Trauma and PTSD

Trigger Warning

This page deals with topics such as trauma, abuse and violence. If you are currently in an unstable phase, please only read this content with appropriate support.

What Is Trauma?

The term comes from Greek and means “severe injury” or “wound.”

An event leads to trauma when threatening situational factors exceed the individual’s coping capabilities. This can lead to a feeling of helplessness and defenseless exposure, permanently shattering one’s self-image and world view.

Traumatizing Events

Such events can include:

• Assaults
• Rape
• Accidents
• Torture and hostage-taking
• Wars and catastrophes
• Sexual traumatization in childhood
• Witnessing an act of violence or a serious accident

Neurobiological Effects

Traumatizing experiences are equivalent to extreme stress for humans. The physiological reaction has effects on the human brain:

The Hippocampus

An area of the brain that helps us integrate and archive things becomes dysfunctional.

The Amygdala

Stores the fears, feelings and sensory impressions of the traumatic situation without temporal classification.

Flashbacks

Triggering stimuli reminiscent of the trauma cause the painfully experienced event to be “triggered” - the affected person is flooded with traumatic images and impressions.

Direct and Indirect Violence

The events that can trigger post-traumatic stress disorder are generally the experience of direct or indirect violence:

Direct Violence

• Violent assaults
• Rape
• Torture and hostage-taking
• Severe accidents
• Catastrophes and wars
• Sexual traumatization in childhood

Indirect Violence

Indirect violence refers to when people witness severe violence. This frequently affects people who are confronted with violence in their professional environment:

• Police officers
• Firefighters
• Disaster relief workers
• Emergency services

Post-Traumatic Stress Disorder (PTSD)

PTSD can develop at any age in principle. The triggers are events so threatening that they exceed the individual’s coping capabilities, are accompanied by feelings of defenseless exposure and helplessness, and thus cause a permanent shattering of one’s self-image and world view.

International Designations

Abbreviation	Designation
PTSD	Post-traumatic stress disorder (English)
PTBS	Posttraumatische Belastungsstörung (German)
PTB	Posttraumatische Belastungsreaktion
PTSS	Posttraumatisches Stresssyndrom

Course Forms

• Acute: Symptoms last less than 3 months
• Chronic: Symptoms last more than 3 months
• With delayed onset: Symptoms begin at least 6 months after the event

Course-Determining Factors

The course of PTSD is variable and is co-determined by the following aspects among others:

1. Characteristics of the traumatic situation: Severity and duration, extent of experienced loss of control

2. Capabilities of the individual: Age and developmental stage, previously developed coping competencies

3. Environmental reactions: Evaluation of the experience by the social environment, extent of protection, understanding and support from attachment figures, the social community and professional help

Personal Assessment

The decisive element that makes an event traumatic is the personal assessment of the victims regarding how helpless and threatened they feel, how far their psychological development had progressed, and how strong their psychological stability was.

Typical PTSD Symptoms

Re-experiencing (Intrusions)

The repeated experiencing of the trauma in intrusive memories (afterimages, flashbacks):

• Reactivation of the traumatic situation with accompanying images, words, affects, bodily sensations, smells
• Recurring distressing dreams
• Acting or feeling as if the traumatic event were recurring

The limbic system, primarily the amygdala, which stores and reactivates the fear and associated associations, is significantly involved in the reactivation.

Triggers for Reactivation

Reactivation can occur through various means:

• Sounds
• Smells
• Similarities with perpetrators (e.g., voices or gestures)
• Times of rest or low stimulation (e.g., before falling asleep)

Traumatized individuals with PTSD are “back in the situation” - they slip away, break down and have difficulty maintaining contact with present reality.

In Dissociative Flashbacks

Affected persons frequently experience agonizing fears from life-threatening distress or painful bodily sensations, without being able to directly recall the traumatizing event. This is a consequence of the disturbed hippocampal function, which prevents episodic remembering.

Such intrusions can escalate to agonizing hypermnesias - non-suppressible memories that are almost constantly present or easily triggered.

Avoidance Behavior

• Conscious avoidance of thoughts, feelings or conversations connected with the trauma
• Avoidance of activities, places or people that evoke memories
• Inability to remember important aspects of the trauma
• Social withdrawal

Emotional Numbing

Traumatized individuals with PTSD frequently experience a general flattening of responsiveness. They feel emotionally dull, blunted and lacking in emotional range:

• Feeling of detachment or estrangement from others
• Restricted range of affect
• Feeling of bottomless loneliness and emptiness
• Feeling of a foreshortened future

Hyperarousal

• Difficulty falling or staying asleep
• Irritability or outbursts of anger
• Difficulty concentrating
• Excessive vigilance (hypervigilance)
• Exaggerated startle response

Diagnostic Criteria According to DSM-IV

Criterion A: Traumatic Event

1. The person experienced, witnessed, or was confronted with events involving actual or threatened death, serious injury, or a threat to the physical integrity of self or others.
2. The person’s response involved intense fear, helplessness, or horror.

Criterion B: Re-experiencing

The traumatic event is persistently re-experienced in at least one of the following ways:

• Recurring distressing memories
• Recurring distressing dreams
• Flashback episodes
• Intense psychological distress when exposed to triggers
• Physiological reactions when exposed to triggers

Criterion C: Avoidance

At least three of the following symptoms:

• Avoidance of thoughts, feelings or conversations about the trauma
• Avoidance of activities, places or people
• Inability to remember important aspects
• Diminished interest in significant activities
• Feeling of detachment from others
• Restricted range of affect
• Sense of a foreshortened future

Criterion D: Hyperarousal

At least two of the following symptoms:

• Sleep disturbances
• Irritability or outbursts of anger
• Difficulty concentrating
• Excessive vigilance
• Exaggerated startle response

Criteria E & F

• The disturbance lasts more than 1 month
• It causes clinically significant distress or impairment

Diagnostic Criteria According to ICD-10 (F43.1)

Stressor

• Event or situation of exceptionally threatening or catastrophic nature
• Would cause deep disturbance in almost anyone

Required Symptoms

• Repeated inescapable recall or re-enactment of the event

Other Typical Symptoms

• Persistent feeling of numbness and emotional blunting
• Indifference to other people
• Avoidance of activities and situations that evoke memories

Common Symptoms

• Autonomic hyperarousal with increased vigilance
• Excessive startle reaction and insomnia
• Anxiety and depression

Rarer Symptoms

• Dramatic, acute outbursts of fear, panic or aggression

Time Frame

Symptoms typically occur within 6 months of the stressful event.

Physical Effects

Physical abnormalities are frequently found in people with PTSD:

In Sexually Traumatized Individuals

In sexually traumatized women, the following are frequently found:

• Lower abdominal complaints and diseases
• Menstrual cycle disturbances (dysmenorrhea, amenorrhea - the failure to begin or cessation of menstruation)
• Sexual disorders
• Miscarriages
• Sometimes complete anesthesia of the lower abdomen

The body remembers what was experienced, without requiring words or understanding.

Disturbed Sexual Experience

Victims of sexual violence frequently cannot experience sexuality later, or experience it only in an alienated way. Sexuality was experienced exclusively as appropriation and violence, also meaning self-sacrifice and sometimes appeasement of the perpetrator.

Prostitution as a Consequence

Prostitution is frequently a consequence of sexual traumatization in childhood. Estimates indicate that approximately 90% of prostitutes were sexually traumatized in childhood.

Oral Traumatization

In many sexually traumatized individuals, symptoms such as chest pressure, gagging reflexes, asthma, hyperventilation, coughing and similar are found. The triggers for these are often oral rapes experienced in the past, during which the victims’ mouths were simultaneously held shut or they were strangled.

General Physical Symptoms

• Chest pressure
• Gagging reflexes, asthma, hyperventilation
• Chronic pain conditions (often head and back)
• Sleep disturbances (both difficulty falling asleep and staying asleep)

Body Memories

The symptoms of PTSD are to be seen as repetitions and re-traumatizations. They are body memories, also represent aggressive mechanisms, but are also self-healing attempts as adaptive achievements or conflict resolution attempts, communication attempts and signals.

Comorbidities

PTSD frequently co-occurs with other disorders:

• Eating disorders - Anorexia nervosa or bulimia, often with nausea, vomiting and a lump in the throat. Many complain of unbearable disgust as a consequence of oral rape in earliest childhood.
• Substance abuse - Medication or alcohol dependence
• Obsessive-compulsive disorders - Checking and washing compulsions
• Depression
• Anxiety disorders - Including dramatic, acute outbursts of fear, panic or aggression
• Suicidality - Auto-aggressive tendencies in the form of self-harm up to suicide attempts
• Psychogenic paralysis - Up to the temporary need for a wheelchair

PTSD and Borderline Disorder

Important Connection

Various studies document that 60% to 85% of people with borderline disorder experienced sexual violence in childhood. Affected persons with severe dissociative identity disorder (formerly multiple personality disorder) were sexually abused in childhood in over 90% of cases.

Early childhood traumatizations frequently lead to the development of “early disorders” such as:

• Borderline personality disorder
• Narcissistic disorder
• Dissociative disorders (up to dissociative identity disorder)
• Somatization disorders and chronic pain conditions

The Connection

In borderline, affected individuals have great difficulties in forming relationships. Since they never experienced good and stable relationships, they must split between “good” and “bad” objects - there is only black or white. Feelings are often split off, and frequently only the great rage finds expression, leading to the defense against closeness and relationships.

Long-Term Consequences

Prolonged exposure to extreme psychological situations (e.g., as a hostage or victim of ritual violence) can lead to Enduring Personality Change After Catastrophic Experience.

This disorder is characterized by:

• An extremely hostile and mistrustful attitude toward the world
• Social emptiness and hopelessness
• A chronic feeling of tension
• A constant feeling of estrangement

Depersonalization as a Survival Strategy

Many physically abused individuals learn to mentally “step out” of their body, to step beside themselves, in order to endure as little as possible. This form of dissociation is called depersonalization and represents an attempt at a creative solution to endure an unbearable reality by altering perception.