Post-Traumatic Stress Disorder is an excellent example of the disruption-reintegration process, this time precipitated by extreme stress. When it is not successfully managed on both a physical and psychological level, it too can become a medical disorder.
Earthquakes, floods, automobile and airplane accidents, wars, and acts of terrorism can easily set off acute episodes of emotional disturbance. This is only to be expected. Here failing to acknowledge those feelings of anger, terror, perhaps despair, which are appropriate to the experience, and then, quickly or gradually, put the pieces of oneself and one's life together again can set the stage for chronic disability. This is a particular risk if the traumatic events are extremely intense and/or prolonged, exposing people to serious and often life-threatening hardship from which there seems to be no obvious escape. Those who survive are expected to be relieved and grateful, determined to quickly put the entire experience well behind them as soon as possible. At least that's what the stiff-upper-lip philosophy teaches.
Of course, nothing could be further from the truth. Terrible personal traumas in childhood, such as physical and sexual abuse, leave scars that can last for years, even for the rest of a person's life, as do combat experiences for many soldiers in front line combat. In the past, acute and immediate episodes of anxiety, depression, or rage were often neither adequately acknowledged and understood nor effectively dealt with. They went underground, becoming chronic, and exerting a destructive influence on the intellectual, emotional, and interpersonal lives of those affected. Such a failure to reintegrate is now officially termed Post-Traumatic Stress Disorder (PTSD), meaning that the physical, psychological, and behavioral consequences of the traumatic experience refuse to go away.
Meeting the Criteria for Post-Traumatic Stress Disorder
To qualify for this diagnosis, a person must have been exposed to a traumatic event in which he or she experienced, witnessed, or was confronted with a situation involving actual or threatened death or serious injury to oneself or others. The emotional response must consist of intense fear, helplessness, and/ or horror.
Anyone who survived or even witnessed first-hand the attacks on the World Trade Center in New York or the bombing in the Bali nightclub filled with unsuspecting young revelers would readily meet these specifications.
But there's more.
• Details of the traumatic event must be persistently and/or recurrently re-experienced in one or more of the following ways:
• Recurrent, intrusive, distressing recollections or dreams of the event
• Acting or feeling as if the traumatic event were recurring, such as a sense of reliving it or having flash-back experiences
• Intense psychological distress and/or physiological reactivity at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event**
• There must also be evidence of persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness that was not present prior to the trauma, as indicated by three or more of the following:
• Efforts to avoid thoughts, feelings, or conversations associated with the trauma
• Efforts to avoid activities, places, or people that arouse recollections of the trauma Inability to recall an important aspect of the trauma
• Markedly diminished interest or participation in significant activities**
• A feeling of detachment or estrangement from others**
• A restricted range of affect (e.g. being unable to experience and demonstrate loving feelings)
• A sense of a foreshortened future (e.g. one does not expect to have a career, marriage, children, or a normal life)**
• Finally, there must be evidence of increased arousal, as shown in difficulty falling or staying asleep, irritability or outbursts of anger, problems concentrating, hyper-vigilance, or exaggerated startle responses**
My Personal Experience With PTSD
Shell-shock was the term that used to be used for PTSD during tile First World War, and later, combat neurosis. The diagnosis seemed to be primarily confined to the military. Most soldiers with various forms of acute stress reactions in the context of combat reintegrated themselves quickly once they were removed from action; had the chance to rest, to and talk about what they had been through with empathic listeners; and then were sent back to duty without delay. But for many, the memories and emotions connected with war continued to linger, sometimes revealing themselves through dreams, as if the unconscious mind was slowly, gradually resolving the psychological pain that had been inflicted.
The scene in the film Spellbound in which Gregory Peck lies in bed in the psychiatric sanatorium and listens fearfully to the roar of dive bombers and the staccato bursts of machine gun fire will be familiar to Alfred Hitchcock fans. I recall a friend of mine who, when he was twenty-four-years old, served with me British forces in China in World War II. Assigned as a military adviser to a Chinese infantry division, he and a few officers were separated from the main body of men when the Japanese attacked by surprise and in overwhelming number. He watched helplessly as heavy armor, supported by fighter planes and artillery, annihilated his comrades-in-arms. For hours, hidden in a nearby wood, trembling with fear, he could not move. Then, arduously, he and the few survivors found their way back to their command base. "Funny," he said to me once," I don't remember being relieved at being alive. I don't remember feeling anything … except numb. I never saw action again.
For years afterward, I had the same dream, over and over again. I'd be there, only a few hundred yards away, watching those troops being blown apart. Blood and the smell of death were everywhere. Then, a couple of years ago, the dream just disappeared." I wish I had known about Post-Traumatic Stress Disorder in 1950 when I really needed to, but then, in those days, not many people did. Please note I do not use the term disorder here, because the reaction becomes a disorder when you don't recognize and deal with it in its syndrome stage. I didn't apply the concept to myself until the early 1990s, and only then did I see how it had become a disorder and increased my vulnerability to the stresses that occurred in my life when I was 39.
At 23, I felt I had all the time in the world stretching before me. I was a third-year medical student. Along with several of my classmates, I was spending the summer between my junior and senior years of medical school studying tropical medicine at the University of Havana, in Cuba. One bright sunny afternoon, a friend and I took a small sailboat out from the Havana Yacht Club. In a brisk breeze, we carelessly sailed out much too far. In those days, few youngsters wore helmets when riding bikes or roller-skating; there was no such thing as a seat belt; and sailors like us often went out to sea without life-jackets. We were not at all prepared for what happened.
Although I had had a good deal of experience with boats, my friend had not. So when it came time to come about, he swung his body toward the wrong side of the boat. We capsized. The mast and sail floated away. With great effort, we were able to right the hull and crawl back into it. But it was filled with water up to our waists.
Helpless, terrified, we sat there as the current drew us slowly along the coast. We knew we were too far from shore to swim; besides, the water was filled with sharks.
All night long we drifted, watching the shore lights flicker off, one by one. A colorfully lit dance boat passed us by, but the loud music drowned out our cries for help. Then came total darkness. Hour after hour passed. I worried about how long the wooden shell would stay afloat and fought against the fear that we would die, either because the boat would sink or because we would drift out to sea and be scorched by the powerful tropical sun when day came. Sometime during the night, my friend screamed out in pain; a large jellyfish, a Portuguese man-of-war, had swum across his abdomen, leaving in its wake huge welts produced by its poison. As I recall, he spoke of committing suicide and I, in desperation, encouraged us both to pray out loud.
Fourteen hours later-Did we fall asleep? Could we have? I can't remember-as dawn came, the sun rose in the distance above lush green hills that looked like a Vermont landscape. We were still the same distance from shore. The current had not carried us away from the coast! From the harbor in the province of Pinar del Rio, we could see an old freighter slowly plowing its way toward us. As it came nearer, I could read a name painted on its side: Lehigh Portland Cement. Later, sitting on the deck of the rescue ship, drinking black coffee and biting on hard biscuits, I still shivered with fear.
We returned to New York and resumed our normal lives. I spoke superficially about the experience with a few friends, but I never really expressed the horror, guilt, and remorse that had gripped me for so many hours at sea. I felt as though I had lost a precious sense of direction in my life. There were often times when I felt as though I were floundering, and times when I actually felt strangely depressed. My academic work fell off-I had been one of the top students in the class. I didn't sleep very well, an insomnia that lasted for years. I felt emotionally numb. I lost interest in many of the things I had once felt excited about. For the first time in my life, I felt socially ill at ease. I married right after graduation and was immediately thrown into the nightmarish pressure of my internship on the medical services at Bellevue Hospital in New York City, an experience my friends and I felt we survived by the skin of our teeth.
On the list above, I've indicated by asterisks (**) the signs and symptoms of PTSD that I had. But I never connected these with my accident until, five years later, I began my own personal psychoanalysis with Dr. Bertram Lewin as part of my preparation for psychiatric work. It was the first time I had spoken with anyone about what it had been like emotionally. I felt greatly relieved, but that was not the end of it. I'm sure that lingering aspects of my post-traumatic stress disorder contributed to and compounded the crisis I faced later at 39. And it was only in the early 1990s that I really put all the pieces together and asked my regular physician to start me on sertralj.ne (called Zoloft: and subsequently approved for the treatment of PTSD by the FDA), and I finally found the last vestiges of distress ebbing away.
Who Is At Risk?
When dangerous events are truly horrific, almost everybody can and will develop some kind of Post-Traumatic Stress Disorder. However, not everyone will develop Post-Traumatic Stress Disorder. The more immediate and intense the threat-if you were actually inside the World Trade Center when the planes struck and you escaped, or if you were a journal.ist covering the war in Afghanistan and traveling with a team of army rangers when they were suddenly ambushed by Taliban militia-the risk is far greater than if you witnessed these events at some distance. A number of people who display a higher level of pre-existing physical, psychological, and interpersonal resilience may weather the worst of traumas successfully, recovering from the impact in a matter of weeks. The professionals now term this short episode "acute stress disorder", unfortunately somewhat obscuring the line between states of disruption that are normal, healthy, and necessary and those that are not.
A number of factors are associated with reduced resilience, thereby increasing the risk of failing to reintegrate following a reaction to trauma: These include:
• A history of an inadequately treated psychiatric disorder, such as chronic depression
• Alcoholism and substance abuse A family history of anxiety, suggesting biological dysfunction that may be conveyed genetically
• Childhood physical and/or sexual abuse
• Adverse life events (such as early separation from one's parents or being a member of a disturbed family)