Ho Chi Minh Trail with my rifle aimed at them. The only problem was that it was on the banks of the Wolf River in Memphis, Tennessee, and it was headlights on 1–40. It was also not 1970 but 1988. I knew if I didn’t get help I was going to kill somebody. Denial/Numbing Accompanying emotions of guilt, sadness, anger, and rage occur as the thoughts continue to intrude into awareness. To keep these disturbing thoughts out of awareness, the individual may resort to self-medication in the form of alcohol or drugs. Self-medication may temporarily relieve depressive, hostile, anxious, and fearful mood states (Horowitz & Solomon, 1975), but what usually occurs is a vicious cycle that alternates between being anesthetized to reality by the narcotic and experiencing elevated intrusion of the trauma with every return to sobriety. The ultimate outcome is increased dependence on the addictive substance as a method of keeping the intrusive thoughts submerged (LaCoursiere, Bodfrey, & Ruby, 1980). Billie Mac: The drinkin’ is no damn good. I know that, but try going without sleep for a week and knowing every time you nod off, that horrible nightmare’s gonna come. Then it starts popping up in the daytime and you drink more to keep it pushed back. As people attempt to cope with catastrophes, they become passive (immobile and paralyzed) or active (able to cope with the situation). Individual reactions fall into three major groupings: momentary freezing, flight reaction, and denial/numbing. In the prolonged stress of a combat situation, denial/numbing is the most common response and allows the soldier to cope and live with the experience in three ways: by believing he is invulnerable to harm, by becoming fatalistic, or by taking matters into his own hands and becoming extremely aggressive. Any of these proactive stances allows the individual to get through the trauma and cope with it without losing complete control (Figley, 1985a, pp. 406–408). Typically, survivors of trauma will let down these defense barriers and will have acute stress disorders immediately after the trauma, but will recover. For those who do not, continued emotional numbing and repression can have severe consequences. Billie Mac: Looking back on it, I can’t believe how callous I have become. SOP [standard operating procedure] was “It don’t mean nothin’, screw it, drive on.” This would be right after a B-40 round had blown your buddy’s brains all over you. You had to put it behind you to survive. A guy fell off the construction site I was working on last fall and splattered himself all over the pavement. I sat on a steel beam about 30 feet above the guy and just kept eating my lunch. No big deal! Submerging emotions out of conscious awareness does not mean that they are summarily discarded. The price is that emotional numbing left in place and not relieved can generalize to other aspects of one’s life and result in later psychological difficulties (Wilkinson, 1983). Shunted into the unconscious for a long time, trigger events in the form of everyday stressors can pile up and cause emotional blowouts when the individual is least prepared for them (Figley, 1985a, p. 408). Increased Nervous Symptom Arousal Autonomic hyperarousal in people with PTSD causes them to be nondiscriminating to stimuli that may hold no threat to them at all. Acoustic startle response is a cardinal feature of the trauma response (van der Kolk, 1996a, p. 221). Billie Mac: I can’t stand the sound of a chopper. Every time I hear one, I want to run. I get the feeling that every time I hear the 5 o’clock traffic chopper, it’s gonna circle in, pick me up, and take me to a hot LZ [landing zone]. One came over the building I was working on. I didn’t hear it at first. When I did hear it, I jumped and fell 10 feet and broke my arm. In the same vein, hypervigilance, when there is no immediate threat, is constantly with the person and causes concentration and attention problems. As these problems distort information processing, the resulting inability to decode messages from the central nervous system causes the person to react to the environment in either exaggerated or inhibited ways (van der Kolk & McFarlane, 1996, pp. 14–15). Billie Mac: This may sound kinda weird, but I don’t ever sit with my back to a door. Matter of fact, I really don’t like sitting anywhere where my back might be to somebody else! I get real jumpy. Dissociation While dissociation is not listed as a symptom of PTSD, dissociation at the moment of trauma is perhaps the most important long-term predictive variable for PTSD and is invariably connected to “complex” PTSD (Herman, 1997, pp. 118–129; Marmar et al., 1991). Dissociation can range from numbing or lack of emotional responsiveness to the event to derealization (“this is not real; it isn’t happening; it’s a bad dream”) or depersonalization (“I’m out of my body and looking at this from a grandstand”) to complete amnesia of the event. Dissociation splits off the memory from conscious awareness, but that does not mean the noxious stimulus event is extinguished. To the contrary, dissociation can be a last-resort adaptive way of coping with the trauma while it is going on, but the lack of integration of the traumatic event seems to be a leading cause of PTSD. If dissociation continues, it can severely interfere with daily living and breed disconnectedness and isolation (van der Kolk, 1996b, p. 286). At its penultimate, dissociation can become dissociative identity disorder (formerly known as multiple personality disorder). Billie Mac: It’s like a lot of times I’m looking at me doing something sorta through a video camera, maybe. Like I’m smaller than real life, and I sorta know it’s me, but it’s not like I’m really there. The first time I did that was when we were in that village and my buddy Al got it. What the person needs most is to bring these thoughts and behaviors into conscious awareness and come to grips with them, so they can be resolved. Yet, rather than confronting the intrusive and threatening material, the person is more likely to deny its existence and use a variety of avoidance responses to escape from the situation (Horowitz et al., 1980). This issue is particularly problematic in therapy and is why those who suffer from PTSD may be particularly resistant and noncompliant to approaches that reexpose them to the feared trauma (Bernstein, 1986). Family Responses Natural disasters leave so few emotional scars because such disasters often strike intact social support systems simultaneously (Figley, 1988). In natural disasters that affect the whole community, everyone becomes a survivor. Family members help each other through the horror of the disaster, and there is no blaming the individual (Figley, 1985a, p. 409; Kaniasty & Norris, 1999). One of the keystones for bridging the gap between traumatic events and a return to adequate and wholesome functioning is a strong support system that is most generally based within the family. But when the trauma is intrafamilial and takes the form of child and spouse abuse, those who are most traumatized are most generally the ones who are denied the most social support within the family. Those who should provide the most comfort are the ones who are inflicting the most pain (Figley, 1985a, p. 411). Further exacerbating family relationships is the ingrained tendency in trauma victims to “not feel.” Whereas the individual would like to be able to demonstrate feelings of caring and love, experience has taught him or her that exposure of feelings is foolhardy because it invariably makes one vulnerable to further pain. These concepts strike at the very heart of what sustains family life—trust. The response of family members is to feel misunderstood, unloved, fearful, and angry. The response is reciprocal and plunges all members deeper into a vortex of family discordance. From a family system perspective, if children, parents, or spouses attempt to regulate the continuing warfare in which the individual is engaging, they will be worn down and out by the effort. The individual may also become so dependent on the stabilizing person (usually the spouse) that the individual’s needs breed resentment in anyone else who demands time and effort (usually children). The outcome of this spiral is what the individual may fear most from the support system—rejection. Feelings of guilt, numbing, anger, and loss plague the individual, and the spiral continues ever downward into more inappropriate behavior patterns and ultimate disintegration of the family. Family members who cannot deal with the trauma may paradoxically turn on the victim. Sadly, this is too often the occurrence in the case of mothers who deny their spouses’ abuse of the children, finally are confronted with the issue by children and family services, and then blame the children for the trouble they have caused! The same is true for rape victims who, if children, may have parents who are psychologically unable to provide support for them and indeed revictimize them for having done something that led to the assault in the first place. If adults, rape victims may have a spouse who is unable to respond in supportive ways or who blames the victim for “promiscuous or seductive” behavior that invited the rape or claims the victim “didn’t resist enough” (Notman & Nadelson, 1976). In attempting to deal with a family member who has suffered a traumatic experience, other members may experience the stress to the degree that they become “infected” by it (Figley, 1988). Indeed, if other family members have inadequate coping skills, their own problems may escalate to crisis proportions as the individual’s reactions to the trauma create stress within the family. Or, if other members of the family have a hidden agenda of keeping the family in pathological homeostasis, they may engage in enabling the individual’s disorder, much as an alcoholic’s family may sabotage attempts at recovery. In summary, it should be clear that treating trauma victims also means treating the family (Tarrier & Humphreys, 2003). Maladaptive Patterns Characteristic of PTSD Summed dynamically, PTSD involves five common patterns: death imprint, survivor’s guilt, desensitization, estrangement, and emotional enmeshment. Death Imprint. The traumatic experience provides a clear vision of one’s own death in concrete biological terms (Ochberg, 1988, p. 12). Particularly in young individuals, the sense of invulnerability is vanquished and is replaced by rage and anger at one’s newfound mortality (Lifton, 1975). For veterans in particular, there is a continuing identity with death. The normal boundary between life and death is toseeksens at is not unusual for veterans to describe themselves as already dead. The only way they have of testing the boundary between life and death is to seek sensation, even if it means danger and physical pain (Brende & Parson, 1985, p. 100). Combined with rage reactions, sensation-seeking behaviors put individuals squarely on a collision path with law enforcement agencies, employers, and families. Billie Mac: After every law officer in Mississippi started chasing me, I ditched the car and ran into a woods. They even had bloodhounds after me. I slipped through them like they were a sieve. It was crazy, but for one of the few times since I’ve been back I really felt alive. I’d done that a hundred times on patrol. Survivor’s Guilt. A second pattern is guilt. Guilt comes in a variety of forms: guilt over surviving when others did not, guilt over not preventing the death of another, guilt over not having somehow been braver under the circumstances, guilt over complaining when others have suffered more, and guilt that the trauma is partly the individual’s fault (Frederick, 1980). Most commonly, guilt takes the form of intrusive thoughts such as “I could have done more, and if I had he/she’d still be here,” or “If I had just done this or that, it (the trauma) wouldn’t have happened.” Dynamically, the basis of these thoughts may be relief that the other person was the one to die, or the individual was lucky to get off so lightly (Egendorf, 1975). Billie Mac: I was the only one in my outfit to get out of the Tet offensive without a scratch. I wonder why. Why me out of all those people? I’ve screwed my life up since then. Why did I deserve to get out clean when all those other good men didn’t? Going to the wall in D.C. last year tore me to pieces. I cried and cried when I saw the names of my buddies up there. Things really got screwed up after that. For other types of trauma individuals, bereavement is closely allied to survivor’s guilt. Facilitating grief includes the expression of affect, reconciliation of the loss of a loved one or a missed part of one’s life, the ambivalence of not having shared the same fate as others, and moving on to new and meaningful relationships (Ochberg, 1988, p. 10). Because numbing of affect is a major dynamic response to PTSD, it is extremely difficult for survivors to let loose their emotions and grieve. Desensitization. A third pattern is desensitizing oneself to totally unacceptable events and then trying to return to a semblance of normalcy in a peaceful world. Feelings of guilt and fear may arise over pleasurable responses to physical violence against others. These feelings may become so acute that the individual conceals firearms for protection against imagined enemies but is simultaneously terrified of the guns and what might happen because of the violence that continuously seethes below the individual’s own calm outer appearance. These strong bipolar emotional currents that flow back and forth within the individual lead to hostile, defensive, anxious, depressive, and fearful mood states that find little relief (Horowitz & Solomon, 1975). Billie Mac: I don’t hunt anymore. I hate it. Yet this one guy who was my boss didn’t know how close he came to getting killed. I was within one inch of taking him out; I was so hot. It would have been a pleasure; the guy was such an ass. Estrangement. A fourth pattern is the feeling that any future relationships will be counterfeit, that they mean little or nothing in the great scheme of things. As the person tries to ward off reminders of the experience, severe interpersonal difficulties occur. Because of the vastly different experiences they have undergone, PTSD individuals become estranged from their peers and truncate social relationships with them because “they don’t understand”—and indeed “they” do not. Victimization may also be part of estrangement. From being victimized in the original trauma, to possible secondary victimization by social ser

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