There are five main types of post-traumatic stress disorder: normal stress response, acute stress disorder, uncomplicated PTSD, comorbid PTSD and complex PTSD.
Normal Stress Response
The normal stress response occurs when healthy adults who have been exposed to a single discrete traumatic event in adulthood experience intense bad memories, emotional numbing, feelings of unreality, being cut off from relationships or bodily tension and distress. Such individuals usually achieve complete recovery within a few weeks. Often a group debriefing experience is helpful. Debriefing's begin by describing the traumatic event. They then progress to exploration of survivors’ emotional responses to the event. Next, there is an open discussion of symptoms that have been precipitated by the trauma. Finally, there is education in which survivors’ responses are explained and positive ways of coping are identified.
Acute stress disorder is characterized by panic reactions, mental confusion, dissociation, severe insomnia, suspiciousness, and being unable to manage even basic self care, work, and relationship activities. Relatively few survivors of single traumas have this more severe reaction, except when the trauma is a lasting catastrophe that exposes them to death, destruction, or loss of home and community. Treatment includes immediate support, removal from the scene of the trauma, use of medication for immediate relief of grief, anxiety, and insomnia, and brief supportive psychotherapy provided in the context of crisis intervention.
Uncomplicated PTSD involves persistent re experiencing of the traumatic event, avoidance of stimuli associated with the trauma, emotional numbing, and symptoms of increased arousal. It may respond to group, psychodynamic, cognitive-behavioral, pharmacological, or combination approaches.
PTSD comorbid with other psychiatric disorders is actually much more common than uncomplicated PTSD. PTSD is usually associated with at least one other major psychiatric disorder such as depression, alcohol or substance abuse, panic disorder, and other anxiety disorders. The best results are achieved when both PTSD and the other disorder(s) are treated together rather than one after the other. This is especially true for PTSD and alcohol or substance abuse. The same treatments used for uncomplicated PTSD should be used for these patients, with the addition of carefully managed treatment for the other psychiatric or addiction problems.
Complex PTSD (sometimes called “Disorder of Extreme Stress”) is found among individuals who have been exposed to prolonged traumatic circumstances, especially during childhood, such as childhood sexual abuse. These individuals often are diagnosed with borderline or antisocial personality disorder or dissociative disorders. They exhibit behavioral difficulties (such as impulsivity, aggression, sexual acting out, eating disorders, alcohol or drug abuse, and self-destructive actions), extreme emotional difficulties (such as intense rage, depression, or panic) and mental difficulties (such as fragmented thoughts, dissociation, and amnesia). The treatment of such patients often takes much longer, may progress at a much slower rate, and requires a sensitive and highly structured treatment program delivered by a team of trauma specialists.
Events that are threatening to life or bodily integrity will produce traumatic stress in its victim. This is a normal, adaptive response of the mind and body to protect the individual by preparing him to respond to the threat by fighting or fleeing. If the fight or flight is successful, the traumatic stress will usually be released or dissipated allowing the victim to return to a normal level of functioning. PTSD develops: when fight or flight is not possible; the threat persists over a long period of time; and/or the threat is so extreme that the instinctive response of the victim is to freeze.
The following are examples of people with PTSD:
- A fire fighter quits his job two years short of retirement because of persistent fiery nightmares and chest pains.
- A young girl has become hyperactive since her tonsillectomy nine months before.
- A previously studious teenaged boy is no longer able to concentrate on his school work and is failing his classes since the death of his grandmother last year. He no longer enjoys going to school, and is becoming increasingly house-bound.
- A Middle Eastern refugee is arrested after a fight in a bar. He says all he remembers is a smell that reminded him of the prison where he was tortured, then he woke up in a police cell.
- A war veteran still awakes screaming from nightmares of combat, thirty years after he was discharged from service.
- A woman who was molested when she was six years old begins to be disturbingly over-protective of her own six year old daughter.
- A man seeks psychotherapy because he is suffering from persistent anxiety and panic attacks.
- A boy is observed aggressively trying to stick pencils and crayons under the tails of his stuffed animals.
DISTINGUISHING ACUTE TRAUMA FROM PTSD
Discussion with professionals who work with both the acute and the long-term aftermath of trauma has led me to conclude that aside from physical injury due to trauma, acute traumatic reactions may be indistinguishable from PTSD in the body and behavior of the victim. The same disorientation, fear, and indications of ANS activations - elevations in heart rate, blood pressure, respiration, shaking, etc. - may be present.
In the aftermath of a disaster, for example, most of those suffering from acute trauma will be easy to spot. Those who have been injured will be obvious. Among the uninjured there will also be many who look stunned, appear pale and faint, or be shaking. Some of those who appear to be suffering from trauma may not even be the actual victims of the disaster, but witnesses or rescuers who may be deeply affected by what they have or are seeing. Some may not be immediately identifiable, they may be highly active - looking for others or after others, organizing help and rescue. A percentage of these may, in the next days or weeks, develop symptoms of trauma.
Months or years later, the vast majority of the survivors, witnesses and rescuers will no longer be suffering psychologically from the after effects of the event. However, a minority will be suffering to an extreme degree, their lives decreased in quality, and a diagnosis of PTSD will be appropriate.
While symptoms of acute trauma and PTSD may not differ very much, response to these must differ significantly. Response to acute trauma may include emergency medical intervention for treatment of injuries and/or medical shock. On the psychological side reassurance and comfort will be the key. Often talking about what happened will be important for the survivor in the immediate aftermath of the event. Telling and re-telling the story to caring individuals may help prevent dissociation, and aid in integrating the experience. Providing physical support - holding, an arm around the shoulders, a comforting hand - may be appropriate, especially if the survivor is hysterical or shaking violently. The victim may be cold and in need of blankets and warm beverages. The victim may need to be reminded that the event is passed and they have survived it, "You're safe now." The more complete and appropriate the response to acute trauma, the greater the chance of preventing subsequent PTSD.
Later, working with those who do develop PTSD may resemble some of the aspects of response to acute trauma. Certainly a reassuring and comforting attitude on the part of the psychotherapist is important. But when the trauma is long past, simple comfort and reassurance will not be enough. The victim of PTSD will feel unable to contain his traumatic experience(s), will have become afraid of his body, and will have lost the sense of what was then and what is now. It is these three areas - containment, positive body awareness, dual time awareness - that must first be strengthened, before addressing the memory of a traumatic event can be done productively.
Containment of out-of-control emotions and thinking processes will help restore a feeling of control over the psychological self. Positive body-awareness will help restore a sense of the body and its sensations as friend, not foe. Dual time awareness will help to separate that the trauma occurred in the past even though it feels as if it is occurring now (Rothschild 1996, Rothschild 1997).
Identification of a portion of those suffering from PTSD will be straightforward. But others may be difficult to spot owing to complicated life or defensive systems. Evaluation of the state of the ANS will assist in diagnosis and in setting treatment objectives where appropriate.
Possible books to learn more about PTSD.Brett, EA, "The Classification of Posttraumatic Stress Disorder," in van der Kolk, BA, McFarlane, AC, & Weisaeth, L (Eds.), TRAUMATIC STRESS: THE EFFECTS OF OVERWHELMING EXPERIENCE ON MIND, BODY AND SOCIETY, Guilford Press 1996.
Diamond, MC, Scheibel, AB, & Elson, LM, THE HUMAN BRAIN COLORING BOOK, Harper Perenial 1985.
Elliott, Diana M, "Traumatic Events: Prevalence and Delayed Recall in the General Population," Journal of Consulting and Clinical Psychology, 65, 811-820, 1997.
Figley, Charles R., Ph.D., TRAUMA AND ITS WAKE, Volume I: The Study and Treatment of Post-Traumatic Stress Disorder, Brunner/Mazel, 1985.
Gallup, Gordon G., Jr., and Maser, Jack D., "Tonic Immobility: Evolutionary Underpinnings of Human Catalepsy and Catatonia", in Seligman, Martin E. P., and Masser, Jack D., PSYCHOPATHOLOGY: EXPERIMENTAL MODELS, San Francisco: W.H. Freeman and Company, 1977.
Herman, Judith L., MD, TRAUMA AND RECOVERY, Basic Books, 1992.
J˙rgensen, Steen, Cand. Psych., "Bodynamic Analytic Work with Shock/Post-Traumatic Stress", Energy and Character, Vol. 23, No. 2, September 1992.
Kluka, RA, Schlenger, WE, Fairbank, JA, Hough, RL, Jordan, BK, Marmar, CR,, & Weiss, DS, TRAUMA AND THE VIETNAM WAR GENERATION: REPORT OF FINDINGS FROM THE NATIONAL VIETNAM VETERANS READJUSTMENT STUDY, New York: Brunner/Mazel 1990.
Levine, Peter, Ph.D., WAKING THE TIGER : HEALING TRAUMA : THE INNATE CAPACITY TO TRANSFORM OVERWHELMING EXPERIENCES, 1997
Loewenstein, Richard, J., M.D., "Dissociation, Development and the Psychobiology of Trauma", Journal of the American Academy of Psychoanalysis, 21(4), 1993.
Marmar, CR, Weiss, DS, Schlenger, WE, Fairbank, JA, Jorday, K, Kulka, RA, & Hough, RL, "Peritraumatic Dissociation and Posttraumatic Stress in Male Vietnam Theater Veterans," American Journal of Psychiatry , 151, 1994.
Nadel, L & Jacobs, WJ, "The role of the Hippocampus in PTSD, panic, and phobia." In N. Kato (Ed.), HIPPOCAMPUS: Functions and clinical relevance. Amsterdam: Elsevier Science B.V. 1996.
Ornstein, Robert & Thompson, Richard, THE AMAZING BRAIN, Houghton Mifflin, USA, 1986
Puglisi-Allegra, Stephan, and Oliverio, Alberto, PSYCHOBIOLOGY OF STRESS, Kluwer Academic Publishers, 1990.
Selye, Hans, M.D., THE STRESS OF LIFE, McGraw-Hill Book Co., 1984.
van der Kolk, Bessel A, M.D., and Fisher, Rita E., Ed.M., "The Biologic Basis of Posttraumatic Stress", Primary Care, Vol. 20, No. 2, 1993. van der Kolk, Bessel, M.D. (1996a), "The Body Keeps the Score: Memory and the Evolving Psychobiology of Post-traumatic Stress", Harvard Psychiatric Review, Vol., 1, 1994.
van der Kolk, BA, McFarlane, AC, & Weisaeth, L (Eds.) TRAUMATIC STRESS: THE EFFECTS OF OVERWHELMING EXPERIENCE ON MIND, BODY AND SOCIETY Guilford Press 1996.