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Posttraumatic Stress Disorder (PTSD) was not recognized as a formal diagnosis in the psychiatric nomenclature until 1980. Since then understanding of the disorder has grown as old myths about trauma were dispelled and new factors were explored. However, while enormous advances have been made in understanding the effects of psychological trauma, there is significant variation among individuals, traumatic events, and the context in which the events occur. Diagnosing and treating PTSD thus often remains an extremely complex matter.1 The focus herein will revolve around my own personal experience with PTSD as a demonstration of one means used to chart a course. I draw mostly on the work of Bessel van der Kol, M.D., co-principal investigator for the DSM-IV Trial for PTSD. As PTSD's preeminent expert, van der Kol represents the institutional standard for the current assessment and treatment of this disorder. In 1977 I was a pedestrian crossing the street with a friend. We were run down by a drunk
careening through the red light. I died on the street that night and was "way up in the air" with a
very strange detached awareness of a hubbub going on far below me. It was as if I had been set loose
into deep space, drifting amidst the stars. Roily clouds scudded towards me, then through me and
beyond, as if I were but a part of some greater cosmic union, privy to a passing meteor shower. I was
enveloped by a profound and peaceful silence until I heard a distant, whispered voice. "I can 't
breathe." It was my own voice, disembodied, at the point of resuscitation by paramedics on the
street below, and it ended the experience, followed by: a coma, amnesia of the actual accident, and 19
months recovery - including five additional surgeries for serious and extensive physical injuries. I didn’t
really reflect on what had happened. I simply moved on.
This experience meets the first set of diagnostic criteria outlined in the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV), under 309.81 Posttraumatic Stress Disorder, in that I had
been confronted with an overwhelming event which involved actual or threatened death and serious
injury. One cannot infer a PTSD diagnosis, however, solely on the basis of exposure to a traumatic stressor.
Indeed, while PTSD is caused by an external traumatic event, only a minority of trauma survivors
develop this condition. Why? Pre trauma vulnerability is one predictor of PTSD, both as a predictor of eventual exposure as well as the onset of PTSD following exposure. It's an important distinction to make
because, as a predictor of exposure, it indicates a vulnerability rooted in earlier traumatization, which has its way out, so to speak, in a compulsion to repeat. As risk factors,
though, earlier formative influences also exist for the development of a variety of mental health
problems, of which PTSD is only one. In fact, in the case of accident victims, studies have shown that
only 15% had PTSD in the absence of some other personality disorder; .2 Conversely, 65% had
preexisting disorders which put them at greater risk of developing PTSD after exposure to a traumatic
incident Disorders with shared characteristics which can be found in the course of treating PTSD
include Panic Disorders, Phobias, Conversion Disorder, Dissociative Disorder and Borderline
Personality Disorder. Whether they be symptoms of a genetic or biological predisposition, or of factors
related to one's life course, rearing environment, mental health or personality (traits such as
introversion, for example), the risk for not only developing PTSD is increased but also the eventuality of
exposure to a precipitating stressor. Thus, the progression from a state of distress to the more severe
symptoms of PTSD is influenced by a range of vulnerabilities, life events or traumas occurring both
before and after the traumatic trigger. With that, it is something of a trap. Accordingly, it seems wise
to routinely explore the possibility that several significant stressors have been experienced by any
adult who presents for a clinical assessment related to trauma,3 as well as to understand how
trauma- and personality disorders reinforce each other as they interact. You will not be able to
successfully treat PTSD without encountering the differential processes at work. To differentiate in terms of diagnostics, the DSM-IV has chosen to simplify the matter by, in addition to exposure to a traumatic stressor, requiring that specific symptoms be present that are unique to PTSD. They include: 1) persistently re experiencing the event, 2) avoiding stimuli associated with the trauma, 3) increased arousal, such as hypervigilence, 4) duration of these symptoms for more than one month, and 5) significant distress or impairment in social, occupational, or other important areas of With this last indicator, the diagnostic criteria also draws the line (or perhaps wisely broadens the scope) for assessment of PTSD to actually include consideration of the other disorders as they may relate to unsuccessful coping, of the individual's inability to moderate or relieve personal stress, or to maintain both a sense of positive personal worth and the capability to meet the requirements of life. When traumatic memories are dissociated from life experience, however, and stored outside of ordinary awareness (e.g. in the case of amnesia), successful coping may seem to be apparent when, in fact, it is not. Instead, other seemingly unrelated symptoms, such as physical ailments, can emerge. And as long as memories of the trauma remain dissociated they can be expressed as other psychiatric symptoms as well, which revisits some of the complexities in diagnosing and treating PTSD. van der Kol quotes J.L. Herman's Trauma and Recovery when he says "traumatized people are frequently misdiagnosed and mistreated in the mental health system. Because of the number and complexity of their symptoms, their treatment is often fragmented and incomplete."4 Physical symptoms directly related to or caused by the initial traumatic stressor (e.g. when pain or other physical ailments are localized to the site of injuries sustained at the time of the initial trauma), can also begin to reappear as a predictor in a delayed onset of PTSD. Other predictors include the increased probability that an individual will be exposed to two or more similar stressors over their life span, often in response to such things as anniversaries of the traumatic event. As a result of the initial trauma, both of my knees had to be rebuilt. Ten years later, I developed difficulty walking due to increasing knee pain. Visiting an orthopedics specialist I was required to revisit the circumstances of the original injury, request files from my surgeon. in the past, as wel1 as initiate a request for authorization for payment to be processed through the covering insurance carrier. Predictably enough, the insurance carrier at first refused. Perhaps not unrelated my knees began to "give out." At the same time, I was enrolled in a graduate psychology program, a process which in and of itself was beginning to stir things up. .5 It was during this period that a driver in front of me ran over a pedestrian in the crosswalk. Essentially recreating the accident I was in ten years before - to the day - the pedestrian died before my eyes. I saw his spirit leave his body, and then the amnesia I had suffered back in 1977 lifted. .1 During the ensuing weeks I could not leave my apartment. When I finally did venture out, I could not bring myself to cross the street, much less drive my car. As the principal witness to the accident, I also found myself repeating to the insurance investigators, to the police, it seems to everyone who asked, "it was an accident, pure and simple," over and over again until the realization hit that in some part of me I was blaming myself for what had happened to me when run down on the street ten years before. To complicate the matter, over the next two months, I experienced a number of other stressors. My employer was bought out in a corporate merger and my job was downsized out. The Whittier earthquake of '87 also hit, and my apartment was severely damaged, then condemned, set to be razed. In the midst of it all my boyfriend and I split up. It was all too much. I put my household furnishings in storage,
packed my car, and headed to a secluded cabin in San Cristobal, north of Taos in the mountains of
New Mexico, hoping to calm things down, if not sort them out. To be distressed is a normal reaction to traumatic or stressful experience, even an acute homeostatic reaction characterized by panic, mental confusion, disorientation, dissociation, insomnia, and agitation. Yet the typical pattern for even the most catastrophic experience is resolution of such symptoms, not the development of PTSD. Even for those who experience chronic PTSD many years after the triggering event (e.g. with veterans of the Vietnam War, for one example), with the passage of time the symptoms will resolve in approximately two-thirds of the cases.7 As a healing process, however, there are other stages which need to be encountered beyond the resolution of acute distress. Exploring the trauma for its own sake has no therapeutic benefits unless it becomes attached to other benefits and the discovery of other meaning. Central to the experience of traumatic stress are feelings of helplessness, powerlessness, and a threat to one's life. As one result many traumatized individuals tend to blame themselves for having been traumatized, because assuming responsibility for the trauma allows feelings of helplessness and vulnerability to be replaced with an illusion of potential control. Such a need arises because trauma attacks the individual's sense of self and predictability in the world, what can appear to be a maddening spiral
into a seeming involuntary disintegration of the capacity to take charge of one's life, and, from there, a fear of involvement with life itself. Many traumatized individuals organize their lives around such a core
conflict, between the fear of re victimization and the endless need for external reassurance and control. In one extreme, it can take the form of excessive interpersonal sensitivity. Indeed, after being exposed to interpersonal traumatic abuse, some people learn to watch their fellow human beings like hawks. Many people who were traumatized by their own caregivers develop an uncanny ability to read the needs and feelings of people who may have power over them. It's a capacity which they can subsequently utilize for self-protection.8 Other people become unable to articulate their wishes, fail to understand another person's point of view, or become unable to compromise - an aberrant exercise in mistrust of not only others, but also oneself. It’s the need to be in control, lest all else should fall
apart. For treatment to be successful, the individual must ultimately come once again to be able to see him or herself as being capable and worthy of having restorative experiences, and to consider oneself also capable of being entrusted with responsibility, intimacy and care. As such, uncovering memories is not enough; they need to be modified and transformed. Thus, treatment is needed to address a complex set of
circumstances, gaining not only a sense of integrity of the physical self (e.g. the control and mastery of physiological and biological stress reactions) but also the unfinished psychological business (disorders, as it were) which grew out of the trauma(s) of the past. To do so, one must at bottom overcome the fear of the traumatic memories often by going back into the horrifying, overwhelming experience itself.9
It is a way to depotentiate the experience (like letting the air out of a balloon, so to speak) and thereby alleviate the compulsion to repeat. Integrating the experience also places it more in a personal historical
context, allowing one to get on with trust in the future course of one's life. The scene was a workshop setting as I laid flat on my back on the ground. Loud, primitive, dirge-like music flooded from the studio speakers, filling my. I began with a sustained, rhythmic. hyperventilative sort of bellows breathing. This had been explained as a means to help bypass intellectual and psychological defenses, part of a process of deep experiential self-exploration to foster hea1ing within the psyche, transformational growth. I became instantly aware of unsettling feelings rising from deep within. It was the physical perception of a severe, almost life-threatening tautness, as if my body was hardening like setting cement. "Keep breathing, " a voice whispered in my ear, and soon the constrictive sensations faded to leave me floating. I was back in the womb, a paradisiacal bliss. This felt good and so I redoubled my breathing efforts hoping to maintain the flux. But my body again soon began to armor, and a monstrous, claustrophobic feeling of agonizing emotions descended on me. The impression was of utter helplessness and hopelessness, and I was convinced that this would never end, that there would be absolutely no way out. And so I screamed, a most primordial, yet purgative cathartic; could it have really come from my mouth? Yet with it, the hydraulic tension
released from my body, as did my awareness itself. I entered another realm, the awareness of a snake, adopting not only its bodily image but also its instinctual sensations and drives as I slithered against and around a fetid log. I felt the moist bark crumbling against my body as I shed
an old skin. This left me in a state far beyond a feeling of relaxation, as if I was drawing upon the memory of some vast sea of awareness, one that we all have shared with all of life since time began. Then the terror returned full force. "Easy enough," I thought and I began to scream again, only this time it
did not completely resolve. It was stuck in my wrists and hands, so I tried to shake it out. Harder. The whole of my arms, my body engaging until I was flailing wildly about, and I crossed a threshold, the absolute utter loss of any control. That's when I saw the headlights fast approaching. And I felt my panic, then the impact, all of my ribs breaking, my arms, my legs, my shoulder, too. My lung collapsed and I was choking on blood as I suffered the horror of the accident which I had so effectively blocked years before, all mixed together with the pain of my broken body, shooting upwards into the center of my head. This was experienced as a supernaturally radiant white light as it exploded like a super nova and I sat bolt upright in the room. I saw the entire group had gathered around me, slack-jawed, their fields
of energy plainly visible to me, hugging their forms. My body was violently trembling, but soon that settled down to leave me with a triumphant, yet peaceful feeling of well-being, as if delivered through a major passage of death and rebirth, kindling, as it did, new feelings for life. The experiential encounter described above was but the first of many hours of such deep exploration undertaken to foster the abreaction of traumatic memories, experiences which ultimately included not only the accident material but also the original trauma of birth. As such it can be an effective modality used for treatment in the PTSD therapeutic course. 9 Yet, in addition to manipulation of the sort of biographical material currently used in contemporary western psychotherapy, it also takes into account -you might say employs -transpersonal and spiritual dimensions as part of a heuristic
healing potential rather than pathology to be avoided. To wit: "Most methods developed for treating trauma focus on re experiencing the event, e.g. hypnosis, implosive therapy, EMDR, and so forth. Such techniques have been shown to be helpful with selected samples of patients. However, they were also found to be potentially detrimental [with reported] severe pathological reactions. Caution is thus highly recommended."10 It's apparent that two dangers face trauma therapists - focusing too much on trauma, or not focusing enough. Indeed, having some patients repeatedly relive traumatic events in therapy could be harmful, provoking increased hypersensitivity rather than habituation. Yet, my personal experience has been to treat such processes as normal and highly desirable manifestations of the human psyche as part of an extraordinary healing course. As such, colluding with patients' avoidance of trauma can also be detrimental. It may reinforce maladaptive coping strategies and prevent the integration of the traumatic information. There are strengths and limitations to be considered in each approach. An important means to developing the appropriate assessment and treatment strategy for any given
individual is to gather data about the person's life, their symptoms, belief systems, strengths, weaknesses, and coping repertoire. In the end, however, the goal remains the same, to help the individual reestablish secure social connections and personal, as well as interpersonal efficacy, and thereby help bring fulfillment and meaning to their life. End
Grof, Stanislov, M.D., with Hal Zina Bennett, The Holotropic Mind: The Three Levels of Human Consciousness and How They ..Shape Our Lives. New York: ilarperCollins Publishers, 1993. ____and Christina Grof. Beyond Death -The Gates of Consciousness. London: Thames Hudson,1980. ____Realms of the Human Unconscious. New York: Dutton Books, 1976. Keikman, Arthur J. "The Meaning of Everything," The Nature of Human Consciousness; A Book of Readings. San Francisco: W.H. Freeman and Company, 1968. Yatri. Unknown Man; The Mysterious Birth of a New Species. New York: Simon and Schuster/Fireside Books, 1988. BIBLIOGRAPHY First, Michael B., Editor. Text and Criteria, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, DSM-IV. Washington, D.C.: American Psychiatric Association, 1994. Grof, Stanislov, M.D. Beyond the Brain.: Birth, Death and Transcendence in, Psychotherapy (Albany, NY: State University of New York Press, 1985. . Ornstein, Robert E. The Psychology of Consciousness. New York: Viking Press, 1972. . Bessel A van der Kolk, Alexander C. McFarlane, and Lars Weisaeth, Editors, Traumatic Stress; The Overwhelming Experience on Mind, Body, and Society New York: The Guilford Press, 1996. |
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