TREATING POST TRAUMATIC STRESS DISORDER (PTSD)

Exposure to a single traumatic event or to chronic trauma stress over a period of time can lead to a medical condition called Post Traumatic Stress Disorder (PTSD). The media and popular culture often portray PTSD in relation to major traumatic experience, such as war Veterans. However, PTSD occurs on a continuum and encompasses a range of symptoms that can be from mild to severe. In addition, PTSD can occur after a single incident or be the result of developmental exposure to traumatic events spanning back to early childhood.

When clients come to therapy, they are often times not aware that their presenting symptoms have their origins in traumatic experiences. Therefore, combining multiple therapeutic approaches, including trauma therapies and EMDR, into your treatment plan may yield the best long-term results for your mental health. 

PTSD can be caused by intentional human causes, unintentional human causes, or acts of nature. Below are some examples. In general, intentional human causes create PTSD symptoms that are the most difficult to resolve. 

Intentional Human Causes

  • Combat

  • Sexual, emotional or physical abuse

  • Torture

  • Criminal assault

  • Terrorism

  • Witnessing abuse, homicide, etc.

  • Kidnapping

  • Riot

  • Alcoholism

  • Suicide

  • Damage to or loss of body parts

  • Cult abuse

Unintentional Human Causes

  • Industrial

  • Fire or explosions

  • Motor vehicle accident

  • Collapse of a building

  • Surgical damage to body or loss of body part

Acts of Nature

  • Hurricane

  • Tornado

  • Flood

  • Earthquake

  • Fire

  • Drought

  • Attack by an animal

  • Sudden life threatening illness

  • Childbirth (for women)

  • Death of a loved one

DSM 5 CRITERIA FOR PTSD

Professionals in all branches of healthcare and medicine have studied PTSD in-depth. Symptoms can be psychological, emotional or physiological and treatments have been developed over many years of clinical practice and research. Below are the DMS 5 criteria for PTSD:

  • Exposure to a stressor in one of the following ways:

    • Directly experiencing the event

    • Witnessing the event as it happened to others

    • Learning that the traumatic event happened to a close family member or friend

    • Experiencing repeated or extreme exposure to details of the traumatic event

  • Presence of one or more of the following symptoms after the event occurred:

    • Recurrent, involuntary, and intrusive distressing memories of the traumatic event

    • Recurrent distressing dreams of the traumatic event

    • Dissociative reactions (e.g. flashbacks, numbing) where the individual feels or acts as if the traumatic event was happening again

    • Intense psychological distress at exposure to internal or external cues that resemble an aspect of the traumatic event

    • Physiological reactions to internal or external cues that resemble an aspect of the traumatic event

  • Avoidance of stimuli associated with the traumatic event, as evidenced by:

    • Avoidance or efforts to avoid distressing memories, thoughts, or feelings about or associated with the traumatic event

    • Avoidance or efforts to avoid external reminders (people, places, etc.) that arouse distressing memories, thoughts, or feelings about or associated with the traumatic event

  • Negative changes in thinking or mood associated with the traumatic event, as evidenced by two or more of the following:

    • Inability to remember aspects of the traumatic event

    • Persistent and exaggerated negative beliefs or expectations about oneself, others or the world

    • Blaming oneself for the traumatic event

    • Diminished interest or participation in significant activities

    • Feelings of detachment or estrangement from others

    • Persistent negative emotional state

    • Persistent inability to experience positive emotions

  • Alterations in arousal, as evidenced by two or more of the following:

    • Irritable behavior and angry outbursts

    • Reckless or self-destructive behavior

    • Hypervigilance

    • Exaggerated startle response

    • Problems with concentration

    • Sleep disturbance

 

DISSOCIATION EXPLAINED

One distinct feature of PTSD is the avoidance symptom, dissociation. In healthy consciousness a person is aware and engaged on all levels of functioning, they feel grounded and whole, and despite being in different situations, they more or less feel like the same person. When memories are recalled, they can be put back again with ease. However, the mind uses a powerful coping mechanism called dissociation in order not to experience overwhelmingly traumatic events.

During the time of the trauma, this is useful to protect the individual from experiencing the emotional or physical pain of the event, but after the trauma is over, the mind may continue to cope this way, leaving the person with separate states of experience that are not integrated.

Given trauma encompasses thoughts, images, feelings, behaviors, and different physiological states, any of these aspects of experience can be dissociated and later intrude upon the person’s awareness when they are triggered. 

Triggers are often harmless stimuli that when similar to the original trauma cause the person’s memory networks to link the trigger to the original trauma memory. Triggers can be in any of these categories: sight, smell, sound, taste, body, significant dates or seasons, stressful events and arousal, strong emotions, thoughts, behaviors, or combinations of these.

One useful way of describing this is to compare a neutral trigger from a positive memory to a neutral trigger to a traumatic memory. Recall your best experience eating a delicious grilled hamburger at your favorite restaurant. Say it was at an outdoor café during the summer and you were with someone special. The day was beautiful, the food was wonderful, and you felt warm and connected to your friend.

Now, after that has passed you may see a reminder of that restaurant (sight), smell the fragrance of flowers in the garden (smell), feel the connection to someone close (emotion), taste the same hamburger (taste), and those stimuli lead to your mind automatically recalling that wonderful day and the delicious hamburger.

This is an example of a seamless memory recall in an un-traumatized mind. In much the same way, trauma memories and the corresponding trigger stimuli can get stored in your body and mind. For example, if a person was sexually abused by an older man who was overweight (sight and tactile), had a hairy chest (tactile), and smelled like a particular brand of fabric softener (smell), then when the person is presented with these neutral stimuli again, an aspect of the original trauma could become recalled, causing the person to become triggered and respond in a way similar to the original trauma, e.g. dissociation, even though the trauma is not occurring. In both cases, the process highlights how the mind stores memories and how it recalls them. 

Dissociation can occur in a variety of forms: depersonalization (feeling outside one’s body), amnesia (forgetting the trauma completely), flashbacks (suddenly re-experiencing the trauma), and dissociative identity disorder (formation of two or more personalities).

Many times someone who is dissociating does not know until they learn about PTSD and how it impacts them. Other times, individual are keenly aware of when they dissociate even though they might not know what it is called or how to stop it. Symptoms of dissociation are vast, but some common symptoms include:

  • Body becomes still or stiff

  • Emotions become numb

  • Does not feel expected pain

  • Drifts off or spaces out

  • Has downward, distant stare

  • Is not involved in present

  • Suffers memory lapses

  • Fantasizes and daydreams excessively

  • Misses conversation

  • Feels like one is watching their body from the outside

  • Alertness is cloudy

  • Things look or sound different

OTHER FEATURES OF PTSD

There are some other noteworthy associated features of PTSD. To illustrate how this is relevant to a sex therapy setting, below are some examples of the impact of trauma on sexual functioning. Many clients who come to therapy for a sexual issue have a history of trauma. However, these associated features could apply to any type of trauma. 

  • Self-Recrimination – feelings of guilt and shame at being responsible for the trauma. For example, someone who feels responsible for their sexual abuse because they had an orgasm during the offending event.

  • Shattered Views of Self, Others & the World – generally most people have positive views of themselves, others, and the world unless they have gone through a negative experience. For example, a woman with a sexual pain disorder anticipates pain during sexual encounters because of listening repeatedly to her mother’s stories of being cheated on and abused by men when she was growing up.

  • Mood Disturbances – depression, anxiety, and hostility.

  • Addictions – addictive behavior provides a means to numb and self-medicate to avoid re-experiencing the trauma. For example, a woman who finds relief during stressful times in connecting sexually and emotionally with men she meets on the Internet (sex and love addict).

  • Somatic (Body) Complaints – Many symptoms of PTSD occur in the body, especially when the traumatic material has not been processed verbally or occurred during childhood when the person didn’t have the ability to articulate verbally their experience. The physical pain can be a distraction from emotional pain.

    Some examples include: chronic pain, hypertension, heavy limbs, lump in throat, numb body parts, exhaustion, and gastrointestinal disturbances. For example, someone who experiences chronic migraines that start immediately upon perceived or actual stress. When the migraine starts, they can focus on the physical pain and in this way avoid dealing with the trigger itself.

  • Death Anxiety – being fearful of dying after having a close encounter with death.

  • Repetition Compulsion – reenacting traumas to try and master and complete them. For example, a man who was sexually abused as a child by an older man will as an adult seek out child pornography of boys even though he is heterosexual.

  • Deliberate Self-Injury – self-harm to the body.

  • Changes in Personality – often in developmental PTSD, where trauma was chronic during childhood, personality disorders can be found in adulthood, for example: antisocial, borderline, and narcissistic. For example, a man who is addicted to sex will repeatedly cheat on his wife with escorts, prostitutes, and with women he meets online. He does not feel remorse for these actions, even though intellectually he knows it is not ethical.

TREATMENTS FOR PTSD

Treatments for PTSD are extensive and there is significant clinical research showing their success in overcoming the impacts of trauma. Common therapies for treating PTSD include:

  • Mindfulness

  • Psychodynamic psychotherapy

  • Exposure therapies

  • Cognitive Behavioral Therapy (CBT)

  • Eye Movement Desensitization and Reprocessing (EMDR)

  • Somatic therapies

  • Hypnotherapy

  • Neurofeedback

  • Medications

  • Ego state therapies

  • Treatments for borderline personality disorder (Dialectical Behavior Therapy - DBT)

  • Breathing retraining

  • Relaxation

  • Anger management

  • Grief therapy

  • Expressive arts therapy