PTS3398 - SECTION 3: CAUSES AND SYMPTOMS OF PTSD
PTSD Scenario: Trauma and the Development of Secondary Problems
James P. is a thirty-nine year-old white male who presents in recovery from multi-substance abuse, and with a history of serious depression, low self-esteem and self-worth, and a serious binge eating disorder. He has very few friends and has not been able to maintain any romantic relationships, spending a lot of time alone. He reports that he grew up the youngest child in a very abusive family, with a distant ineffective father and a non-nurturing mother with serious psychological difficulties, as well as two older siblings who bullied, humiliated and controlled him virtually all of his childhood.
From a very early age, he was overweight and a compulsive eater, reporting that he was the subject of a great deal of teasing at school. He was not allowed to engage in any after school activities when growing up, as his mother forced him to perform menial janitorial work at a local parochial school to make extra money for the family. When client came into his teenage years, he discovered some real talent as an athlete, and become a star on his high school football teams, getting in touch with stored reserves of anger that fueled his very aggressive play. Client also reports getting in a number of fights during his high school years, enjoying the release from this but reporting that his anger scared him as well. He reports that the only two states he seemed to be capable of were complete surrender/submission or explosive anger.
Although his sports abilities provided a sense of status, client reports he was unable to receive much pleasure from it, as he always had the feeling of being a fake or phony and still remained extremely unhappy. Nevertheless, he was able to leverage his sports success and good grades into a scholarship to a good college away from home. During his freshman year at college, he developed serious problems with social anxiety, accompanied by an acute sense of depersonalization and a collapse of any sense of self-confidence. During this period he first began to abuse alcohol, then got heavily into club drugs and cocaine. Client had one semi-serious suicide attempt during this time, which he never told his family about. After college, client was able to be accepted into a prestigious graduate program, during which time he began to attend 12-step programs and was able to stop using alcohol and drugs.
However, with the cessation of drug use, client began to have increasing difficulties controlling his binge eating, and his weight began to increase steadily except for a couple of occasions when he forced himself to adhere to a strict diet. A difficult career transition precipitated a major drop in client’s sense of identity and a final crisis of confidence, at which point his binge eating began to spiral completely out of control, at which point he entered counseling. A thorough assessment process revealed the presence of a fairly serious attachment disorder, dysthymia, anhedonia, significant self-loathing, extreme hopelessness and pessimism, and very poor skills at relationships and interpersonal effectiveness. Client presented with enormous difficulties in sorting out his affective life, as all of his emotional responses to his childhood problems felt like a great mass of undifferentiated feelings that had nowhere to go. Additionally, client has serious distortions in how much weight he has gained and what his body looks like.
Causes and Symptoms of PTSD
PTSD is unique among psychiatric diagnoses because of the great importance placed upon the etiological agent, or what was the actual traumatic stressor or event. (Friedman, 2009)
Experiencing a traumatic event directly or indirectly is the known cause for PTSD. The National Institute of Mental Health reports the following as life-threatening trauma:
- Being a victim of or witnessing violent crimes
- Surviving a car or plane crash
- Living through a hurricane or tornado
- Surviving a foreign or domestic terrorists attack
- Direct exposure to combat or war related violence (National Institute of Mental Health, n.d.)
A clinician cannot diagnose PTSD unless the patient has experienced a qualified traumatic event and the traumatic event has been verbalized or relayed to the clinician by the patient or by a reliable source - if the patient is unable communicate this information.
A qualified traumatic event is something that is considered to have left the client in fear for their lives, or witnessing an event or incident that is so horrifying to them that they cannot mentally process it.
People encounter traumatic events throughout their lives, and what is traumatic to one person may not be for another. Not all people who experience traumatic events will exhibit symptoms, so not all traumatic events necessarily lead to a diagnosis of PTSD.
There are some studies that show a person’s temperament may make him or her more likely to exhibit PTSD pursuant to exposure to a trauma, and to exhibit more profound symptoms if PTSD develops. (Yoon, 2009) (Strelau, 2005)
Not surprisingly, a temperamental inclination towards emotional reactivity was one trait that was predictive of the development of PTSD. If a person is inclined to have stronger emotional reactions to all events, it is only sensible that their response to traumatic events might be stronger than less emotionally reactive persons.
The degree to which a person expresses this kind of emotional reactivity will also be dependent on other factors, such as ego strength, degree of emotional support available, and other components of their psychosocial make-up that should be gathered as part of a comprehensive psychosocial assessment process.
Because of this, the clinician should not be caught up trying to determine if the person's response to the event should or should not have been considered traumatic. In other words, "take the client where he or she is". Only the client can explain how the event affects him or her.
With this information, the clinician can then fill in the other pieces of the diagnostic picture and thus be prepared to target the interventions that will cover as many components possible of the client’s difficulties.
For further information on how to perform a comprehensive psychosocial assessment, you might consider yourceus.com’s course, Psychosocial Assessment: A Comprehensive Overview for Mental Health Clinicians.
Pre-Disposition and Comorbidity: High Risk and Common other Conditions
There are several risk factors for other conditions associated with PTSD. A greater understanding of the pathogenesis or the actual physical cause and development of PTSD could help us to have a better understanding of the commonly co-morbid diagnoses of anxiety and depression. This helps create a base of understanding that leads to better treatment.
The research demonstrates a clear relationship between exposure to interpersonal violence and PTSD. Additionally, victimization - particularly sexual abuse, parental physical assault, and kidnapping - are significantly associated with increased risk for Major Depressive Episode (MJD). From this study, nearly three fourths of all adolescents diagnosed with PTSD had at least one comorbid diagnosis. (Kilpatrick, et. al, 2003)
Factors of predisposition include:
- Previous personal or family history of a psychiatric diagnosis
- Family history of depression or anxiety
- Lower economic levels
- Suicidal ideation and prior suicide attempts
- Childhood difficulties in school
- Existing substance abuse addiction or dependence
Depression is a common problem in which severe and long lasting feelings of sadness or other problems get in the way of a person’s ability to function. In any given year, as many as 18.8 million American adults - 9.5% of the adult population - experience some type of depression. Unlike a blue mood that comes and goes, depression is a persistent problem that affects the way a person eats and sleeps, thinks about things, and feels about him or herself.
“In a National Institute of Mental Health (NIMH)-funded study, researchers found that more than 40 percent of people with PTSD also had depression at one-month and four-month intervals after the traumatic event”. (Shalev, et al, 1998)
In addition, for the year 2020, the NIMH, reports the following statistics:
- An estimated 21.0 million adults in the United States had at least one major depressive episode. This number represented 8.4% of all U.S. adults.
- The prevalence of major depressive episode was higher among adult females (10.5%) compared to males (6.2%).
- The prevalence of adults with a major depressive episode was highest among individuals aged 18-25 (17.0%).
- The prevalence of major depressive episode was highest among those who report having multiple (two or more) races (15.9%).
- An estimated 4.1 million adolescents aged 12 to 17 in the United States had at least one major depressive episode. This number represented 17.0% of the U.S. population aged 12 to 17.
- The prevalence of major depressive episode was higher among adolescent females (25.2%) compared to males (9.2%).
- The prevalence of major depressive episode was highest among adolescents reporting two or more races (29.9%).
Depression has many causes. Clearly, difficulty coping with painful experiences or losses can contribute to depression. People returning from a war zone sometimes experience feelings of guilt, painful memories, or regret about their war experiences and may have difficulties adjusting to “normal” life. Trouble coping with these feelings and experiences can play a significant role in the development of depression.
However, some types of depression are genetic and run in families, and depression may be associated with chemical imbalances and other changes in the brain. When trying to discern the degree to which the traumatic events are contributors to the depression, it is important to gather all of the family and background information that is available as part of a thorough assessment process.
Symptoms are Not Always Invisible
Some have claimed that PTSD is an invisible syndrome, and although post-traumatic symptoms may sometimes not be readily recognized by the person suffering from PTSD, the symptoms can be extremely visible to others.
For example, people whose depressive symptoms are associated with PTSD may have signs of emotional lability and be visibly weepy. In such cases, the patients may cry at the smallest events, and can be relatively inconsolable.
Individuals who have not learned to control their anger associated with PTSD may find him or herself in physical altercations with strangers or family members. Alternatively, these symptoms may manifest themselves as bar fights or road rage. The onlooker may not know that the instigator suffers from PTSD, but the symptoms of violence can be very visible.
Perhaps less visible signs may be the symptoms associated with:
- A depressive state in which the individual is unable to socialize and thus feels isolated, even to the point of being a “shut in”
- Excessive use of alcohol or other substances to numb the pain
- Phantom or unexplained body pains and aches that leave the client in so much pain that he or she is unable to perform major life functions
Combined with alcohol or other mood-altering legal and illegal drugs, these symptoms can manifest themselves until the person:
- Is unable to gain or maintain employment
- Is unable to gain or maintain meaningful relationships
- Judgment is so impaired that he or she drives under the influence
- Engages in countless other uncontrollable behaviors
The development of alcohol or other substance abuse or dependence may go unnoticed if the PTSD sufferer remains reclusive and unemployed.
Others may use the alcohol or other legal or illegal drugs to release their inhibitions and forgo reasonable judgment, allowing them opportunities to release and express their painful emotions in behavioral ways. This can lead to poor behavioral decisions that create legal problems – and additional trauma.
For some PTSD sufferers, the increased amounts of alcohol or cocaine heighten the anger symptoms associated with PTSD. Consequently, they may engage in domestic violence, road rage, and other personal acts of violence.
Three Categories of PTSD
There are three main categories of PTSD:
- Acute: in which the symptoms last for less than three months
- Chronic: in which the symptoms last for three months or more
- Delayed Onset: if symptoms do not appear until six months. The delayed onset can be
triggered by the event’s anniversary date or by experiencing another traumatic event. (American Psychiatric Association, 2005)
It is important to understand that a person diagnosed with PTSD does not usually stay at one level. The person who has experienced a traumatic event may go for long periods of time with few or no symptoms, and then suddenly - seemingly without warning - cascade down to a very debilitating level.
Primary and Secondary Symptoms
Identification of PTSD is important because it is associated with markedly higher rates of depression and other physiologic condition, poorer physical health, missed work, and impaired functioning at work and home.
In addition, the combination of PTSD and depression is linked to greater or deeper depression in severity and duration, as well as physical complaints and overall functioning, or what used to be described as Global Level of Functioning (GAF).
Post-Traumatic Stress Disorder (PTSD) can have biological, psychological, emotional, interpersonal, occupational and social components. That is, it can affect the body as well as the mind, the interpersonal life as well as the personal life of the client. Depression, fears or phobias can have a very broad impact on numerous aspect of the client’s overall well being.
Because it is sometime difficult to distinguish between the symptoms, clinicians should complete a thorough bio-psychosocial evaluation in which every attempt is made to distinguish between physical complaints that have a primarily biological or medical cause and physical complaints that may be indicative of residual emotional trauma. For example, a person with PTSD may experience body pains, muscle aches and headaches that cannot be explained by an organic or medical reason.
While most clinicians would think of PTSD as primarily a psychological event, physiological symptoms can be brought on by long-term neurobiological changes that occur in the brain as a result of trauma. PTSD is “associated with a host of chemical changes in the body’s hormonal system, and autonomic nervous system.” (National Council on Disability, 2009)
Neuroimaging, although in its relatively early stages, is allowing scientists to see the “foot print” of psychological trauma in the brain. When trauma occurs, there is increased blood flow in the area of the brain that controls conflict resolution and decision-making, the prefrontal cortex. This can be seen in changes to the images of the brain.
The biological change may be at least partially attributable to the presence of the “stress hormone”, cortisol, which, among other physiological effects, causes areas of the brain to incur damage. The high levels of stress, in particular, tend to decrease the size of the hippocampus, an important part of the brain structure that is important in memory processing and emotion. In fact, physicist Norbert Schuff confirmed this when he captured the Department of Veterans Affairs attention by presenting colorful brain images of those Iraq and Afghanistan veterans diagnosed with PTSD. (Berton, 2008)
Other studies have noted similar neurotoxic effects from the brain’s exposure to too much cortisol in extended periods of stress. For example, a study from Stanford University states it succinctly, saying that “severe stress can damage a child’s brain.” (Carrion, 2007)
Social Workers and other mental health providers do not need to know all of the details of the neurology of stress. However, a very elementary understanding may help the clinician to make a neurological or psychiatric referral, if appropriate.
Physical symptoms of PTSD can manifest or show themselves in many ways, and sometime closely resemble Fibromyalgia, presenting as:
- Stomach aches
- Unexplained body aches
- Lethargy or feeling tired
- Insomnia or hypersomnia (sleeping too much)
- Extreme changes in appetite and weight
- Other unexplained physical complaints absent any known physiological findings.
For more detailed information on distinguishing between medical and psychological elements of a patient's symptomatology, you may consider taking yourceus.com’s course, Differential Diagnosis: Identifying Common Medical Conditions Frequently Misdiagnosed as Mental Health Problems.
One of the more common psychological symptoms of PTSD is hyper-arousal, or if someone seems to startle easily. Sometimes this is also called exaggerated response. Hyper-arousal may become more apparent as time lapses in untreated patients, because the constant state of fear elevates exaggerated responses.
Hyper-arousal or exaggerated responses may be surprising to the observer. For example, a person surrounded by people in the work place, a movie theatre, and etcetera, may jump, look surprised or terrified when someone approaches them or perhaps touches their shoulder.
Other psychological symptoms:
- Criminal behavior,
- Hyperactivity (A person who cannot sit still or is always on the go),
- Attention deficit (Inability to concentrate or stay focused),
- Compulsiveness and/or aggressive behavior (Fighting physically and verbally),
- Disorderly or malicious conduct (i.e. fighting with strangers),
- Specific phobias (an unfounded fear of a particular thing, object or activity),
- Hallucinations (seeing or hearing things that are not there)
- Disassociation, and
- Sexual promiscuity
Depersonalization is a sense that someone has that they are there, but not really there. They describe seeing themselves walking and talking, but it is like a dream. It is a feeling on unreality.
Dissociation is a process of the mind that disconnects someone from their:
- Sense of their own identity.
For example, a person who is experiencing a horrifying event may subconsciously remove the surrounding circumstances or go into a state of shock. It is the mind’s protective process that allows the person a mental escape when a physical escape is impossible.
That is why a person describing a scene where trauma has occurred they often reply with statements like:
- I just cannot remember,
- It happened so fast,
- It is all a blur, and so on.
This dissociative process is very common with people who have experienced a traumatic event and gone on to develop PTSD. In order to protect themselves from the pain arising from the traumatic memory, they try remove or block the recollection of the event from their ongoing memory processes.
This may only be a temporary process for some people, as they try to hold the memory separate long enough to process it at a tolerable pace. However, if the recollection of the event has been impressed into their ongoing memory stores, and consciously or subconsciously they remain sufficiently afraid of that memory, they may need to utilize ongoing dissociation to keep the memory away.
This ongoing dissociation process can also affect other stored memories, and is a reason why patients with PTSD will often report a sense of lost identity.
Most clinicians are aware that dissociation has several different levels. Common or mild instances are behaviors that we see in people every day such as:
- Daydreaming or in the "zone",
- Getting lost in reading a book or watching a movie,
- Parking lot amnesia or forgetting where you have parked after being in a shopping mall,
- Highway hypnosis or losing track of where you are driving or losing track of driving time.
More profound dissociative events are a potential feature of PTSD, and the conscientious clinician will be alert to the possibility that they can occur. If a clinician lacks the experience in responding to this kind of symptomatology, it is not advisable to attempt to engage in treatment, but rather to refer to a clinician with more experience in managing this sort of problem.
Disassociation: Illustrative Case
Doctors Butler and Moffic illustrated the following case of PTSD due to a motor vehicle accident in American Family Physician.
A 34-year-old man presented to his new family physician with headaches, insomnia, gastrointestinal discomfort, and persistent worry. He was otherwise healthy but reported that he had sustained a broken jaw and hip, as well as a compound fracture of the left leg, in a traffic accident 12 years earlier. He was evaluated, treated with anxiolytic medication and referred for counseling.
The patient said he often became preoccupied with family and work details while driving and pulled over to the roadside as often as twice per week for 20 to 30 minutes at a time, during a dissociative state. He reported that in the accident (when he was 22 years of age), he had been driving a van and struck a bridge abutment. The patient had been trapped against the steering wheel and dashboard, semiconscious and in severe pain.
Emergency personnel arrived about 45 minutes later, during which time the patient could smell gasoline. It took workers 30 minutes to extract the patient from the vehicle. He reported that he had felt disconnected from these events and that he had lost bowel control.
After extensive rehabilitation, the patient returned to work but immediately experienced difficulties. He feared “contamination,” developed showering rituals, and would only walk around garbage cans by facing them. He became nauseated by the smell of gasoline, refused to drive, was anxious in public, and drank to calm his nerves. The patient left his job and began receiving psychiatric care; after two years of treatment with medication and psychotherapy, he again found employment.
The patient recognized the similarity between his dissociative driving events and the features of his accident. He also revealed that he maintained one accident- related ritual: following each bowel movement, he would spend 20 to 30 minutes cleaning himself. (Butler, 1991)
Evidence supports that traumatic events such as sexual abuse, combat trauma, rape, and domestic violence generally increase a person's suicide risk, and a large body of research indicates that there is a correlation between PTSD and suicide, but again, much of the research surrounding suicide and PTSD is limited to combat veterans. (National Institute of Justice, 2003)
In 2003, the National Institute of Justice found a clear relationship between victimization and mental health problems such as PTSD and suicides. While some studies suggest that suicide risk in victims is higher due to the symptoms of PTSD, others claim that suicide risk is higher in these individuals because of other related psychiatric conditions. (Hedenko, n.d.)
Army Times echoes this correlation as Michelle Tan reports that, in January 2009, “The Army is Killing Itself,” and more soldiers committed suicide than died in combat, with the previous year producing the highest reported toll from suicide in nearly thirty years. (Tan, 2009)
Thanks to mental health efforts in response to these concerns, and following rises in suicide rates to near epidemic levels through the 2010s, the rates for suicide finally began to show declines. As noted by the VA:
- In 2019 and 2020, Veteran suicides decreased in consecutive years by 307 and 343 deaths — the biggest decrease in the suicide count and rate since 2001.
- From 2018 to 2020, the age- and sex-adjusted suicide rate among Veterans fell by 9.7%
- Among women Veterans, the age-adjusted suicide rate fell by 14.1%, compared to 8.4% among non-Veteran women. The age-adjusted suicide rate for women Veterans in 2020 was the lowest since 2013, and the age-adjusted suicide rate for Veteran men was the lowest since 2016.
- From 2019 to 2020, Veteran suicide rates fell across all racial groups.
- Comparisons of trends in Veteran suicide and COVID-19 mortality over the course of 2020 and across Veteran demographic and clinical subgroups did not indicate an impact of the COVID-19 pandemic on Veteran suicide mortality.
One of the most distressing symptoms that can arise in certain cases with PTSD is sexual promiscuity. This can occur for a number of reasons. Some individuals who suffer from PTSD become sexually permissive because they have low self-esteem/self worth and believe that that they are either not worthy of a long-term relationship or that they need to be punished. These individuals may ultimately come to believe that the only way they can financially support themselves is through prostitution.
At the other end of the spectrum, you find individuals who were sexually abused or raped, and who use sex as a way of regaining control. They may stage rape scenarios to re-live their trauma, but in these rape scenarios, they are in control.
A relatively realistic example of how one might engage in sexual promiscuity to regain control over a previous trauma is represented in the movie “The General’s Daughter”, released in 1999. In this movie, a very educated woman engages in a secret life in which she would recreate the previous trauma, with multiple sexual partners, in an attempt to gain control over her feelings of helplessness.
Again, this is a symptom that can express itself in ways that have serious implications for the life of the sufferer of PTSD and that can present enormous clinical challenges for the clinician who is attempting to intervene. Without adequate preparation, education and experience, it is not advisable for clinicians to continue treatment when problems are at this level of magnitude. It is preferable to make a responsible referral to a clinician who is better prepared to address the client’s problems.
Sometimes overlooked are the social symptoms that can drastically reduce the quality of life of those suffering from PTSD and, in some instances, create anguish and havoc in the lives of other people with whom the patient has close relationships. Social symptoms often overlap psychological symptoms and may include:
- Criminal behavior such as vandalism and violence, including personal assaults
- Avoidance, such as avoidance of crowds or social functions
- Irritability or rude behavior
- Withdrawn or anti-social behavior (Thompson & Massat, 2005)
These symptoms can impair relationships, disrupt marriages, and aggravate difficulties in parenting, which can then create problems for children. In this way, the consequences of trauma and the “long arm” of PTSD may span generations.
For example, a person who has difficulties controlling anger may find him or herself in physical altercations with strangers and even often with family members.
Common to many PTSD sufferers are visual or auditory flashbacks. The longer the trauma lasted, or the more powerful the trauma, the more intense the flashbacks can be.
Nearly all of us have seen a movie in which a veteran is found hiding behind a large object for no apparent reason, or one in which a veteran hears a helicopter and dodges behind a couch for cover. However, Hollywood flashbacks and real-life flashbacks are quite different.
In real life, it is hard for someone suffering PTSD to explain his or her flashbacks, and since no one else can hear or see what they see, this sort of episode may be considered closer to a hallucination rather than to a flashback. (Wellness Directory of Minnesota, 2006)
Flashbacks are more like momentarily waking dreams or nightmares. The person's mind is flooded with images and or sounds from the traumatic experience. If the person is alone at the time, he or she may not be able to distinguish between a flashback, a hallucination, or the current time reality.
For those patients who have few or no symptoms, or have successfully managed their symptoms under most normal conditions, symptoms can sometimes instantly be exacerbated from a “trigger.” This experience, when it happens for the first time, can be very distressing or dismaying for the client, as they may feel that they have escaped their trauma unaffected by it.
Through operant conditioning, absolutely anything can trigger symptoms of PTSD. Triggers can be:
- Commercial advertisements
- Written or spoken words
- Camera flashes
- Thunderstorms, hurricanes, tornadoes, or other loud noises
One of the more frequent triggers for PTSD is loud noises, especially for a client who has been exposed to combat situations. Human beings appear to be programmed from birth to exhibit the startle reflex when exposed to loud noises, and this is inborn reactivity to loud noises is likely amplified by exposure to combat situations where loud noises are representative of explosions and life-threatening danger.
Other kinds of sounds, as well as specific smells, may also be triggers for PTSD symptoms. If a person experiences a traumatic event in the presence of specific sounds or smells, those sounds or smells can become deeply associated with the presence of the trauma through operant conditioning. The sounds or smells can then produce an experiential flashback to the trauma upon exposure.
For example, a person who has been raped may associate the smell of their rapist or the smells and sounds of the area in which the event occurred. Simply passing by a place or another person that has that same or a similar smell may suddenly trigger or exacerbate a person's PTSD symptoms.
Someone who has survived a tornado may cringe with fear at the sound of trains, confusing that sound with the sounds of tornadoes. Likewise, camera flashes can be a common trigger for those who have experienced night terrorism or night combat, since the flashes can too closely resemble gunfire or explosions. It may not be unusual for a person who is aware that this is one of his or her triggers to avoid having their pictures taken or to leave the room during a social event when cameras are likely to be flashing.