Defining and understanding Post Traumatic Stress Disorder

The purpose of this paper is to gain a better understanding of trauma, post- traumatic stress disorder and the effect that they can have on women and children. Through being able to clearly understand and define trauma and PTSD, one can develop an appreciation and understanding of the primary causes for the diagnosis.

Merriam-Webster.com (2010), classifies the word trauma as a noun defining it as “an emotional upset or a disordered psychic-emotional behavioral state resulting from severe mental or emotional stress or physical injury”. This definition can elevate the word to describe not just an event, but a state of emotion, a feeling or a sensation that can affect a person at his or her psychic core of being. By using this definition of trauma this writer was able to develop a deeper appreciation of how the experience of intimate partner violence, rape, abuse, or criminal violence can affect a person, and in some cases cause permanent changes to his or her being.

Since actions between domestic partners can vary widely, there is some controversy as to “whether violence in the home qualifies as a traumatic event” (Margolin & Vickerman, 2007, p.614). Although violence in the home can be a contributing factor in post-traumatic stress disorder in women and children, PTSD can also be a result of exposure to repeated or situational violence caused by both single and repeated experiences outside of the home. These types of experiences can include: major national or environmental catastrophes, random acts of violence in public schools or the workplace, acts of terrorism or a one time event like a car accident. At one time PTSD was thought to be a problem that was experienced only by combat veterans. It is now more thoroughly understood and the diagnosis can be applied to any repeated experience of a traumatic event (s). The PTSD alliance states that “one of 13 people in this country – will develop PTSD during their lifetime [and that] women are twice as likely as men to develop PTSD” (ptsdalliance.org). This could be because women can experience trauma associated with intimate partner or sexual assault more than men do.

Diagnostic Criteria

The Diagnostic and Statistical Manual of Mental Disorders IV-text revision, (DMS-IV-TR) classifies Post-traumatic stress disorder (PTSD) as an Axis 1 anxiety disorder. Axis 1 disorders initially cover symptoms of clinical disorders having to do with specific mood disorders including anxiety, substance abuse and impulse-control disorders Not otherwise specified (NOS). “PTSD is an enduring distressing emotional disorder that follows exposure to severe helpless- or fear inducing event” (Durand & Barlow, 2009, p.155). Although it is classified by the DSM as an anxiety disorder, it is different from the generalized anxiety disorders, stress, fear or panic disorders because of how the symptoms present. Anxiety is not the leading symptom in PTSD.

Since the underlying cause of PTSD is a major trauma event or series of events in the client’s history this event must satisfy “the seriousness and subjective requirements of a traumatic stressor (Criterion A) as well as the presence and severity of 17 associated symptoms” (Criterion B-D) (Barlow 2007, p.74). Since anxiety does not usually present as the leading symptom, the necessary criterion (A-D) can result in a preliminary diagnosis of PTSD. Meeting criterion for the diagnosis may not be easy for some as trauma survivors may not readily disclose their personal trauma history.

Symptoms of PTSD are divided into 3 separate classifications:

Acute- Acute symptoms are recent and would include symptoms over a period of less than 3 months.

Chronic- Chronic symptoms describe symptoms over a period of less than 3 months

Delayed- Delayed onset symptoms describe symptoms where it has been at least 6 months since the event has passed before symptoms surfaced.

Assessments and Testing

PTSD can be assessed through various testing batteries. Testing and assessments can vary from structured interviews to self report questionnaires. The Clinician Administered PTSD Scale (CAPS) is an instrument that can be used in clients over the age of 15. The CAPS consist of a structured interview process that can assess the client’s PTSD symptoms and issues. The assessment can provide the clinician/ therapist insight to issues related to re-experiencing symptoms, avoidance and numbing symptoms, hyper arousal symptoms and trauma related to guilt to name a few. The CAPS assessment has a different version for children aged 8-15 that looks at developmental, academic and social functioning. Other testing and assessment batteries for PTSD are the PTSD Symptom Scale Interview (PSS-I) “that provides a snapshot of the client’s experience of symptoms over the past two weeks. This time frame differs from the standard one month time frame of other measures” (www.va.gov.professional)

Evaluations can include structured clinical interviews (SCID) the Anxiety Disorders Interview Schedule-Revised (ADIS), Structured Interview for PTSD (SI-PTSD). Each testing standard offers a different option for helping the clinician begin to understand how the frequency and the severity of the symptoms of PTSD are affecting the client’s life.

Although originally thought to affect only combat exposed veterans, PTSD has moved into the public sector and is now considered to be part of the “epidemiology [that] has been directly linked to . . . trauma” (AFP, 2003, p.2403). PTSD can be associated with affective disorders, emotional dysregulation, impulse control issues, substance abuse and if left untreated, suicide.

Etiology

The original event that trigged the PTSD for the client can be a personal experience, or the witnessing of a traumatic event. The diagnostic criterion for PTSD is such that it takes into account not only the traumatic event itself that was either experienced or witnessed by the client, but the client’s perception of the event as well.

There can also be other contributing factors that may need to be considered. The clinician taking the assessment should be sure to obtain a complete family medical history as well as mental health historical information as there is a hypothesis that people who have a predisposition to depression, anxiety disorders or a family history of these are more likely to develop PTSD.

Theoretical Models

“The concept of PTSD has been accompanied by a variety of theoretical models (neuro-psychiatric, psycho analytical, cognitive behavioral) to explain its origins and maintenance in the traumatized individual” (Newman, 2001, p.11883). With a diagnosis of PTSD, the client must have episodes of flashbacks or reliving of the traumatic event, including avoidance of situations that may trigger the flashback. Indicators that a client may be suffering from PTSD can be determined if the client is having difficulty falling asleep, is exhibiting aggression, or hypervigilance. This is just a small list of symptoms that a client may demonstrate but these behaviors must not have been present before the client’s experience to the trauma.

PTSD and Children

It has been recently discovered that in children, the probable consequence of exposure to domestic violence “is now recognized as a potential precursor to PTSD” (Margolin & Vickerman, 2007, p.613). A child’s experience of violence in the home may be a catalyst in the development of PTSD. Children may display their symptoms as non compliance or aggressive outbursts. It can also present in repetitive play of trauma scenarios, dreams, displays of physical reactivity or feelings of the reoccurring trauma and emotional regulation difficulties. A child’s exposure to violence resulting in secondary trauma can affect all areas of development, and impulse control, affect regulation, social skills and the ability to form lasting relationships. Everyday memory and general functioning can be affected in children diagnosed with PTSD.

A child exposed to domestic violence or abuse in the home can suffer affects in his or her perception of safety and security, and can have a negative effect on attachment to the parent or primary caregiver. A disorganized attachment can occur when the caregiver or parent is both “the source for safety and the source for danger” (Margolin & Vickerman, 2007, p.614). The impact of both abuse and neglect can be far reaching and long term. “Studies have shown PTSD [to be] associated with lasting changes in neurobiological symptoms and brain areas that mediate stress response and cognition, learning, visual and verbal memory, and deficits in attention and executive functioning” (Fani, Ashraf, Reid, Afzal, Jawed& Bremner, 2009). There can also be significant impairments in verbal learning, visual memory, total situation recall and long term memory storage causing issues in school or social settings. Studies have revealed that an “increase in gluco-corticoids affect development in children’s brains” (Margolin & Vickerman, 2007 p.615) and these can cause alterations in brain activity that is associated with memory, the amygdala and the prefrontal cortex. Treatment for children who have PTSD can include cognitive behavior therapy (CBT), elements of exposure, eye-movement desensitization and reprocessing (EMDR) and group psychotherapy, play therapy or psychodrama.

PTSD, Women and Feminist Theory

Feminist therapy theory “understands the experience of trauma, both interpersonal and impersonal . . . within the context of social emotional and political environments” (Brown, 2004, p.246). This includes acts of racial discrimination and sexual harassment. This is a seemingly broad category, but one that in some cases can be a part of a person’s daily experience. Ethical guidelines for feminist therapists stress awareness of cultural differences, power differentials, and social change as part of the ongoing efforts to encourage and educate those around them. Since the theory is integrative and inclusive a therapist working with trauma survivors within feminist theory can offer the client an eclectic mix of treatment strategies. “The question that must first be answered is whether such a treatment strategy would support an egalitarian, empowering, competency based therapy in which outcome is feminist consciousness” (Brown, 2007. p.467). Offering a collaborative process a feminist therapist looks for the client’s strengths in helping him or her move toward healing.

By looking specifically at women as trauma survivors it is clear that one has to differentiate the types of trauma experienced between men and women and determine if there are any similarities. “Women need not to experience severe violence to experience PTSD symptoms . . . Psychological abuse may be as dangerous as physical violence” (Hughes & Jones, 2005, p.6). Incidents of verbal or psychological violence or trauma can increase a woman’s chances of getting PTSD.

Some feminist therapists and theoreticians feel that day after day a women’s life experience can provide opportunities to experience trauma, and that these daily traumatic experiences can be equal to the experience of males serving in a time of war in the military. Toward a Radical Understanding of Trauma and Trauma Work (Barstow, 2003) presents a call to action and a change of purpose in understanding the effects of trauma and the experiences of women in society. Her position states that therapists should consider that trauma in women does not necessarily have to be a direct result of battering, or sexual assault (Barstow, 2003, p.11), and that women and people who are oppressed can experience secondary trauma by the unequal access to resources based simply on gender, race and socio-economic class.

A supporter for change, Barstow was an advocate for the altering of Criterion A in the DSM. Citing Brown (1995) on the process of changing the definition of the criteria to include all people who may be oppressed since “tying trauma to a physically dangerous event or events per se is inadequate especially in the case of oppressed people” (p.5).

People can experience secondary and subtle trauma daily by living in the world as it is with the need for 24/7 news , as it is no longer acceptable to learn of a catastrophic event, but rather to be witness to it on television. The need to be connected, visually and electronically provides continuous contact with others providing the experience of something that would not ordinarily be witnessed. The occurrence of catastrophic event in another part of the world, say a shooting rampage at a workplace in India, guarantees that people living in a small town in Kansas will be affected by the experience of it. The same can be true for the brutal rape and murder of a child at the hands of his or her parent or relative. “National epidemiological studies conducted within the United States have found rates of civilian exposure to trauma to be as high as 87.7%. (Sledjeski, Spearman & Dierker, 2008, Riggin, 2009, p.46).

Feminist therapy theory “understands the experience of trauma, both interpersonal and impersonal but within the context of those social, emotional and political environments” (Brown, 2004, p.426). This understanding includes acts of racial discrimination and sexual harassment in the definition of an event that can lead to a diagnosis of PTSD. This is seemingly a broad category, but in some cases can be a part of a person’s daily experience. Feminist theory can be used in any strategy that treats suffering or emotional pain and since the theory itself is integrative and inclusive a therapist working with trauma survivors within feminist theory can offer clients a range of treatment strategies. “The question that must first be answered is whether such a treatment strategy would support an egalitarian, empowering, competency-based therapy in which an outcome is feminist consciousness” (Brown, 2004 p.467).

Gender Differences

Comparing the differences in trauma experienced by women or men, feminist therapists believe that the “clusters of symptoms [not unlike those experienced by combat veterans] also existed in women who were traumatized by abuse, such as incest, molestation, rape, harassment, battering and stalking” (Berg, 2002, p.6).

Reactions of both men and women to traumatic events may appear to be different solely due to role modeling and societies expectations. Gender stereotypes can affect how one responds to trauma. Women for the most part were taught as girls to be emotional, that it is ok to cry, and to be aware of other people’s feelings. Men were usually taught as boys the exact opposite in being told to be tough, not to cry, or be vulnerable; but instead to defend themselves. Regardless of where one stands in his or her belief of stereotypical classifications, understanding trauma symptoms and being aware of where the client is within these roles may help the clinician to identify symptoms of PTSD in both men and women.

A study recently published in the Annals of General Psychiatry (2010), on the combined effect of gender and age on post traumatic stress disorder attempted to define if men or women show differences in lifespan distributions of the disorder. The study looked at:

1) 6,548 participants, 2,768 (42.3%) men and 3,780 (57.7%) women

2) Results showed men and women differed in lifespan distribution of PTSD.

3) The highest prevalence was seen for men in the early 40’s for women early 50’s

4) Women had a female to male ratio of nearly 3:1 with the highest percentage found in 21-25 year olds. (2010)

Moving forward

Since the core of feminist theory lives in the statement “the personal is the political” (Brown, 2004, p.468) it seems that the focus on helping the client find a process that will allow him or her to gain a sense of empowerment. Feminist theory exists with the understanding that no person is separate form his or her environment. Therefore it is important to cultivate understanding of not only the problem or the trauma, but the context (cultural, socio-economical) in which the client lives and the process of developing connection with others and returning to a state of wellness.

The simple absence of symptoms is not the goal of feminist trauma treatment. Consciousness of one’s own kinship with other

trauma survivors and the creation of non blaming means asserting

a sense of control are constructed as equally important to

symptom remission. (Brown, 2004, p.469)

Resiliency and Recovery

Knowing all that the field knows about the effects trauma, PTSD and recovery one needs to understand how people recover and find effective coping strategies to move forward after experiencing a traumatic event that results in PTSD. A new term for this is post traumatic stress resilience. Since post traumatic stress resilience includes several different behavioral strategies, a strong understanding of the personal characteristics that are associated with resiliency is necessary.

Resiliency is a character trait that reflects a successful passage through traumatic or difficult situations or circumstances coming out on the other end not unharmed, but with an attitude that one can move on. The ability to ask for help and deal with stress effectively as well as having a strong support network are all contributing factors in building post traumatic stress resilience. Being able to disclose the details of the trauma and identifying as a survivor and not a victim are others. A look at post traumatic stress resilience on a spectrum one can find that one end of the spectrum contains a most favorable coping strategy that characterizes resilient behavior as a stipulation in continuing situational adaptation, while the other end of the spectrum contains minimal coping strategies that can increase risk factors for the development of PTSD and any level of psychopathology.

Conclusion

If Maslow really did understand that the road to self actualization included having to battle the personal demons and experiences of pain or tragedy that humans can hold on to, then for therapists or counselors there can be an understanding that “positive changes following adversity” (Joseph & Butler, 2010, p.2) can happen for clients. The movement toward Positive psychology has made it possible for the concept of personal growth after trauma to even be considered possible. PTSD Research Quarterly (2010) reports encouraging findings in the “term positive growth has now become the most widely used term to describe the field”.

These changes in how trauma is treated or described whether under conventional guidelines or through the new lens of feminist theory or positive psychology, does not necessarily mean that there will be freedom from distress, or less psychological pain for the client. But they could result in the client finding a place of comfort and understanding in the search for healing and wellness. Whatever the outcome is, one thing is in particular comes to mind. Strategies used when working with clients who have exposure to trauma resulting in PTSD should include an approach that helps the client learn the skills required to become empowered and strong.

The goal of treatment is not just to get to a place where there is an absence of symptoms, but to gain a better understanding and acceptance of what has happened. Helping the client gain a sense of control and begin healing after trauma may happen as the client begins to understand that he or she is not alone in this journey. Taking steps in cultivating relationships and working for change can be the first step in working toward recovery.