Jewish World Review June 25, 2002 / 15 Tamuz 5762

Post Traumatic Stress Disorder (PTSD): A very real condition

By Dr. Abraham Twerski, M.D. | It is rather strange that a condition which should have easily been identified on the basis of common sense was not recognized by the psychiatric profession until relatively recently. The term Post Traumatic Stress Disorder did not appear in the American Psychiatric Association manual until 1980. The reason this is important is because it indicates an attitude that can have bearing on recognizing the problem and instituting proper treatment.

After World War I, soldiers who showed symptoms of anxiety, irritability, nightmares and inability to cope with life were considered to have "a bad state of nerves" which was termed "shell shock." It was thought that they were cowards who wished to evade combat. They were subject to shame and threatened with court-martial. It wasn't until 1941 that the first clinical study entitled The Traumatic Neuroses of War was published.

The author, Dr. Kardiner, pointed out that war neurosis was considered by many physicians to be a "hysterical neurosis," and that this term led people to think that the patient was weak willed, malingering and trying to get something for nothing. After World War II, a more enlightened attitude developed, with the realization that prolonged combat could break even the strongest soldier, and that the psychiatric casualties of war were as real and as inevitable as gunshot and shrapnel wounds. It was not until the Vietnam war that the condition of "traumatic neurosis" was legitimized.

The resistance to recognizing that trauma can have long-term psychological effects still persists. Although there is sympathy for those who were victims of catastrophic trauma such as an earthquake, tornado or terrorist attack, there is a less positive attitude toward people who sustained personal trauma. As a result, people who have suffered personal trauma are hesitant to seek help for their problems. They may do their utmost to cope and may actually function quite well, but the unresolved residuals of the trauma may cause emergence of symptoms at any time. Shame and guilt may result in the memory of the trauma being buried in the subconscious mind, beyond one's awareness.

Children who suffered abuse or molestation may have difficulties in school performance and socialization. A variety of pedagogic and psychological techniques may be used to help them, but as long as the trauma remains a secret and unattended, they are not likely to succeed. The emotional aftermath of childhood trauma may cause serious disturbances in marriage and in parenting. People seeking psychological help may not even recall traumatic events of childhood. These must be skillfully elicited and dealt with.

Young children are extremely impressionable, and childhood trauma may have a much greater impact than similar trauma in adulthood.

After World War II, some psychiatrists tried to treat the combat neurosis by administering sodium amytal ("truth serum"). Under the effect of this drug, some patients were able to recall and describe the trauma. However, mere recollection did little to relieve their symptoms. What is necessary is an understanding and integration of the experience into consciousness. One must become aware of the emotions incident to the trauma, how they have caused the memory to be walled off and how they are affecting one's current behavior.

Symptoms of PTSD can occur anywhere from days to years after the trauma. Their effect on a person's functioning may range anywhere from minimal to totally disabling.

The primary symptoms fall into three categories: Hyperalertness, Intrusions and Suppression.

Hyperalertness means that the person is constantly on guard, as if danger is lurking and may occur at any moment. He is easily startled by noises or by any unexpected movement. The ring of an alarm clock or someone entering the door without knocking may trigger a reaction. The mind may perceive these as a threat, and the body may respond with the features of the "fight or flight" reaction. A person with hyperalertness may find it impossible to relax. He may have difficulty in falling asleep and may awaken several times during the night, with or without nightmares. Sleep deprivation may result in poor concentration, impaired memory and moodiness.

People who live with expectation of danger may actually precipitate some mishap. The tension and suspense that something terrible is going to happen may be so intolerable that they do something "to get it over with." They may start a business venture and do something to make it fail. They may have a good relationship and act in a manner that will make the other person reject them. They may be more prone to accidents. Each failure or accident may reinforce their feeling that the world is stacked against them.

The consequences of their anxiety breeds more anxiety in a vicious cycle that is reminiscent of the words of Job, "I felt great anxiety, and what I feared would happen did happen to me" (Job 3:25).

A person should experience joy in life. People with morbid expectations may be unable to accept feeling joy. They may fear that if they enjoy something they may lose it. One young mother with PTSD said that she dreads walking over to the baby's crib for fear that she would not find the child alive. "I don't feel I deserve to have such a beautiful baby." There was no logic to this fear. It was a symptom of her expecting something terrible to happen. Parents with PTSD who have morbid expectations may be so overprotective of their children that they cause them to become hyperalert and anxious and stifle their growth.

Intrusion means that the traumatic incident keeps coming back and intruding into their awareness. Any one of many things that is in any way reminiscent of the traumatic incident may cause the person to feel he is reliving it. This is called a "flashback." In order to avoid flashbacks the person may restrict his activities to avoid something that may trigger one. The person may avoid reading a newspaper, a book, or meeting people who may in some way trigger a flashback. He may become isolated and socially withdrawn. For example, some Holocaust survivors may avoid reading anything referring to the Holocaust, or even meeting other survivors for fear of experiencing a flashback of terror. Night terrors in the way of dreams are intrusive.

People who have experienced a personal assault at night may not leave their homes at night. A child who leaves the home at night may trigger an intrusive thought, and they may forbid their children to go out at night.

Suppression refers to keeping the thought out of awareness. Because it is a subconscious process it should more correctly be referred to as "repression." It is similar to the bodily defense of fainting upon an acute pain so that the pain cannot be felt. Some people describe the experience of a trauma as though it was not happening to them. This repression can occur both at the moment of the trauma or at any time later. Something which is too painful to realize may be banished from awareness

Clinically, this is especially important in cases of child molestation. The memory of the experience may be so laden with the negative feelings of fear, shame and guilt, that the person may not recall it. Nevertheless, the memory exists in the subconscious mind, from where the noxious feelings of fear, shame and guilt associated with the incident continue to exert their effect. The person may be depressed and/or have problems ranging from low self-esteem to loathing oneself, without a clue as to why one feels that way. She may employ any of the coping tactics described in my book Life's Too Short. Difficulties in interpersonal relationships and disturbances of marriage may be the result of such incidents. Because the causative trauma is not recalled, the person may attribute these difficulties to a variety of other causes, none of which are true. Even in therapy, the focus may be on resolving these other causes, which does nothing to alleviate the problem because the real cause is not addressed.

Some people may recall a traumatic incident and even describe it, but the memory is devoid of emotion and meaning. Allowing oneself to think about the memory might bring back the painful feelings one wishes to avoid.

Rape is one of the most devastating traumas a human being can experience. Proper management of the acute trauma may help forestall severe PTSD, but support and therapy may be necessary for a longer time. A man who had been mugged at night developed a fear of night. He took a job where he worked from 11PM to 8 AM, because that enabled him to stay awake all night. He was frightened of being defenseless when asleep.

The feeling of loss of control that is characteristic of trauma may result in strange ways of trying to gain control. Some people may develop superstitions or magical thinking. Some people may say that they had premonitions of a disaster and that they have omens about what may happen. Some may convince themselves that they brought the trauma onto themselves, and although this may cause them to feel guilty, the idea of "I caused it" can mean "because I made it happen, I can make it not happen." Ironically, the painful feeling of guilt may provide a modicum of relief because it may give them a sense of control. This may also explain recurrent nightmares.

The two symptoms, intrusion and suppression, have opposite effects. Intrusion tries to bring the trauma into awareness, and suppression tries to keep it out of awareness. The person with PTSD is caught in the middle, vacillating between states of intense emotion and no feeling at all. This why the person may be unstable and unpredictable, alternating between impulsive behavior and no action at all.

With so many possible symptoms, mood alternation and unpredictable behavior, the person with PTSD may be erroneously diagnosed and treatment may be ineffective. It is, therefore, important to be aware of PTSD, to prevent it when possible, to recognize it early, and to institute proper treatment.


Helping our kids deal with trauma
The Creator helps those who help themselves
Knowing what to expect
Psychological fallout in the shadow of terrorism
Self-esteem in the face of world terrorism

Abraham J. Twerski, M.D. is a psychiatrist and ordained rabbi. He is the founder of the Gateway Rehabilitation Center in Pittsburgh, a leading center for addiction treatment. An Associate Professor of Psychiatry at the University of Pittsburgh School of Medicine, he is a prolific author, with some 30 books to his credit. He has recently launched a new 12 step program for self esteem development Send your comments by clicking here.

© 2002, Abraham J. Twerski, M.D.