Information Thread: PTSD

It may be that, when combined, the person's psychological history, the nature of the trauma, and the availability of post-trauma support cause PTSD symptoms to develop after a traumatic event. However, someone without risk factors who is exposed to a traumatic event also may develop symptoms.

Biologic Theories

The amygdala, a structure in the brain, is part of the limbic system that is involved in the expression of emotion, especially fear, autonomic reactions (e.g., increased heart rate and blood pressure, the startle response), and emotional memory. Dysfunction in this structure may produce symptoms of PTSD.

Overwhelming trauma can cause changes in brain function that produce symptoms of PTSD: hyperarousal, numbing, sleep disturbance, irritability, intrusive emotions and memories, flashbacks, outbursts, and memory impairment.

The body responds to stress and trauma by releasing several stress hormones (e.g., norepinephrine, epinephrine). When a person is subjected to repeated or severe trauma, the physiological stress response becomes hyperactive and hyperarousal and intrusive symptoms of PTSD develop.

There also may be a biological component to numbing and other dissociative symptoms of PTSD. Some studies show that when people who have been exposed to prolonged or repeated trauma are exposed to any stimulus reminiscent of the trauma, the brain releases opiates (e.g., endorphins, enkephalins) that can produce emotional nonresponsiveness, or numbing, and amnesia.

Serotonin depletion may result from repeated exposure to severe stress and trauma, which may be a factor in the development of irritability and violent or angry outbursts in people with PTSD.

Risk Factors

Risk factors for PTSD include previous trauma; a predisposing mental health condition; the type and severity of the traumatic event; and lack of adequate and competent support for the person after the trauma. However, PTSD can develop in people who do not possess any of these risk factors.

Pretrauma Risk Factors

The psychological history of a person may include risk factors for developing PTSD after a traumatic event:

Borderline personality and dependent personality disorders
Low self-esteem
Previous trauma
People with borderline personality disorder often have a history of physical and/or sexual abuse, neglect, hostile conflict, and parental loss or separation. Dependent personality disorder is characterized by low self-esteem, fear of separation, and the excessive need to be cared for by others. All of these features may predispose someone for PTSD who experiences a traumatic event.
People who have experienced previous trauma(s) are at risk for developing PTSD. Repeated exposure to trauma causes hyperactive release of stress hormones, which may be instrumental in creating symptoms of PTSD.

Trauma-Related Risk Factors

The severity, duration, proximity to (direct or witnessed), and type of traumatic event are the most significant risk factors for developing PTSD.

Directly experienced traumatic events include the following examples:

Combat
Kidnapping
Natural disasters (e.g., fire, tornado, earthquake)
Catastrophic accident (e.g., auto, airplane, mining)
Violent sexual assault
Violent physical assault
Witnessed traumatic events include the following examples:
Seeing another person violently killed or injured
Unexpectedly seeing a dead body or body parts
Whether or not the event was perpetrated in a sadistic manner (e.g., torture, rape) occurred accidentally (e.g., fire), or occurred as an "act of God" can affect whether a person develops PTSD and whether the disorder is acute, chronic, or has a delayed onset of symptoms.

Post-trauma Risk Factors

Symptoms and duration of PTSD may be more severe if there is a lack of support from family and/or community. For instance, a rape victim who either is blamed for the assault or not believed (e.g., in the case of rape by a family member) may be at greater risk for developing PTSD.

Acute Stress Disorder

The person has been exposed to a traumatic event in which both of the following were present:

The person experienced, witnessed, or was confronted with an event
or events that involved actual or threatened death or serious injury, or
a threat to the physical integrity of self or others.

The person's response involved intense fear, helplessness, or horror.

Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms:

A subjective sense of numbing, detachment, or absence of emotional
responsiveness.

A reduction in awareness of his or her surroundings (e.g., "being in a daze").

Depersonalization - dissociative amnesia (i.e., inability to recall an important aspect of the trauma).

The patient persistently re-experienced the traumatic event in at least one or
more of the following ways: recurrent images, thoughts, dreams, illusions,
flashback episodes, or a sense of reliving the experience; or distress on exposure
to reminders of the traumatic event.

Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts,
feelings, conversations, activities, places, people).

There are marked symptoms of anxiety or increased arousal (e.g., difficulty
sleeping, irritability, poor concentration, hypervigilance, exaggerated startle
response, motor restlessness).

At least 1 of the following applies:

The patient feels marked distress from the symptoms.

They interfere with usual social, job or personal functioning.

They block the patient from doing something important such as getting legal or medical help or telling family or other supporters about the experience.

The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks
and occurs within 4 weeks of the traumatic event.

The disturbance is not due to the direct physiological effects of a substance
(e.g., a drug of abuse, a medication) or a general medical condition, is not
better accounted for by Brief Psychotic Disorder, and is not merely an
exacerbation of a preexisting mental disorder.

Associated Features:

These symptoms may occur and are more commonly seen in association with an interpersonal stressors such as childhood sexual or physical abuse, domestic violence, impaired affect, self-destructive and impulsive behavior, dissociative symptoms, somatic complaints or a change from the individual’s previous personality characteristics.

Differential Diagnosis:

Some disorders display similar or sometimes even the same symptom. The clinician, therefore, in his diagnostic attempt has to differentiate against the following disorders which one needs to be ruled out to establish a precise diagnosis.

Mental Disorder Due to a General Medical Condition;
Substance-Induced Disorder;
Brief Psychotic Disorder;
Major Depressive Episode;
Posttraumatic Stress Disorder;
Adjustment Disorder;
Malingering.

Cause:

When an individual who has been exposed to a traumatic event develops anxiety symptoms, re-experiencing of the event, and avoidance of related stimuli lasting less than four weeks they may develop acute stress disorder.

Treatment:

Counseling and Psychotherapy:

Anxiety disorders are responsive to counseling and to a wide variety of psychotherapies. More severe and persistent symptoms also may require pharmacotherapy.

Psychotherapies include focused, time-limited therapies that address ways of coping with anxiety symptoms more directly rather than exploring unconscious conflicts or other personal vulnerabilities These therapies typically emphasize cognitive and behavioral assessments.

It is possible that more traditional forms of therapy based on psychodynamic or interpersonal theories of anxiety also may be used However, these therapies have not yet received extensive empirical support

Pharmacotherapy:

Antidepressants:
Clomipramine

Benzodiazepines:
Alprazolam;
Clonazepam
Diazepam
Lorazepam

SSRI class:
Fluoxetine
Sertraline
Paroxetine
Fluvoxamine
Citalopram

Combinations of Psychotherapy and Pharmacotherapy:

Some patients with this disorder may benefit from both psychotherapy and pharmacotherapy treatment modalities, either combined or used in sequence

What Is Psychological Trauma?
By Esther Giller
President and Director, The Sidran Foundation

We all use the word "trauma" in every day language to mean a highly stressful event. But the key to understanding traumatic events is that it refers to extreme stress that overwhelms a person's ability to cope. There is no clear divisions between stress (which leads to ) trauma (which leads to ) adaptation. Although I am writing about psychological trauma, it is also important to keep in mind that stress reactions are clearly physiological as well.

Different experts in the field define psychological trauma in different ways. What I want to emphasize is that it is an individual's subjective experience that determines whether an event is or is not traumatic.

Psychological trauma is the unique individual experience of an event or enduring conditions, in which:

The individual's ability to integrate his/her emotional experience is overwhelmed, or
The individual experiences (subjectively) a threat to life, bodily integrity, or sanity.
Thus, a traumatic event or situation creates psychological trauma when it overwhelms the individual's perceived ability to cope, and leaves that person fearing death, annihilation, mutilation, or psychosis. The individual feels emotionally, cognitively, and physically overwhelmed. The circumstances of the event commonly include abuse of power, betrayal of trust, entrapment, helplessness, pain, confusion, and/or loss.

This definition of trauma is fairly broad. It includes responses to powerful one-time incidents like accidents, natural disasters, crimes, surgeries, deaths, and other violent events. It also includes responses to chronic or repetitive experiences such as child abuse, neglect, combat, urban violence, concentration camps, battering relationships, and enduring deprivation. This definition intentionally does not allow us to determine whether a particular event is traumatic; that is up to each survivor. This definition provides a guideline for our understanding of a survivor's experience of the events and conditions of his/her life.

Jon Allen, a psychologist at the Menninger Clinic in Topeka, Kansas and author of Coping with Trauma: A Guide to Self-Understanding (1995) reminds us that there are two components to a traumatic experience: the objective and the subjective.

"It is the subjective experience of the objective events that constitutes the trauma...The more you believe you are endangered, the more traumatized you will be...Psychologically, the bottom line of trauma is overwhelming emotion and a feeling of utter helplessness. There may or may not be bodily injury, but psychological trauma is coupled with physiological upheaval that plays a leading role in the long-range effects".
In other words, trauma is defined by the experience of the survivor. Two people could undergo the same noxious event and one person might be traumatized while the other person remained relatively unscathed. It is not possible to make blanket generalizations such that "X is traumatic for all who go through it" or "event Y was not traumatic because no one was physically injured." In addition, the specific aspects of an event that are traumatic will be different from one individual to the next. You cannot assume that the details or meaning of an event, such as a violent assault or rape, that are most distressing for one person will be same for another person.

Trauma comes in many forms, and there are vast differences among people who experience trauma. But the similarities and patterns of response cut across the variety of stressors and victims, so it is very useful to think broadly about trauma.

Single Blow vs. Repeated Trauma

Lenore Terr, in her studies of traumatized children, has made the distinction between single blow and repeated traumas. Single shocking events can certainly produce trauma reactions in some people:


Natural disasters such as earthquakes, hurricanes, floods, volcanoes, etc.

Closely related are technological disasters such as auto and plane crashes, chemical spills, nuclear failures, etc. Technological disasters are more socially divisive because there is always energy given towards finding fault and blaming.

Criminal violence often involves single blow traumas such as robbery, rape and homicide, which not only have a great impact on the victims, but also on witnesses, loved ones of victims, etc. (Interestingly, there is often overlap between single blow and repeated trauma, because a substantial majority of victimized women have experienced more than one crime.) Unfortunately, traumatic effects are often cumulative.
As traumatic as single-blow traumas are, the traumatic experiences that result in the most serious mental health problems are prolonged and repeated, sometimes extending over years of a person's life.

Natural vs. Human Made

Prolonged stressors, deliberately inflicted by people, are far harder to bear than accidents or natural disasters. Most people who seek mental health treatment for trauma have been victims of violently inflicted wounds dealt by a person. If this was done deliberately, in the context of an ongoing relationship, the problems are increased. The worst situation is when the injury is caused deliberately in a relationship with a person on whom the victim is dependent---most specifically a parent-child relationship.

Varieties of Man-Made Violence


War/political violence - [Massive in scale, severe, repeated, prolonged and unpredictable. Also multiple: witnessing, life threatening, but also doing violence to others. Embracing the identity of a killer.

Human rights abuses - kidnapping, torture, etc.

Criminal violence - discussed above.

Rape - The largest group of people with posttraumatic stress disorder in this country. A national survey of 4000 women found that 1 in 8 reported being the victim of a forcible rape. Nearly half had been raped more than once. Nearly 1/3 was younger than 11 and over 60% were under 18. Diana Russell's research showed that women with a history of incest were at significantly higher risk for rape in later life (68% incest history, 38% no incest).

Domestic Violence - recent studies show that between 21% and 34% of women will be assaulted by an intimate male partner. Deborah Rose's study found that 20-30% of adults in the US, approved of hitting a spouse.

Child Abuse - the scope of childhood trauma is staggering. Everyday children are beaten, burned, slapped, whipped, thrown, shaken, kicked and raped. According to Dr. Bruce Perry, a conservative estimate of children at risk for PTSD exceeds 15 million.

Sexual abuse- According to Dr. Frank Putnam of NIMH, at least 40% of all psychiatric inpatients have histories of sexual abuse in childhood. Sexual abuse doesn't occur in a vacuum: is most often accompanied by other forms of stress and trauma-generally within a family.
We must be careful about generalizations about child sexual abuse: research shows that about 1/3 of sexually abused children have no symptoms, and a large proportion that do become symptomatic, are able to recover. Fewer than 1/5 of adults who were abused in childhood show serious psychological disturbance.

More disturbance is associated with more severe abuse: longer duration, forced penetration, helplessness, fear of injury or death, perpetration by a close relative or caregiver, coupled with lack of support or negative consequences from disclosure.


Physical abuse often results in violence toward others, abuse of one's own children, substance abuse, self-injurious behavior, suicide attempts, and a variety of emotional problems.

Emotional/verbal abuse

Witnessing. Seeing anyone beaten is stressful; the greater your attachment to the victim, the greater the stress. Especially painful is watching violence directed towards a caregiver, leaving the child to fear losing the primary source of security in the family.

Sadistic abuse- we generally think about interpersonal violence as an eruption of passions, but the severest forms are those inflicted deliberately. Calculated cruelty can be far more terrifying than impulsive violence. Coercive control is used in settings like concentration camps, prostitution and pornography rings, and in some families.
One of the best-documented research findings in the field of trauma is the DOSE-RESPONSE relationship --the higher the dose of trauma, the more potentially damaging the effects; the greater the stressor, the more likely the development of PTSD.

The most personally and clinically challenging clients are those who have experienced repeated intentional violence, abuse, and neglect from childhood onward. These clients have experienced tremendous loss, the absence of control, violations of safety, and betrayal of trust. The resulting emotions are overwhelming: grief, terror, horror, rage, and anguish.

Their whole experience of identity and of the world is based upon expectations of harm and abuse. When betrayal and damage is done by a loved one who says that what he or she is doing is good and is for the child's good, the seeds of lifelong mistrust and fear are planted. Thus, the survivor of repetitive childhood abuse and neglect expects to be harmed in any helping relationship and may interact with us as though we have already harmed him or her.


Summary

Psychological effects are likely to be most severe if the trauma is:

Human caused
Repeated
Unpredictable
Multifaceted
Sadistic
Undergone in childhood
And perpetrated by a caregiver
Who Are Trauma Survivors?

Because violence is everywhere in our culture and because the effects of violence and neglect are often dramatic and pervasive,


most clients/patients/recipients of services in the mental health system are trauma survivors.
Because coping responses to abuse and neglect are varied and complex,


trauma survivors may carry any psychiatric diagnosis and frequently trauma survivors carry many diagnoses.
And, because interpersonal trauma does not discriminate,


survivors are both genders, all ages, all races, all classes, all sizes, all sexual orientations, all religions, and all nationalities. Although the larger number of our clients are female, many men and boys are survivors of childhood abuse and trauma. Under-recognition of male survivors, combined with cultural gender bias has made it especially difficult for these men to get help.
What are the Lasting Effects of Trauma?

There is no one diagnosis that contains all abuse survivor clients; rather individuals carrying any diagnosis can be survivors. Often survivors carry many diagnoses.

Abuse survivors may meet criteria for diagnoses of:


substance dependence and abuse,
personality disorders (especially borderline personality disorder),
depression,
anxiety (including post traumatic stress disorder),
dissociative disorders, and
eating disorders, to name a few.
PTSD is the only diagnostic category in the DSM that is based on etiology. In order for a person to be diagnosed with PTSD, there had to be a traumatic event. Because most diagnoses are descriptive and not explanatory, they focus on symptoms or behaviors without a context: they do not explain how or why a person may have developed those behaviors (e.g., to cope with traumatic stress).

For purposes of identifying trauma and it adaptive symptoms, It is much more useful to ask "What HAPPENED to this person" rather than "what is WRONG with this person."

Symptoms as Adaptations

The traumatic event is over, but the person's reaction to it is not. The intrusion of the past into the present is one of the main problems confronting the trauma survivor. Often referred to as re-experiencing, this is the key to many of the psychological symptoms and psychiatric disorders that result from traumatic experiences. This intrusion may present as distressing intrusive memories, flashbacks, nightmares, or overwhelming emotional states.

The Use of Maladaptive Coping Strategies

Survivors of repetitive early trauma are likely to instinctively continue to use the same self-protective coping strategies that they employed to shield themselves from psychic harm at the time of the traumatic experience. Hypervigilance, dissociation, avoidance and numbing are examples of coping strategies that may have been effective at some time, but later interfere with the person's ability to live the life s/he wants.

It is useful to think of all trauma "symptoms" as adaptations. Symptoms represent the client's attempt to cope the best way they can with overwhelming feelings. When we see "symptoms" in a trauma survivor, it is always significant to ask ourselves: what purpose does this behavior serve? Every symptom helped a survivor cope at some point in the past and is still in the present -- in some way. We humans are incredibly adaptive creatures. Often, if we help the survivor explore how behaviors are an adaptation, we can help them learn to substitute a less problematic behavior.

Developmental Factors

Chronic early trauma -- starting when the individual's personality is forming -- shapes a child's (and later adult's) perceptions and beliefs about everything.

Severe trauma can have a major impact on the course of life. Childhood trauma can cause the disruption of basic developmental tasks. The developmental tasks being learned at the time the trauma happens can help determine what the impact will be. For example, survivors of childhood trauma can have mild to severe deficits in abilities such as:


self-soothing
seeing the world as a safe place
trusting others
organized thinking for decision-making
avoiding exploitation
Disruption of these tasks in childhood can result in adaptive behavior, which may be interpreted in the mental health system as "symptoms." For example, disruptions in:



self-soothing can be seen as agitation
seeing the world as a safe place paranoia
trusting others paranoia
organized thinking for decision-making psychosis
avoiding exploitation self-sabotage
Physiologic Changes

The normal physiological responses to extreme stress lead to states of physiologic hyperarousal and anxiety. When our fight-or-flight instincts take over, the wash of cortisol and other hormones signal us to watch out! We humans are incredibly adaptive. When this happens repeatedly, our bodies learn to live in a constant state of "readiness for combat," with all the behaviors-scanning, distrust, aggression, sleeplessness, etc. that entails.

Cutting edge neurological research is beginning to show to what extent trauma effects us on a biological and hormonal basis as well as psychologically and behaviorally. Research suggests that in trauma, interruptions of childhood development and hypervigilance of our autonomic systems are compounded and reinforced by significant changes in the hard-wiring of the brain.

This may make it even more challenging (but not impossible) for survivors of childhood trauma to learn to do things differently. But it may also hold the promise of pharmaceutical interventions to address the biological/chemical effects of child abuse.

So, as scientists learn more about what trauma is, we are seeing see that it is truly a complex mixture of biological, psychological, and social phenomena.

SYMPTOMS
The person has been exposed to a traumatic event in which both of the following were present:
the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
the person's response involved intense fear, helplessness, or horror
Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms:

a subjective sense of numbing, detachment, or absence of emotional responsiveness
a reduction in awareness of his or her surroundings (e.g., "being in a daze")
derealization
depersonalization
dissociative amnesia (i.e., inability to recall an important aspect of the trauma)
The traumatic event is persistently reexperienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience; or distress on exposure to reminders of the traumatic event.

Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, conversations, activities, places, people).

Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness).

The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or impairs the individual's ability to pursue some necessary task, such as obtaining necessary assistance or mobilizing personal resources by telling family members about the traumatic experience.

The disturbance lasts for a minimum of 2 days and a maximum of 4_weeks and occurs within 4 weeks of the traumatic event.

The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition, is not better accounted for by Brief Psychotic Disorder, and is not merely an exacerbation of a preexisting mental disorder.

Positive Motivations for Sexual Healing After Abuse
The following are some suggestions from Staci Haines book entitled: "survivors guide to sex"

I want to gain a freedom in my body. I want to be able to move, make noise, and express myself fully.

I want to heal the shame that runs my sex life so that I feel relaxed and excited during sex.


I want to enjoy touching myself.


I want my body back, all the way.


I want pleasure and being present in my sex life to be the norm, instead of fear and checking out.


I want to have sex in the ways I am interested in. I want to be more courageous sexually.


I want to be able to respect and communicate my sexual boundaries.


I want to learn that I am loved for me and not for sex alone.


I want to be able to make my own sexual choices.


I want to have sex and intimacy at the same time.

Body Memories
From Author Pamela Perez




I have often been asked to explain something about body memories (or, as the professional community refers to it, somatic memory). Let’s see if we can explain something about that in this article. First, a bit of terminology. The word “somatic” refers to the soma, the body. Somatic memories (body memories) are common in those who have experienced trauma. Science has demonstrated for us that trauma and abuse have a long-term physiological impact on our bodies as well as our minds.

In earlier articles we have talked about other types of memory – namely, explicit (declarative) and implicit (procedural) memory. It may be helpful to read “A Short Introduction to Memory Processes Parts I & II” if you have not already done so. In this article we’d like to emphasize the point that dissociation is often accompanied by more than just “perceptual” problems in the survivor of abuse. Abuse affects the physical as well as the cognitive (all forms of knowing - how we see, perceive, reason), whether it is remembered or not. “Somatic dissociation” (a term used by Scaer, 2001), is often a problem experienced in parts of the body (that is, other than the brain). Symptoms will often present themselves as physical problems that often cannot be explained by the usual means (lab tests, x-ray studies, routine examinations). These often fall into the category of stress or psychosomatic disorders. (For those of you who aren’t sure what that means, the word “psychosomatic” refers to “Relating to or concerned with the influence of the mind on the body, and the body on the mind, especially with respect to disease;” (dictionary reference below). It does not mean something that is “only in your head” or is not a legitimate problem.

As we have emphasized before, trauma is a physiological as well as a psychological experience. “Even when the traumatic event causes no direct bodily harm, traumatic events exact a toll on the body as well as the mind,” (Rothschild, 2000). Survivors typically report physical problems such as persistent headaches and migraine, abdominal tract problems (constipation, diarrhea, cramping, nausea), palpitations (racing heart), light headedness and dizziness, visual disturbances, hot/cold flashes (sweating, chills), TMJ (teeth grinding, jaw clenching), fibromyalgia, muscle spasms, tremors, sleep disorders, etc. The list goes on! The problem is that there is often no apparent “cause” as far as the physician can see, and the patient fears (with good reason) being labeled as neurotic or attention-seeking and not likely to be taken seriously. This is an unfortunate problem we hear about over and over again (from both the doctors and their patients)!

I do want to emphasize, though, in all fairness to the physicians out there, patients with chronic PTSD do cycle in and out of these states, and so coming to a clear diagnosis can indeed be a difficult task, to say the least! Dr. Robert Scaer, M.D. wrote an excellent article on this subject, “The Neurophysiology of Dissociation and Chronic Disease.

What causes such distressing symptoms to occur year after year in the body, even when the memories and flashbacks are being worked on in therapy? “Trauma is in the nervous system, not in the event,” say Heller & Heller (2001). They talk about how “survival energy” causes the body to become mobilized for fight or flight, but when that energy cannot be released, it ends up being “converted into symptoms.” This makes sense when you understand the processes the body goes through in order for it to survive the kind of threat that trauma imposes upon it. “Because the part of the brain in charge of survival basically takes a ‘memory snapshot’ of elements considered part of the danger of the [event], associations to the original event fuel fears, hyper-reactivity or disconnection” (Heller & Heller, 2001). Symptoms are related, in part, to an over-activated nervous system.

What kind of symptoms are we referring to, and how can they be classified? Scaer (2001) talks about the dilemma that classification of symptoms of dissociation presents. “Symptoms assume many and varied forms and expressions. They may be emotional, perceptual, cognitive or functional. They may involve altered perception of time, space, sense of self and reality. Emotional expressions may vary from panic to numbing and catatonia. Altered sensory perceptions may vary from anesthesia to analgesia to intolerable pain…” (no wonder different “parts” (alters) respond differently to medication!). “Cognitive symptoms may involve confusion; perceptual symptoms include ignoral (ignoring) and neglect; memory alteration may appear as hypermnesia in the form of flashbacks and fugue states.” The list goes on. Scaer further quotes Mayer-Gross (1935) in his article, pointing out that “depersonalization, in its most extreme expression, may encompass perception of several separate states of self in the form of distinct and separate personalities (dissociative identity disorder), each with distinct personality characteristics and even physical attributes.” For those of us familiar with DID and PTSD these findings are of no surprise.

There aren’t any quick fixes or magic answers here, but my hope in writing this article is that we will attain at least some understanding about how and why the body experiences somatic memories that at times appear unrelated to anything in our immediate awareness. body memories are a normal (if there is such a thing) part of the abuse survivor’s experience, particularly those with DID/PTSD, and by realizing this, perhaps some of the distress about this will be alleviated.


Information on Somatic Memory (Body Memories)

What is the 'Stockholm Syndrome'?

In 1973, four Swedes held in a bank vault for six days during a robbery became attached to their captors, a phenomenon dubbed the Stockholm Syndrome. According to psychologists, the abused bond to their abusers as a means to endure violence.

Is the 'Stockholm Syndrome' used to describe reactions to traumas other than hostage situations?

The Stockholm Syndrome is an emotional attachment, a bond of interdependence between captive and captor that develops 'when someone threatens your life, deliberates, and doesn't kill you.' (Symonds, 1980) The relief resulting from the removal of the threat of death generates intense feelings of gratitude and fear which combine to make the captive reluctant to display negative feelings toward the captor or terrorist. In fact, former hostages have visited their captors in jail, recommended defense counsel, and even started a defense fund. It is this dynamic which causes former hostages and abuse survivors to minimize the damage done to them and refuse to cooperate in prosecuting their tormentors.

"The victims' need to survive is stronger than his impulse to hate the person who has created his dilemma." (Strentz, 1980) The victim comes to see the captor as a 'good guy', even a savior. This condition...occurs in response to the four specific conditions listed below:

-A person threatens to kill another and is perceived as having the capability to do so.

- The other cannot escape, so her or his life depends on the threatening person.

-The threatened person is isolated from outsiders so that the only other perspective available to her or him is that of the threatening person.

-The threatening person is perceived as showing some degree of kindness to the one being threatened.

Victims' Observed Strategies for Survival

Victims have to concentrate on survival, requiring avoidance of direct, honest reaction to destructive treatment. Become highly attuned to pleasure and displeasure reactions of victimizers. As a result, victims know much about captors, less about themselves. Victims are encouraged to develop psychological characteristics pleasing to captors: dependency, lack of initiative, inability to act, decide, think, etc. Both actively develop strategies for staying alive, including denial, attentiveness to victimizer's wants, fondness for victimizer accompanied by fear, fear of interference by authorities, and adoption of victimizer's perspective. Hostages are overwhelmingly grateful to terrorists for giving them life. They focus on captor's kindnesses, not his acts of brutality. Battered women assume that the abuser is a good man whose actions stem from problems that she can help him solve. Both feel fear, as well as love, compassion and empathy toward a captor who has shown them any kindness. Any acts of kindness by the captors will help ease the emotional distress they have created and will set the stage for emotional dependency of Counterproductive Victim Responses

Denial of terror and anger, and the perception of their victimizers as omnipotent people help to keep victims psychologically attached to victimizers. High anxiety functions to keep victims from seeing available options. Psychophysical stress responses develop.

To go to this website to read more in detail click the link below:

Stockholm Syndrome

Why is anger a common response in those with PTSD?

Anger is usually a central feature of a survivor's response to trauma because it is a core component of the survival response in humans. Anger helps people cope with life's adversities by providing us with increased energy to persist in the face of obstacles. However, uncontrolled anger can lead to a continued sense of being out of control of oneself and can create multiple problems in the personal lives of those who suffer from PTSD.

One theory of anger and trauma suggests that high levels of anger are related to a natural survival instinct. When initially confronted with extreme threat, anger is a normal response to terror, events that seem unfair, and feeling out of control or victimized. It can help a person survive by mobilizing all of his or her attention, thought, brain energy, and action toward survival. Recent research has shown that these responses to extreme threat can become "stuck" in persons with PTSD. This may lead to a survival mode response where the individual is more likely to react to situations with "full activation," as if the circumstances were life threatening, or self-threatening. This automatic response of irritability and anger in individuals with PTSD can create serious problems in the workplace and in family life. It can also affect the individuals' feelings about themselves and their roles in society.

Another line of research is revealing that anger can also be a normal response to betrayal or to losing basic trust in others, particularly in situations of interpersonal exploitation or violence.

Finally, in situations of early childhood abuse, the trauma and shock of the abuse has been shown to interfere with an individual's ability to regulate emotions, which leads to frequent episodes of extreme or out of control emotions, including anger and rage.

How can posttraumatic anger become a problem?
Researchers have described three components of posttraumatic anger that can become maladaptive or interfere with one's ability to adapt to current situations that do not involve extreme threat:

* Arousal: Anger is marked by the increased activation of the cardiovascular, glandular, and brain systems associated with emotion and survival. It is also marked by increased muscle tension. Sometimes with individuals who have PTSD, this increased internal activation can become reset as the normal level of arousal and can intensify the actual emotional and physical experience of anger. This can cause a person to feel frequently on-edge, keyed-up, or irritable and can cause a person to be more easily provoked. It is common for traumatized individuals to actually seek out situations that require them to stay alert and ward off potential danger. Conversely, they may use alcohol and drugs to reduce overall internal tension.

* Behavior: Often, the most effective way of dealing with extreme threat is to act aggressively, in a self-protective way. Additionally, many people who were traumatized at a relatively young age do not learn different ways of handling threat and tend to become stuck in their ways of reacting when they feel threatened. This is especially true of people who tend to be impulsive (who act before they think). Again, as stated above, while these strategies for dealing with threat can be adaptive in certain circumstances, individuals with PTSD can become stuck in using only one strategy when others would be more constructive. Behavioral aggression may take many forms, including aggression toward others, passive-aggressive behavior (e.g., complaining, "backstabbing," deliberately being late or doing a poor job), or self-aggression (self-destructive activities, self-blame, being chronically hard on oneself, self-injury).

* Thoughts and Beliefs: The thoughts or beliefs that people have to help them understand and make sense of their environment can often overexaggerate threat. Often the individual is not fully aware of these thoughts and beliefs, but they cause the person to perceive more hostility, danger, or threat than others might feel is necessary. For example, a combat veteran may become angry when others around him (wife, children, coworkers) don't "follow the rules." The strength of his belief is actually related to how important it was for him to follow rules during the war in order to prevent deaths. Often, traumatized persons are not aware of the way their beliefs are related to past trauma. For instance, by acting inflexibly toward others because of their need to control their environment, they can provoke others into becoming hostile, which creates a self-fulfilling prophecy. Common thoughts people with PTSD have include: "You can't trust anyone," "If I got out of control, it would be horrible/life-threatening/intolerable," "After all I've been through, I deserve to be treated better than this," and "Others are out to get me, or won't protect me, in some way."

How can individuals with posttraumatic anger get help?
In anger management treatment, arousal, behavior, and thoughts/beliefs are all addressed in different ways. Cognitive-behavioral treatment, a commonly utilized therapy that shows positive results when used to address anger, applies many techniques to manage these three anger components:

* For increased arousal, the goal of treatment is to help the person learn skills that will reduce overall arousal. Such skills include relaxation, self-hypnosis, and physical exercises that discharge tension.

* For behavior, the goal of treatment is to review a person's most frequent ways of behaving under perceived threat or stress and help him or her to expand the possible responses. More adaptive responses include taking a time out; writing thoughts down when angry; communicating in more verbal, assertive ways; and changing the pattern "act first, think later" to "think first, act later."

* For thoughts/beliefs, individuals are given assistance in logging, monitoring, and becoming more aware of their own thoughts prior to becoming angry. They are additionally given alternative, more positive replacement thoughts for their negative thoughts (e.g., "Even if I am out of control, I won't be threatened in this situation," or "Others do not have to be perfect in order for me to survive/be comfortable"). Individuals often role-play situations in therapy so they can practice recognizing their anger-arousing thoughts and applying more positive thoughts.

There are many strategies for helping individuals with PTSD deal with the frequent increase of anger they are likely to experience. Most individuals have a combination of the three anger components listed above, and treatment aims to help with all aspects of anger. One important goal of treatment is to improve a person's sense of flexibility and control so that he or she does not feel re-traumatized by his or her own explosive or excessive responses to anger triggers. Treatment is also meant to have a positive impact on personal and work relationships.

Avoidance is a common reaction to trauma, and it can interfere with emotional recovery and healing. It is understandable that individuals who have experienced stressful events want to avoid thinking about or feeling emotions related to those events. Research with a wide variety of populations (e.g., survivors of sexual abuse, rape, assault, and motor vehicle accidents) indicates that those individuals who try to cope with their trauma by avoiding thoughts and feelings about it tend to have more severe psychological symptoms. Because the research clearly suggests that avoidance can interfere with recovery and healing, this fact sheet provides an overview of this common reaction to trauma.

What does emotional avoidance mean?
Emotional avoidance in the context of trauma refers to people’s tendency to avoid thinking or having feelings about a traumatic event. For example, a rape survivor may try to suppress thoughts about her rape by forcing herself to think about other things whenever the thoughts arise, or by simply trying to push away thoughts about the rape. She may use emotional avoidance by stopping herself every time she begins to feel sadness about the rape, or by bringing her attention to something that makes her feel less sad. She may say things to herself like, “Don’t go there,” or “Don’t think about it.”

What does behavioral avoidance mean?
Behavioral avoidance generally refers to avoiding reminders of a trauma. An extreme example of behavioral avoidance would be for someone who lived in Manhattan to move out of the city after the 9/11 terrorist attacks to avoid reminders of the trauma. Less extreme examples might involve remaining in Manhattan but making sure to avoid Ground Zero to avoid difficult emotional reminders. Other examples would include individuals who try to avoid driving after they have been in car accidents, or assault survivors who go out of their way to avoid the scene of their attack.

Doesn’t avoidance help people cope with trauma?
Not when it is extreme or when it is the primary coping strategy. Many people were raised hearing advice like, “just try not to think about it,” “try to think about positive things,” or “don’t dwell on it.” These suggestions seem very logical—especially if you grew up hearing them regularly. However, although the desire to turn one’s attention away from painful thoughts and feelings is completely natural, research indicates that the more people avoid their thoughts and feelings about difficult life stressors, the more their distress seems to increase and the less likely they are to be able to move on with their lives.

Is all avoidance bad?
No, not all avoidance is bad. If you have experienced a traumatic event in your life, it can be extremely useful to learn ways to focus your thoughts and feelings on things that are not related to the trauma. This is typically referred to as “distraction.” Distraction is a useful and necessary skill that allows us to get on with our daily routines even when we are feeling very distressed. If it weren’t for our ability to distract ourselves, we would have difficulty getting on with our lives after traumatic life events. Our ability to use distraction skills allows us to go to school or work, buy groceries, etc.—even in the face of difficult life events.

While distraction and avoidance can be very useful in the short-term, they become problematic when they are the primary means of coping with trauma. When we caution against the use of avoidance, we are really cautioning against the use of avoidance or distraction as the primary means of coping with a trauma. If an individual were to avoid thinking about or having feelings about a trauma all of the time, they would likely have a much harder time recovering from the trauma.

“But if I let myself experience my emotions, I would be overwhelmed by them…”
One common reaction to the suggestion that people should allow themselves to feel difficult emotions is a fear that those emotions will overwhelm them. Sometimes people are afraid that if they start crying, they’ll cry forever. Other people worry that if they let themselves experience the anger inside them, they will lose control. Attending therapy with someone who is knowledgeable about trauma can be very useful for individuals who harbor these fears.

Symptoms of PTSD are generally of three types:

Intrusive
Dissociative states
Flashbacks
Intrusive emotions and memories
Nightmares and night terrors

Avoidant
Avoiding emotions
Avoiding relationships
Avoiding responsibility for others
Avoiding situations that are reminiscent of the traumatic event

Hyperarousal
Exaggerated startle reaction
Explosive outbursts
Extreme vigilance
Irritability
Panic symptoms
Sleep disturbance

Intrusive memories and emotions interfere with normal thought processes and social interaction. Flashbacks feature auditory and visual hallucinations. For example, the sounds and images of combat often comprise the content of flashbacks experienced by military veterans. Flashbacks can be triggered by ordinary stimuli such as a low-flying airplane or a loud noise, anything that brings to mind an aspect of the event. Nightmares and night terrors also feature aspects of the traumatic event.
Dissociative symptoms include psychic numbing, depersonalization, and amnesia.

People with PTSD commonly avoid stimuli and situations that remind them of the traumatic event because they trigger symptoms.

People experiencing hyperarousal symptoms are always on the alert for danger or threat and are easily startled.

Complications
Complications develop in people with chronic PTSD and delayed onset PTSD. These include the following:

Alcohol and drug abuse or dependence
Chronic anxiety
Depression and increased risk for suicide
Divorce and separation
Guilt
Low self-esteem
Panic attacks
Phobias
Unemployment

Phobias of objects, situations, or environments that remind the person of the event often develop as complications of PTSD.

Panic attacks can be triggered by stimuli reminiscent of the event.

People with chronic PTSD and complications often become unemployed because severe symptoms interfere with their ability to perform their jobs and function socially in the workplace.

PTSD Information