“The things we fear most are the things we have already lived through” — One Hour Photo
Post-Traumatic Stress Disorder (PTSD) is a condition that, in everyday language, is often described approximately with expressions such as “having been traumatized” or “not having gotten over the trauma.”
These expressions, as well as the concepts of trauma and stress themselves, are used rather vaguely and ultimately come to mean, in a general sense, a form of psychological distress that develops following particular unpleasant events or situations.
PTSD is characterized by a specific course and refers to “pathological” stress, that is, a form of physiological and cerebral strain and activation in response to “overwhelming” events that prevents adaptation from taking place, or simply disrupts the normal mechanisms of adaptation, resulting in an unresolved and distressing trauma.
First of all, reference is made to events in which the person has experienced a concrete threat to their physical safety and/or confinement or captivity, regardless of the current physical consequences or bodily after-effects.
Such “overwhelming” events therefore include natural disasters, accidents, assaults, victimization involving coercion, physical violence, or threats.
There are also possible forms in which the violent act was committed against a third person who was very emotionally close to the individual who witnessed the violence.
The disorder does not always develop immediately, although there is usually an initial phase referred to as “acute stress.”
This phase may then subside into an apparent—and sometimes excessive—cooling-off period, characterized by indifference and emotional numbing, or by a paradoxical sense of detachment.
This may be followed by the recurrence of a state of “stress” after the event has ended, at a later point in time, which is precisely what is referred to as post-traumatic stress.
In other words, the person continues to live, or begins once again to live, as though the dangerous situation were still ongoing or as though it had only just ended.
The person is plagued by memories, thoughts, and flashbacks concerning the event and lives in a state in which these memories consciously overlap with reality, “as if” they were still experiencing the situation.
The event may become the sole or predominant theme of the person’s thoughts, conversations, and forms of expression, including play, drawings, and writing.
The person may adopt opposite attitudes, sometimes alternating between them. On the one hand, there may be terror at coming into contact again with places or details that could evoke the event. On the other hand, the person may begin deliberately recalling the event, as though trying to find a solution, a meaning, or a “why.”
In the first forms, which are “ego-dystonic,” the person describes the thoughts as unwanted and intrusive and adopts an isolated and defensive attitude, convinced that the best solution is to “disappear” from the world so as not to be forced to confront the world in which the events occurred. Sometimes this may even involve choosing to change one’s living environment.
In the second case, the person seems absorbed by the idea that they must go all the way, that they must repeatedly relive the event in a ritualized way in order to find a way out, or else sink completely into it, unable to conceive of a genuine life beyond it.
In both cases, the person experiences the event as a watershed between a before and an after, so that their entire life experience revolves around the meaning of something that should never have happened, but has happened and can no longer be changed.
This “actualization” and absolutization are precisely the characteristics that correspond to the person’s suffering.
The memory is excessively vivid, and therefore the natural mechanisms of forgetting or “putting something into the background” fail to become activated.
The brain operates as though it were in the midst of a war from which there is no escape, a war that can only be managed.
Naturally, in most cases, people are able to overcome the traumas they have experienced. However, if this process is interrupted and actually goes into reverse, as in Post-Traumatic Stress Disorder (PTSD), the trauma tends to remain unresolved.
In the normal course of recovery from trauma, a person moves from a phase of acute reaction to a phase of cooling down, during which they may even be surprised by how easily they have recovered, followed by a process of adaptation involving the recovery and organization of memories and the development of explanations and motivations that allow them to move forward.
In pathological trauma, by contrast, these phases are more pronounced—both the first (acute stress) and the second (cooling down)—and are followed by post-traumatic stress, without the person managing to move on to the adaptation phase.
Adaptation does not depend so much on whether the person can explain or justify what happened, but rather on whether the mechanism that places the event in the background succeeds. The event is then organized in a functional way, remaining in the background rather than occupying the foreground of consciousness.
What appears abnormal is the inability to respond effectively—that is, the failure of the “positive” stress mechanism. It is somewhat like learning to perform a movement incorrectly because the appropriate muscle was not activated, with the result that the incorrect movement is eventually learned and later causes problems.
The likelihood of this inability increases with the severity of the violence or accident experienced, but there are also biological vulnerability factors that vary even when the type of traumatic event is the same.
The traumas associated with the greatest risk are those involving personal violence—for example, an assault rather than a natural disaster. Among symptoms of comparable overall severity, the symptoms associated with greater risk are dissociative symptoms during the initial phase.
A pronounced period of emotional blunting following the trauma is a risk factor for the subsequent development of PTSD.
It is difficult to monitor a person’s reaction to trauma in real time in order to determine exactly which physical parameters might serve as warning signs that the reaction is taking a pathological course.
In the disorder, however, it is known that the response to stimuli that evoke the trauma is explosive—for example, involving flight or violence—while the response to ordinary stimuli is blunted.
Anxiety-provoking stimuli elicit a nonspecific reaction, as though a defensive or counterattack response had become a standardized mode of reacting even to stimuli that have nothing to do with the original trauma.
People who have experienced a trauma but recovered from it may nevertheless be unable to withstand repeated trauma.
This can happen because, even in people who are not psychologically distressed, repeated exposure to the same type of trauma—for example, rape or robbery—may eventually trigger the disorder.
People who have already experienced trauma of the same type, such as rape, are therefore at greater risk of developing post-traumatic stress than people experiencing such violence for the first time.
PTSD is theoretically preventable, although it is not always easy to intervene with a traumatized person. Another difficulty is that many people believe that treating someone who has experienced violence is somehow a “forced intervention” that prevents them from trying to stop thinking about what happened or from coping with it on their own.
This attitude is unjustified, and it is always advisable to determine whether there is a particular risk of PTSD and whether the person’s reaction to the trauma is proceeding in a physiological and adaptive manner.
When PTSD is diagnosed, it is important that the characteristic symptoms be identified, because depressive symptoms and behavioral abnormalities are often apparent, while thoughts and memories may be disclosed reluctantly or, at least, not easily—especially when they involve personal violence, whether sexual or otherwise, or events that the person witnessed or participated in.
PTSD can also develop, not infrequently, in people who have committed acts of violence against others under particular circumstances, which they subsequently experience with feelings of guilt and shame and with the sense that they must “pay for” what they did by being condemned to remember it forever.
The post-traumatic stress mechanism can become incorporated into other psychiatric conditions, such as bipolar disorder, thereby becoming a risk factor for self-harming behavior or alcohol and substance abuse.
The disorder is treatable.
There are medications and psychotherapies that can effectively help develop the detachment from the memory that failed to develop previously, thereby restoring the natural balance between memory and backgrounding or fading, which allows memories to be integrated without endlessly pursuing a nonexistent “why” and without living one’s life around a problem that was created by others—or by fate—but that ultimately comes to determine the meaning of the victim’s life.
Treatment is therefore a kind of support structure that helps the circuits involved in the trauma response activate the appropriate mechanisms for processing and putting the experience into perspective.
Many people who have become obsessively “attached” to their trauma do not immediately accept treatment because they believe they must find the solution themselves, whether that solution ultimately brings happiness or unhappiness, by confronting their trauma face to face.
It is instead important to set this way of thinking aside temporarily and explore what benefits treatment may offer.