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|POST-TRAUMATIC STRESS DISORDER|
The expression post-traumatic stress disorder (PTSD) has been used for several decades. Many books have been written about the topic of traumatic experiences and the long-term impacts. Surprisingly, even the most knowledgeable experts have been struggling with the physiology of PTSD and with its seemingly unpredictable outcome. Unlike other works, which only rely on clinical observation and psychology, this page explains post-traumatic stress from an additional viewpoint that incorporates the physiology of the human brain. This approach represents a dramatic change in the understanding of this disorder. Without the inclusion of the brain function and architecture, the study of PTSD is prone to quickly deteriorate to guesses, uncertainties, or unrealistic expectations.
WHAT IS TRAUMA?
A trauma or traumatic experience arises from any real event that produces undue degree of mental stress. The brain reacts to the excessive stimulation in many ways. The common theme is that the human organism perceives the experience as harmful to its well-being. From this viewpoint, trauma and common everyday stress represent unpleasant mental stimuli that only differ in their degrees of stress effects. The mildest forms of stressful but non-traumatic experiences include everyday challenges. More significant stress is associated with all major changes in a person's life, including positive changes. Most people do not realize it, but relocation to a new place, getting a new job, marriage, birth of a child, purchase of a house, house remodeling, sending a child to college, and similar changes are very stressful. Half a dozen of such beneficial changes in one year can result in a heart attack, development of cancer, or mental exhaustion. By contrast to common stress, traumatic stimuli are more intense, and one event is usually more than enough to produce serious harm to a person's mental health. Mild traumas can include identity theft, significant financial loss, property loss, loss of treasured personal items, loss of occupation, gross invasion of privacy, breakup, divorce, natural death in the family, forced exile, or imprisonment. Severe traumas include witnessing or being the subject of a severe injury, rape, torture, mutilation, murder, mass killings, or life-threatening flooding, volcanic eruption, tornado, hurricane, or forest fire.
In the above experiences, the bigger the potential harm to the victim is, the more traumatic the experience becomes. This is why threat to one's life, deprivation of fundamental biological needs, sexual violation, and deliberately inflicted personal injury are the most severe traumatic experiences. More specifically, severe traumas are associated with seemingly inescapable situations when a person is buried in an avalanche, is trapped in a submarine at the bottom of the sea, or is directly threatened by fire. Although such dangers and happenings are very fearful and can overwhelm the survival instinct, even higher degree of stress is produced when the harm comes in the form of interpersonal acts; that is when another person willfully harms the victim. This includes torture, mutilation, or rape.
What makes a trauma stressful is not only the happening itself, but the intent and the potential effect on the victim. If your cousin accidentally shoots you in the leg, there is no trauma, other than your physical pain. But when someone threatens you with a gun for hours and then shoots you in the leg with a promise that the next bullet will hurt much more, that is an extremely traumatic situation. Similarly, a massive forest fire is not scary when you watch it from a safe place, but being surrounded by a wall of fire from all sides with almost no possibility of escape is an extreme trauma that can make even the strongest minds frantic.
Traumas usually owe their significance to direct experience by the victim in real time. But some traumas are so powerful that they do not have to be experienced by the victim. When a mother watches a videotape of her child being set on fire, or when she sees her child fall from a window of a tall building, or when she sees her child being attacked and eaten by a bear, she is having an extreme experience.
Now compare the above mentioned horrific images with a movie that shows American Natives fighting the U.S. cavalry in a western. There are countless Indian warriors who are shot on foot or on horses. No blood or dismembered bodies, just Indians who are hit by bullets and die without causing trouble and undue distress to the viewers. This is a nice clean program that is suitable even for the youngest viewers. The images and the outcome of the battle are socially acceptable and are suitable material for our children, who need to learn that a good Indian is a dead Indian. But the same society objects to detailed depictions of murder, blood, violence, and sex on television. And yet the society goes to war to do these unacceptable things.
By contrast, some interpersonal acts are so fundamentally evil and horrific that they traumatize even those who commit them. After a failed attempt to kill Adolf Hitler in World War II, the conspirators were hanged on hooks and left to very slowly die in excruciating pain. The filmed scene pleased Hitler, who liked watching it for personal amusement. But neither his Propaganda Minister Goebbels nor many of the SS troops who were shown the images were able to keep watching. Some just left the room, and some even vomited.
Another important aspect of trauma is its relativity. When President George Bush was describing how the 9/11 hijackers cut the throat of a female flight attendant, he appeared and sounded angry, disgusted, horrified, and traumatized. But when American rockets and airplanes were incinerating, pulverizing, dismembering, mutilating, and terrorizing thousands of residents of Baghdad, whose only crime was that they lived under a brutal dictator, the President and his administrators appeared jubilant.
WHAT IS POSTTRAUMATIC STRESS DISORDER?
PTSD is an all-catch term that refers to the overall manifested consequences of a past traumatic experience. External post-traumatic symptoms that can be seen by an observer include one or more of the following: strong startle reflex, agitation, hypervigilance, hallucinations, paranoid fear, aggressive protective reaction, passive protective reaction, acting out in sleep, or loss of consciousness. Internal manifestations may only be known to the affected subject and usually include nightmares, flashbacks, anxiety, fear, feeling of depersonalization, or loss of awareness of one's body.
The above positive symptoms of traumas have been extensively described in clinical literature. By contrast, little is mentioned about the negative symptoms of PTSD. In fact, PTSD is largely defined by its positive symptoms. Although the negative symptoms are inseparable from a traumatic experience, only few have been included in the medical profile of PTSD. Clinical manifestations of negative responses include trance, spacing out, emotional shutdown, complex dissociation, or hidden switching between personalities. These dissociative mechanisms do not produce stress at the present, but have evolved in response to stress during or relatively shortly after a traumatic experience. A common negative symptom of severe traumas is repression of memories. Inaccessibility of information about an experienced trauma is the opposite of the positive symptoms of PTSD. The traumatized subjects may lose some or all conscious awareness of their experiences, and the information may not be retrievable during consciousness. In some cases, only deep hypnosis is capable of bringing forth the memories. In extreme cases, not even hypnosis will work.
The above characteristics indicate that PTSD floods the conscious mind with unwanted reminders of a stressful experience, but repressed memories keep the knowledge away from consciousness. Both types of these post-traumatic consequences are persistent, are difficult to correct, and arise from incorrectly processed traumatic memories.
The emergence of positive versus negative aftereffects depends on the subject's ability to tolerate traumatic stress. If the trauma is tolerable, the person is aware of the aspects of the trauma and reacts to them with fear or similar positive symptoms. Experiences that are too stressful to be perceived in full consciousness result in awareness that is not conscious, but is only lucid. Thanks to this dissociative state, unpleasant emotions are not experienced. The subject perceives the world factually, but without the negative emotional valence or without the personal, social, or moral meaning of the facts.
WHY DO PTSD SYMPTOMS EXIST?
Post-traumatic stress disorder develops because the traumatic information is not correctly processed during the actual episode or because the trauma resulted in lasting damage to the brain. Both scenarios can produce repetitive reminders of the trauma or nonvolitional acts during wakefulness or sleep. The poorly handled traumatic knowledge is not incorporated into the mind during memory consolidation, and the goals of memory consolidation are not met. The trauma now remains partially or fully isolated from the overall biographical experience. Another aspect of traumatic experiences is that the damaged brain fails to properly coordinate the various neural systems. As a result, the brain is unable to correctly activate or shut down neural structures, and leakage of traumatic information into consciousness or into executive circuits gives rise to the symptoms of PTSD.
Penetration of traumatic material into consciousness commonly happens in nightmares that result in awakening. In fact, nightmares would not be what they are if the subject remained asleep. The interesting aspect of nightmares is that they can be triggered even by made up material, that is by events that never happened in any shape or form. As the dreaming human brain is waking up under the stimuli of the unconscious, the emotional brain processes the information before the conscious mind does. Perception of the dream events and of the emotional valence occurs before the brain can rationally explain what is happening within the overall context. It takes several seconds to realize that the imagery is a dream and that the here and now has nothing to do with the dangers depicted in the dream. Thereafter, several additional minutes are needed to completely erase the emotional effects of the dream and return the brain to a calm state. This is the normal process of suppression of nightmares that are unreal. Such fabricated nightmares are unlikely to appear again and usually are resolved the very first time. By contrast, nightmares that relate to true experiences keep coming back until all the important aspects are explained in one's consciousness and until all the episodic gaps are accounted for, and until all the loose ends are tied together.
Whether or not someone develops PTSD or is only temporarily affected by a traumatic event depends on his state of the brain and mind. A traumatic event is perceived as traumatic by both healthy and previously traumatized/brain-damaged subjects. A man with no previous trauma is resilient and able to handle the present trauma up to a point. The healthy man may deal with the current trauma factually and respond to it in full consciousness. Or he may temporarily dissociate and fail to process the trauma in full consciousness while the situation persists. But once the man is safe and can reprocess the information, his circuits of emotional intelligence can place the events and their meaning in perspective and make them part of personal history. This major step need not be the end of reminders of the traumas, because the memories must still undergo the process of consolidation, which may last about two years. If some issue is not fully resolved during this period, the subject may have another dream or a flashback about the material. This is, in essence, a message that something does not fully fit together. The issue is not the trauma, but the broken, incomplete, or otherwise damaged associations of the trauma with the remaining biographical experience. The man does not understand the trauma, the reason for the event, its meaning, and its lasting effect. The outstanding issues need to be processed in full consciousness to correctly place the traumatic event in context and to allow the completion of memory consolidation.
As an example, a driver is injured in a car crash. The subject may not have seen the oncoming vehicle and may have lost consciousness. After regaining consciousness, the victim feels sore and has a broken limb. The subject is fearful for a week or two, and any sight of a moving vehicle gives him a feeling of extreme vulnerability. But a month later, he is back behind the wheel and goes on with his life as if he experienced no trauma. He is able to function normally only because of his properly functioning mind. He has taken the time to analyze the events that led to the accident and to acknowledge the consequences. Recognition and acceptance of the facts and effects of the trauma turn the information into a common one. The memory of the trauma now has the same properties as any other information has and can be consolidated in a standard way. But a man who has experienced previous traumas, has succumbed to permanent dissociation, or has lost a significant amount of his emotional intelligence will fail to appropriately process and consolidate his memories, and will develop a lifelong condition known as PTSD.
The remarkable thing about traumatic memories is that they can be resolved and consolidated even decades after the traumas if the brain functions correctly. The Author had a traumatic experience in very early childhood, but he had absolutely no awareness that anything happened to him. Nevertheless, he would have the same recurrent nightmare every four or five years all the way into adulthood. Then he remembered a story his mother had once told him, and he made the connection with the nightmare. The dream vanished and has not bothered him in twenty years.
In the long run, every healthy person can manifest the symptoms of a past trauma when voluntarily re-experiencing the past. The memories and their emotional effects never go away, but the healed victim can decide if, when, and to what degree the memories may reach the conscious mind. If no voluntary decision is made to think of the past, the memories remain dormant and do not bother the subject. And even if they happen to resurface because of some direct sensory stimuli, the memories can be quickly explained in the overall context (in current time, space, and social environment versus the past) and do not result in overwhelming emotional states. By contrast, people who develop PTSD re-experience their traumas involuntarily and very frequently. The subjects have poor control over the flow of traumatic memories into consciousness. Thus, resolved traumas cause no problems in daily lives, but unresolved traumas do not become part of the consolidated personal history, remain fragmented, and are brought to consciousness because of their cognitive incompatibility. In a way, such memories behave like a small stone in the shoe. The stone is there all the time. It is mostly harmless and acceptable to live with. But the stone occasionally moves around and causes sharp pain.
SUSCEPTIBILITY TO THE DEVELOPMENT OF PTSD
Clinical work shows that not every person develops the classical symptoms of PTSD. Some people live through traumas with little aftereffect. The usual reason for mild and brief consequences is a good preexisting neuropsychological condition. A person with fully functioning mind and intact emotional intelligence can not only understand what is happening during traumas, but can also realistically assess the situation after the trauma and accept that nothing could have been done to prevent the trauma, and one should not blame oneself or be ashamed of anything. The trauma happened, and avoiding it was not possible.
A subject who has lived through previous severe traumas or is exposed to a very severe trauma at the present responds to his current experience differently. Very severe traumas are overwhelming and are not processed correctly. The traumatic experience damages the brain and the mind. The subject may not correctly associate cause with effect in matters of personal or social issues because of compromised emotional intelligence. In fact, every trauma somewhat diminishes emotional intelligence, and preexisting traumas are major predictors of the subject's response in the current traumatic situation. The more traumatized a subject was prior to the current traumatic event, the less able he is to handle the current trauma. For this reason, people who are victims of long-term childhood abuse will fare poorly in present traumatic situations. The subjects' post-traumatic symptoms will likely be strong and plentiful. The victims will predictably try to distance themselves from the reminders of the traumas, and thus enhance the emotional affect of the unrelenting reminders of the troubling experiences.
The typical methods people with PTSD use to suppress reminders of traumas include general busyness, chain smoking, and numbing of consciousness with alcohol, drugs, and medications. These approaches are often successful, and the traumas remain hidden from consciousness. But the subconscious mind becomes even more fragmented, disorganized, and neurobiologically damaged. In turn, the damage reflects back into consciousness and causes further decline of intellectual abilities and especially emotional intelligence. (See Multiple Personality Treatment for the explanation of the physiology.) Malfunction of the mind predisposes the subject to getting oneself into another traumatic situation while the cognitive faculties are severely compromised. And this fact leads to even deeper neuropsychological damage and more prominent post-traumatic aftereffects. For many victims affected in this manner, the only way out is suicide.
POSTTRAUMATIC STRESS ONSET
The first signs of an experienced trauma may occur immediately, but it usually takes up to a month to clinically distinguish between a direct aftermath of a trauma that is followed by spontaneous recovery, and the lasting consequences that represent PTSD. Clinical cases indicate that the positive symptoms of PTSD are strongly attenuated while the subject remains in the traumatic environment. A person who is tortured, kept as a sex slave, confined to a battlefield, or otherwise depends on her abuser will have very few positive symptoms while staying in the harmful situation. In many cases, the mental confinement leads to profound dissociation that shows as negative symptoms or unnatural display of satisfaction with one's fate. For example, a battered wife with a broken nose pleas with the judge to release her husband because he treats her good. Another extreme is a girl who is raped by her father. She defends him against such accusations and describes him as the best father there ever was. Another example is a soldier who keeps risking his life because he mindlessly cares about his unit or branch of service.
The above examples are extreme, but similar mechanisms also exist in the workplace. An employee does his job and is happy, not recognizing how much he has to sacrifice for his employer. A similar situation exists in a production hall filled with noises, harmful fumes, and danger on every step. The environment is inhumane, but becomes imprinted in the worker's mind so strongly that he considers it part of his soul and is unwilling to leave. He is unable to recognize the harm to his health at this point. Doing so would render him incapable of carrying out his duties. Also submarine crews or astronauts suffer from undue suppressed stress that only waits to break through at the most inconvenient moment. Some Russian cosmonauts had to be removed from the space program because they succumbed to overwhelming fear. This is a particularly important finding because cosmonauts do it voluntarily, feel good about their job, are dedicated, but then may succumb to the fears they had been trying to keep under control.
All the above mentioned subjects live in environments and relationships that promote the relevant mindsets. Release of a subject from the relationship allows the person's mind to put aside fear, to give up the priorities associated with the relationship, and to focus on personal needs and desires. The sudden change may lead to a burnout in a hard worker. The job may suddenly seem overwhelming and uninteresting. Similarly, a combat veteran who is on a leave may recognize the hopelessness of his existence in the military and may desert, determined never to harm anyone again. A victim of intrafamilial abuse who finds a caring partner may unexpectedly become flooded with unbelievable images of rape, torture, and mental abuse by her parents.
How soon after leaving the threatening environment the repressed traumatic memories emerge is not possible to predict. Some victims of childhood abuse leave their homes only to enter other abusive relationships with their partners and never have a chance to manifest their PTSD symptoms. The traumas are suppressed. Also a combat veteran who joins the police may unknowingly remain in the structured environment of subordination and may never have a chance to mentally relax until he retires. Then all the traumas of the past may come to haunt him.
In general, victims of traumas try to avoid the reminders of their painful experiences, or the subjects seek such experiences excessively. A schoolgirl who is regularly raped at home may become a prostitute because she is attracted to the familiar lifestyle and the familiar emotional and mental experiences. A soldier who retires may sign up as a security contractor in the war zone. A person who is beaten by the big boys in the neighborhood may become a professional boxer or wrestler. Thus, traumatized subjects preferably choose occupations that allow them to be close to past experiences. Sometimes the subjects continue as victims, at other times as abusers, or as both victims and abusers.
THEORY OF RESOLUTION OF TRAUMAS
To resolve a trauma means to process the experience in full consciousness, engage the neural circuits of emotional intelligence, interpret the meaning and significance of the experience, store the memories correctly, and successfully complete the process of memory consolidation. These steps are absolutely essential if resolution is to be achieved. Failure in just one step of the process may cause that the trauma remains unresolved.
Clinical work shows that severely traumatized patients have often suffered irreversible brain damage and have compromised emotional intelligence. They are unable to interpret the meaning of their experiences in the overall cognitive context. The experiences are not understood in terms of their overall effect and context, and retain their traumatic nature. A less traumatized patient might be able to comprehend the meaning of the trauma and might store the memories in such a way that the traumas would lose their prominence and would be degraded to common information. However, because of dissociation and partial loss of emotional intelligence, even these healthier patients need to undergo repetitive counseling and repetitive retrieval of their painful memories before the subjects succeed.
Next to low emotional intelligence, trauma victims frequently suffer from complex dissociative disorders. This neural damage prevents consolidation of memories. Neural structures responsible for processing of memories are not communicating with the rest of the brain or have been damaged. Under the circumstances, there is little medical science can do.
ATTEMPTS TO FIX THE BRAIN MACHINE
A large number of doctors are trying to treat PTSD by employing their inadequate knowledge of the brain. They want to give the biological machine the necessary chemicals, electric shocks, or intracranial stimulation to restore normal function. It has become clear over the years that PTSD can damage the hippocampus, the HPA axis, and the prefrontal lobes, and so doctors should try to restore the functions of these neural structures. But the good doctors do not know how the brain works and are using treatment approaches that are ineffective and even harmful. Pharmacology is usually perceived as a panacea for PTSD, and psychiatrists do not hesitate to prescribe drugs. When a patient appears sad and unresponsive, he gets antidepressants. When a patient has nightmares, he is given sedatives. When a patient reports intrusions of threatening thoughts and images into his consciousness, he is given neuroleptics. In all these approaches, doctors aim to make the patient polite, docile, well-behaved, and feeling good about himself. But this strategy interferes with conscious processing of memories and with the process of memory consolidation. The patient may now appear calm, but he is unable to work with his chemically blocked emotions and memories, and is also unable to achieve progress. The very treatment blocks his recovery.
OBSTACLES TO PROGRESS IN TREATMENT
Preexisting traumas and brain damage are the biggest obstacles when a person tries to resolve one's traumatic experiences. It is now clearly established that soldiers have been traumatized as children and have lost their emotional faculties. With this mindset, they join the armed forces to fight enemies of their country. Many soldiers openly declare that they have joined the service because they love their country. In reality, the subjects are acting out their unresolved past traumas. They want to dominate, plunder, rape, and kill. The military gives them the opportunity to do so.
A soldier in combat experiences many life-threatening situations. He sees his colleagues being wounded, killed, shredded, torn to pieces, or burned alive. The experiences are overwhelming and lead to post-traumatic stress. When the soldier finally reaches the veteran's mental health system, he is an emotional wreck. Doctors try to heal him, but often fail. The reason behind the failure is the soldier's mind.
When the soldier was in combat, he not only saw his colleagues or himself being in danger, but he also killed, tortured, or mutilated the enemy. In addition, he committed many crimes against civilians, from theft, to rape, torture, and murder. When therapy tries to negotiate the soldier's suffering, the process fails if it only addresses traumas directed against the soldier. Healing mandates to process all the traumas, even the actions directed against others. Most soldiers are incapable of seeing themselves as rapists, torturers, murderers, or sadistic psychopaths. It is horrendous to think about the deeds they did. A heroic conquerer belonging to the master race distances himself from such memories and from the associated neural circuits of his emotional intelligence. But by dissociating himself from his most advanced mental faculties, the soldier is also robbing himself of the ability to resolve his traumas. Incidentally, he has few sensible options left. He has no choice but to remain a psychopath with unresolved PTSD. Surprisingly, many doctors are appalled by such cynical dismissal of a patient. They do not see him as evil, but as a mentally sick man who needs help. So they treat him to make him feel better about himself. He is still evil because of his past behaviors and because of his permanently damaged brain. And it will always stay that way.
PTSD TREATMENT BUT NOT CURE
Treatment of incest victims, who have typically endured years of abuse, has shown that they can get rid of their positive symptoms of PTSD, but fail to improve their emotional intelligence. They largely retain their inability to make proper choices in life and fail to comprehend complex social, interpersonal, or natural phenomena. These cognitive deficits come together with antisocial tendencies and interpersonal criminal behaviors. If any improvement occurs in choosing partners, jobs, or goals, the process is slow and hyperspecific. Any change in the overall context may easily offset the therapeutic gains. The treatment outcome suggests that traumas can lead to permanent and irreversible brain damage. The development of PTSD manifests the existence of such damage.
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|Unpublished work © 2010-2017 Martin Dak. All rights reserved.|