Over the past decade, as I have worked with cops, firfighters, abuse victims and children of addicts, I have learned that there are many causes for PTSD. It has also affirmed my belief that PTSD is real and harmful, not only to those who have it, but also to those around them. It impacts the way we act, react, our motivation and our capacity to feel–well, anything.
Terrifying experiences that shatter people’s sense of predictability and invulnerability can profoundly alter their coping skills, relationships and the way they perceive and interact with the world. The criteria for Post Traumatic Stress Disorder (PTSD) are 1) exposure to a traumatic event(s) in which the person witnessed or experienced or were 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, and 2) the persons response involved intense fear, helplessness or horror DSM IV p. 427-28). Gradual Onset Traumatic Stress Disorder can be caused by repeated exposure to sub-critical incidents such as child abuse, traffic fatalities, rapes and personal assaults.
Nevertheless, not all people exposed to trauma are traumatized. Why? In 1998, Pynoos and Nader proposed a theory to assist in explaining why people have different reactions to the same event. They asserted that people are at greater risk of being negatively impacted by traumatic events if any of the following are present: 1) they have experienced other traumatic events within the preceding 6 months, 2) they were already stressed out or depressed at the time of the event, 3) the situation occurred close to their home or somewhere they considered safe, 4) the victims bear a similarity to a family member or friend and 5) they have little social support.
It has been argued that officers, emergency service personnel, children of addicts and abuse victims experience traumatic events or threats to their safety on an almost daily basis. Being abused, not knowing when or if your parents will come home, repeatedly seeing children murdered, people burned in car fires and devastated victims starts to take its toll. People like idealistic officers who joined the force to change the world and protect the innocent begin to feel like nothing they do makes a difference, they cannot even keep their zone safe (criteria 3). This is especially problematic for officers who live in or near their work zone and often leads to frustration and burnout (criteria 2). Children start to feel that the whole world is uncontrollable and unsafe.
It is still not totally accepted within the law enforcement community for officers to discuss the impact of situations on them. Anger, humor and sarcasm are but a brief outlet for what many officers dream about at night. As their condition worsens, many officers withdraw, because they are fearful of seeking help or support for fear it is a one way ticket to a fitness for duty evaluation or will get out and be an obstacle for future promotions. Several studies in recent years have shown that Post Traumatic Stress Disorder (PTSD) is among the most common of psychiatric disorders.
Another thing that distinguishes people who develop PTSD from those who are just temporarily overwhelmed is that people who develop PTSD become “stuck” on the trauma, keep re-living it in thoughts, feelings, or images. It is this intrusive reliving, rather than the trauma itself that many believe is responsible for what we call PTSD. For example, I have worked with officers who have responded to child abuse calls and had a child of their own who was a similar age (criteria 4). In the course of daily life children get hurt and have bad dreams. As parents they have seen looks of pain and fright on their kids faces. This makes it just that much easier to envision the looks of terror and agony on the face of the child as their parent beat them. Sometimes this visualization gets corrupted and officers suddenly they start to see their child in their mental re-enactment of the trauma, obviously a much more powerful memory. These officers are much more likely to be traumatized by the incident and potentially get stuck.
Traumatized individuals begin organizing their lives around avoiding the trauma. Avoidance may take many different forms: keeping away from reminders, calling in sick to work, or ingesting drugs or alcohol that numb awareness of distress. The sense of futility, hyperarousal, and other trauma-related changes may permanently change how people deal with stress, alter thier self-concept and interfere with their view of the world as a basically safe and predictable place. In the example above, these people often became even more overprotective of their children, suspicious of others, and had difficulty sleeping, because every time they close their eyes they see the child.
One of the core issues in trauma is the fact that memories of what has happened cannot be integrated into one’s general experience. The lack of peoples ability to make this fit into their expectations or the way they think about the world in a way that makes sense keeps the experience stored in the mind on a sensory level. When people encounter smells, sounds or other sensory stimuli that remind them of the event, it may trigger a similar response to what the person originally had: physical sensations (such as panic attacks), visual images (such as flashbacks and nightmares), obsessive ruminations, or behavioral reenactments of elements of the trauma. In the example above, sensory triggers that triggered some of the officers memories were certain cries, hearing or seeing a parent spank their child, returning to the same neighborhood for other calls and, of course, television shows or news reports that involved descriptions of abuse.
The goal of treatment is find a way in which people can acknowledge the reality of what has happened and somehow integrate it into their understanding of the world without having to re-experience the trauma all over again. To be able to tell their story, if you will.
The Symptoms of PTSD
Regardless of the origin of the terror, the brain reacts to overwhelming, threatening, and uncontrollable experiences with conditioned emotional responses. For example, rape victims may respond to conditioned stimuli, such as the approach by an unknown man, as if they were about to be raped again, and experience panic.
Remembrance and intrusion of the trauma is expressed on many different levels, ranging from flashbacks, feelings, physical sensations, nightmares, and interpersonal re-enactments. Interpersonal re-enactments can be especially problematic for the officer leading to over-reaction in situations that remind the officer of previous experiences in which she or he has felt helpless. For example, in the child abuse example above, officers may be much more physically and verbally aggressive toward alleged perpetrators and their reports tend to be much more negative and subjective.
Hyperarousal. While people with PTSD tend to deal with their environment by reducing their range of emotions or numbing, their bodies continue to react to certain physical and emotional stimuli as if there were a continuing threat. This arousal is supposed to alert the person to potential danger, but seems to loose that function in traumatized people. This is sort of like when rookie officers start and a hot call is toned out, they usually have an adrenaline rush. After two or three years, the tones hardly have any impact on them. Since traumatized people are always keyed up they often do not pay any attention to that feeling which is supposed to warn them of impending danger.
Numbing of responsiveness. Aware of their difficulties in controlling their emotions, traumatized people seem to spend their energies on avoiding distress. In addition, they lose pleasure in things that previously gave them a sense of satisfaction. They may feel “dead to the world”. This emotional numbing may be expressed as depression, and lack of motivation, or as physical reactions. After being traumatized, many people stop feeling pleasure from involvement in activities, and they feel that they just “go through the motions” of everyday living. Emotional numbness also gets in the way of resolving the trauma in therapy.
Intense emotional reactions and sleep problems. Traumatized people go immediately from incident to reaction without being able to first figure out what makes them so upset. They tend to experience intense fear, anxiety, anger and panic in response to even minor stimuli. This makes them either overreact and intimidate others, or to shut down and freeze. Both adults and children with such hyperarousal will experience sleep problems, because they are unable to settle down enough to go to sleep, and because they are afraid of having nightmares. Many traumatized people report dream-interruption insomnia: they wake themselves up as soon as they start having a dream, for fear that this dream will turn into a trauma-related nightmare. They also are liable to exhibit hypervigilance, exaggerated startle response and restlessness.
Learning difficulties. Being keyed-up interferes with the capacity to concentrate and to learn from experience. Traumatized people often have trouble remembering ordinary events. It is helpful to always write things down for them. Often keyed-up and having difficulty paying attention, they may display symptoms of attention deficit disorder.
After a trauma, people often regress to earlier modes of coping with stress. In adults, it is expressed in excessive dependence and in a loss of capacity to make thoughtful, independent decisions. In officers, this is often noticed because they suddenly begin making a lot of poor decisions, their reports lose quality and detail and they are unable to focus. In children they may begin wetting their bed, having fears of monsters or having temper tantrums.
Aggression against self and others: Both adults and children who have been traumatized are likely to turn their aggression against others or themselves. Due to their persistent anxiety, traumatized people are almost always stressed out, so it does not take much to them set off. This aggression may take many forms ranging from fighting to excessive exercise or obsession about something—anything to keep them from thinking about the trauma.
Psychosomatic reactions. Chronic anxiety and emotional numbing also get in the way of learning to identify and discuss internal states and wishes. May traumatized people report a high frequency of headaches, back and neck aches, gastro-intestinal problems etceteras. Since the stress is being held inside, the body begins to become distressed.
After a trauma, people realize the limited scope of their safety, power and control in the world, and life can never be exactly the same. The traumatic experience becomes part of a person’s life. Sorting out exactly what happened and sharing ones reactions with others can make a great deal of difference a persons recovery. Putting the reactions and thoughts related to the trauma into words is essential in the resolution of post traumatic reactions. This should, however, be done with a professional specializing in PTSD due to the wide range of reactions people have when they start confronting and integrating the memories of the trauma.
Failure to approach trauma related material gradually is likely to make things worse. Often, talking about the trauma is not enough: trauma survivors need to take some action that symbolizes triumph over helplessness and despair. The Holocaust Memorial in Jerusalem and the Vietnam Memorial in Washington, DC, are good examples of symbols for survivors to mourn the dead and establish the historical and cultural meaning of the traumatic events. There are several events for survivors of traumas that officers can also take part in. These events remind survivors of the fact that there are others who have shared similar experiences. Other symbolic actions may take the form of writing a book, taking political action or helping other victims.
PTSD is real, and can be resolved with time, patience and compassion.