The idea for this podcast episode comes from listener Phoebe Gavin of New York City. In addition to being an OIF veteran, Phoebe is a member of Iraq and Afghanistan Veterans of America (IAVA), the first and largest non-profit, non-partisan association for new veterans. Thank you, Phoebe, and all your fellow veterans, for your service.
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Let’s begin with two adapted-from-real-life stories to paint a more accurate picture of PTSD. Consider proceeding with caution if you’re a super-empathizer or a survivor yourself. A pleasant spoiler: both people I describe are doing fine now.
Two PTSD Test Cases
We’ll start with Kim. Kim is a 26-year-old former patient. As a child, her alcoholic parents neglected her, leaving her alone for long stretches of time. Even when they were present, they were often too drunk to notice anything. A male neighbor took advantage of the situation and molested Kim for several years. Each time Kim tried to speak up, her parents told her, beer bottle in hand, that she was lying. The abuse finally stopped when she reached puberty. Kim was functional, though promiscuous, through high school, but when she saw the neighbor at a local car wash several years ago, something snapped.
When Kim first started coming to therapy, she was having nightmares, flashbacks, and panic attacks almost every day. Seeing any unfamiliar man, even a grocery store checkout clerk, automatically triggered the thought that he was going to force himself on her. As a result, she had dropped all her college courses and stayed in the house as much as possible. Several of Kim’s friends were supportive, even if they didn’t always understand. Her mother, however, told her to snap out of it and said she was just trying to get attention.
Larry is another former patient. He has diabetes and was in a freak accident that left him locked in a self-storage unit for 48 hours. He was in ketoacidosis and in and out of a diabetic coma by the time he was found, and the emergency room doctors said he had the highest blood glucose levels they had ever seen. After two weeks in the ICU, he was released. Once home, Larry had a horrible time sleeping because every room in his house reminded him of being locked in the storage unit. To make things worse, going to sleep and waking up reminded him of passing in and out of his coma. He couldn’t make it through a day at work. His wife told him to pull it together.
Kim and Larry both had post-traumatic stress disorder, or PTSD, which is the only mental disorder that must be caused by an outside event.
What Is PTSD?
The trauma that sparks PTSD can be experienced directly, like combat, assault, being in a fire, or Kim’s or Larry’s experience. But witnessing something horrific is also valid, like watching someone drown or get shot. Similarly, repeated exposure to the aftermath of tragedy counts as well; this category might include child protective service counselors who deal with child abuse day in and day out, or the cleaning crews dispatched to mop up grisly crime scenes.
As of the most recent version of the diagnostic bible, the DSM 5, there are 4 groups of symptoms, plus one that occurs only in some cases:
Symptom #1: Intrusion. Also called re-experiencing, these are the memories that come rushing back, seemingly out of nowhere, and are so lifelike that you feel you’ve been sucked right back to the trauma. Re-experiencing makes you relive the worst moments of your life again and again.
Re-experiencing can include flashbacks, nightmares so vivid they feel real, or intense memories. The smell, the house, or the stretch of highway that re-ignites the traumatic memory is called a trigger. For example, every time Larry woke up in a dark room, the trigger of darkness sent him right back to the storage unit. Kim would get triggered whenever anyone looked her straight in the face, which is how she remembers her abuser. In other examples, a song that was playing during an assault might set off a flashback, as might the sound of fireworks for a traumatized combat veteran.
Symptom #2: Hyperarousal and reactivity. For some, hyperarousal (which has nothing to do with sexual arousal) means being terrified all the time. Constantly being on edge, jumpy, paranoid about perceived danger, or vigilant for threats leads to trouble sleeping and concentrating. For example, Kim was always on alert for men and literally ran away if a strange man approached her.
For others, hyperarousal may play out as feeling aggressive, impatient, irritable, or angry, or as self-destructive behavior like cutting, getting into fights for no reason, or promiscuity, all of which make sense when you think about it—powerful short term distraction must be a welcome, if dangerous, diversion.
In sum, hyperarousal is being on constant alert. You're always ready for attack. In a war zone overseas or a war zone of your own household, hyperarousal is simply called being ready. However, once you’re safe, whether that’s post-deployment or post-abuse, it can seem impossible to turn off.
Symptom #3: Avoidance. This is a big one. Your brain is smart and it wants to stay far, far away from anything even remotely related to the trauma. Someone assaulted in a parking lot at night, for example, will likely stay away from all parking lots at all times. Car accident survivors often won’t get in a car. Victims of traumatic break-ins might move.
Avoidance isn’t limited to locations; it can also include thoughts, memories, and emotions. For instance, many survivors can’t or won’t talk about what happened. Others avoid trusting anyone. Strong emotions may also be avoided—you may not be able to feel loving, affectionate, sexual, or sad; you may be unable to grieve a loss. Avoidance can also take the form of using alcohol or drugs to block out overwhelming feelings.
See also: How Do You Know If You Have a Drinking Problem?
Avoidance is often far-reaching; to feel safe, the mind builds in a wide buffer, no matter the cost. For example, a colleague of mine had a patient named Claire who was assaulted by a supposed friend while she slept. As a result, Claire spent years avoiding sleep, believing it was unsafe, which made sense given her experience. She worked double shifts, took night classes, and lived on coffee, which in our workaholic culture, no one questioned. Only after she fell asleep while driving did she seek help and finally connect the dots.
Symptom #4: Negative thoughts and feelings. Negative thoughts about the self and the world are near-universal in PTSD. In order to wrap the mind around an unthinkable experience, the brain does all sorts of gymnastics: “If I hadn’t fought back, this wouldn’t have happened.” “If I had fought back, this wouldn’t have happened.” “It’s my fault.” “I should have died instead of my buddy.” “If I look attractive, I’ll be attacked.” “My selfishness killed him.” “I am vulnerable at all times.” “I can’t trust anyone ever again.” “I wasn’t worth protecting, so that’s why no one helped me.” Negative thoughts may also take the form of questions: “What did I do wrong?” “What did I do to deserve this?”
Negative thoughts cause a quick slide into negative feelings. You may withdraw from the world, feel numb, or not feel much besides anger. It’s also common to lose interest in your life or be unable to picture a future; for example, you may believe you’ll die sooner than other people or won’t reach milestones like finding a partner, having children, or graduating from school. Likewise, you may have a hard time feeling positive emotions, like love or joy, and lose interest in people or things that used to be important. At worst, you may feel life isn’t worth living, wish you were dead, or try to hurt yourself. Please, call 911 or go to the emergency room if you’re worried you can’t stay safe.
See also: 11 Little-Known Signs of Depression
Symptom #5: Dissociation. In the most recent diagnostic rule book for mental health professionals, the DSM 5, a dissociative subtype of PTSD has been defined for the first time. Dissociation, broadly described, is feeling detached from who you are, what is happening, or your body. In a series of 2012 studies, 12-30% of folks with PTSD, mostly those with severe symptoms and exposure to childhood or adult sexual traumas, experienced dissociative symptoms.
Dissociation during the trauma makes it more likely that PTSD will develop, and can make it harder to treat. Survivors who dissociated during their trauma may report feeling as if they were outside their body observing the scene, feeling as if it wasn’t really happening, or there may be blanks in their memory.
Even well after the trauma, dissociation may occur as a symptom of PTSD, most often in reaction to triggers or stress.
There are variations on dissociation, including depersonalization, which is a feeling that you’re not real. For example, you may have the experience of not recognizing yourself in a mirror, feel invisible, feel like a robot, or look at your hand, for instance, and think, “This is not my hand.” There’s also derealization, or a sense that the world is not real, which may feel spacey or like a dream.
In sum, dissociation is the brain’s attempt to cope and process during a time of danger. When the body can’t physically escape, the brain goes to extremes to get through the trauma and create emotional distance, even at a steep cost.
To wrap up, let’s circle back to Kim and Larry, both of whom, after a lot of hard work in treatment, are doing well today. Both have up days and down days, and while the memories of their respective traumas will never be pleasant, Kim and Larry can function and move forward rather than being dragged back into the past by PTSD.
If you recognized yourself or someone important in your life in today’s show, please seek out a qualified psychologist or psychiatrist. PTSD should be diagnosed in person by a qualified professional. And thankfully, PTSD is treatable. Have courage and, just as importantly, have hope.
Disclaimer: All content is strictly for informational purposes only. This content does not substitute any medical advice, and does not replace any medical judgment or reasoning by your personal health provider. Please always seek a licensed physician in your area regarding all health related questions.
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