Preface to Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body and Society

Text of the Preface to a book, Traumatic Stress: the effects of overwhelming experience on mind, body, and society. edited by Bessel van der Kolk, Alexander McFarlane, and Lars Weisaeth, published by Guilford Press, 1996.

Copyright by the editors; posted at the Trauma Information Pages web site with permission.

Preface

"[This] subject (the traumatic neuroses) has been submitted to a good deal of capriciousness in public interest. The public does not sustain its interest, and neither does psychiatry. Hence these conditions are not subject to continuous study, but only to periodic efforts which cannot be characterized as very diligent. Though not true in psychiatry generally, it is a deplorable fact that each investigator who undertakes to study these conditions considers it his sacred obligation to start from scratch and work at the problem as if no one had ever done anything with it before"
-- Kardiner and Spiegel, 1947, p.1

The recognition of Post Traumatic Stress Disorder as a formal diagnosis in the psychiatric nomenclature in 1980 has spawned a vast literature on the treatment of victims of many different sorts of trauma and produced an explosion of scientific investigations about the ways in which people react to overwhelming experiences. It has been about twenty years since the contemporary scientific study of trauma began, and the time seems ripe to attempt to synthesize what has been learned, and to delineate some of the dilemmas and challenges that lie ahead. To accomplish this, we invited some of our most knowleagable colleagues from around the world to participate in an effort to integrate our current knowledge about what we do and do not know about trauma and distill the research and clinical wisdom that has been accumulated over these years.

Over the past five years this group has met, in various configurations, on numerous occasions, to present our data, discuss our research and compare our impressions about the state of the field of traumatic stress. These discussions always involved clinicians and researchers who did their work in different places around the globe, because the human response to trauma is universal, and who came from a many different theoretical and practical orientations, because the human response to trauma cannot be understood from one frame of mind alone.

The study of traumatic stress confronts clinicians and researchers alike with the necessity to approach their subject with a blend of objective science and an awareness of the sociopolitical context in which the trauma is imbedded. In this book we attempt to summarize the current state of knowledge about the effects of trauma on psychological, biological, and social systems, and to examine the interrelationships between these different realms. We then present a range of treatment options that have been developed for different trauma populations over the past two decades.

The acceptability of traumatic stress as a concept continues to be challenged by social and political dynamics, as well as by a variety of legitimate scientific considerations. For more than a century and a half the recognition of the effects of trauma on individuals and on society has been marked by controversies. The study of trauma emerged from curiosity about whether the unexplainable physical symptoms seen in accident victims and in hysterics had biological or psychological causes. Because these patients claimed to be helpless, and because they suffered from strange symptoms that were susceptible to suggestion, they have always invited vehement disputes about the genuiness of their complaints and they have always been suspected of malingering and of suffering from 'false memories" or 'compensation neuroses'.

Since the beginning, the issue of memory has been central to the study of trauma: Ever since psychiatrists and psychologists have devoted themselves to the study of impact of trauma on consciousness, they have noted that traumatic memories are stored in a state-dependent fashion, which may render them inaccessible to verbal recall for prolonged periods of time. When traumatic memories are dissociated from other life experiences, and stored outside of ordinary awareness, they may be expressed in such seemingly incomprehensible symptoms as physical ailments, behavioral re-enactments, and as vivid sensory re-living experiences. The reenactent of trauma in social relationships is a major source of ongoing tragedy: the problems that many victims display by "having" their memories (in feelings states or behaviors), rather than as "owned" recall, has always been an enormous source of shame in victims, and of strong aversions to these patients in society. The issue of dissociated experience raises critical issues about responsibility, and about the mutual obligations between victims and society: Not being consciously aware of what one is reenacting makes it difficult to take responsibility for one's actions. It is difficult to be an effective human being when one feels helpless and it is virtually impossible to trust in the rules, or to be guided by empathy, when one feels that one's life is being threatened.

The acceptance of PTSD as a diagnosis was closely related to the recognition of the effects of trauma in veterans of the Vietnam war. Following acute trauma, the relationships between the patients' reactions and what led up to them still can be easily understood. In those individuals, the haunting memories of the trauma seem to be the paramount problem. However, over time, after people develop their secondary adaptations to trauma, the connections between the patients' symptoms and their histories can become obscured. For example, the generalized affect dysregulation and constriction of ego functioning seen in almost all traumatized individuals are not easily pegged to particular life experiences. This issue gets even more complex in people who were traumatized as children: trauma early in the life cycle fundamentally affects the maturation of the systems in charge of the regulation of psychological and biological processes. The disruption of these self-regulatory processes makes these individuals vulnerable to develop chronic affect dysregulation, destructive behavior against self and others, learning disabilities, dissociative problems, somatization, and distortions in concepts about self and others.

This book is divided into seven sections: 1) background issues and history, 2) acute reactions, 3) adaptations to trauma, 4) memory: mechanisms and processes, 5) social, developmental and cultural issues, 6) treatment, and 7) future directions.

SECTION 1. Background Issues and History

This section examines the reaction to trauma as a process of adaptation over time. Rather than a unitary disorder consisting of separate clusters of symptoms, PTSD needs to be seen as the result of a complex interrelationship between psychological, biological and social processes that shift, depending on the maturational level of the victim, and the length of time that the person has been exposed to the traumatic imprints. Central to understanding these processes is awareness of the nature of traumatic memory and its biological substrates. In many chapters of this book we explore various facets of the psychological and biological processes that lead to the dominance of the trauma in memory and to its maintenance over time. In Chapter 2 we discuss how the issue of responsibility, individual and shared, is at the very core of how a society defines itself. We discuss how different societies have had very different approaches to the question of whether inescapably traumatic events that befall its members become a shared burden, morally and financially, or whether victims are held responsible for their own fate and left to fend for themselves. This opens up the issue of human rights: Do people have the right to expect support when their own resources are inadequate or do they have to live with their suffering and not expect any particular dispensation for their pain? Are people encouraged to attend to their pain (and learn from the past) , or should they cultivate a "stiff upper lip", which does not allow them to reflect on the meaning of their experience? The resistances to the acknowledgment of trauma are explored, as are the price and the benefits of denial.

In Chapter 3 we discuss how the issues raised in Chapters 1 and 2 have been conceptualized over the past century and a half and we examine the troubled relationship of the psychiatric profession with the idea that reality can profoundly and permanently alter people's psychology and biology. Mirroring the intrusions, confusion and disbelief of victims whose lives are suddenly shattered by traumatic experiences, the psychiatric profession periodically has been fascinated by trauma, followed by stubborn disbelief about the relevance of our patients' stories. Psychiatry has periodically suffered from marked amnesias in which well established knowledge was abruptly forgotten, and the psychological impact of overwhelming experiences ascribed to constitutional or intrapsychic factors alone. From the earliest involvement of psychiatry with traumatized patients, there have been vehement arguments about etiology: whether it is organic or psychological; whether it is the event itself, or its subjective interpretation; does the trauma itself cause the disorder, or pre-existing vulnerabilities; are these patients malingering and suffer from moral weakness or do they suffer from an involuntary disintegration of the capacity to take charge of their lives ? Should people examine their reactions to the trauma in order to overcome it, or should they be helped to ignore it and go on with their lives ? The history of these arguments is summarized in this chapter, and the status of current knowledge presented in the rest of the book.

SECTION 2. Acute Reactions

This section, written by Arieh Shalev and Zahava Solomon, who both have long experiences studying responses to acute trauma in Israel, addresses the broad range of adaptations to traumatic stress and examines the underlying processes which mould the symptomatology. This section examines the progression from acute response to long term outcome, taking into account issues of vulnerability, temperament and adjustment. In response to acute trauma, people may experience a range of reactions, including dissociation. Acute stress reactions, a new category in DSM IV, may or may not progress to full blown PTSD. The symptoms of PTSD emerge as part of a longitudinal process of adjustment to the effects of trauma. These chapters examine the merits of the ongoing debate about whether PTSD is a normal or abnormal response to traumatic stress and when clinicians should intervene. Furthermore, these chapters explore what we know about long term effects of acute trauma to predict eventual impairment and disability.

SECTION 3. Adaptations to Trauma

This sections start off with a chapter which delineates the background issues for the development of PTSD as a diagnostic category in the DSM III and DSM IV. Since the place of psychiatric problems within diagnostic systems determine how clinicians and investigators conceptualize the inner stucture of a disorder, this raises the very important question whether PTSD is most appropriately classified as an Anxiety Disorder. This chapter examines the rationale for establishing a separate Axis for Stress Disorders in the DSM system of diagnostic classifications, which could include dissociative disorders, adjustment disorders, grief reactions and a variety of characterological adaptations. The subsequent chapters of this section, on the nature of the Stressor, and on Vulnerability and Resilience, examine the interactions between external events and subjective response. In this regard, the meaning of the trauma, the physiological response, pre-existing personality structures and experiences, as well as the degree of social support all are critical factors in the ultimate response to trauma. The stressor criterion defines who is and who is not included in the diagnosis, and hence this determines the prevalence of PTSD. These chapters summarize the epidemiological studies conducted to date which emphasize the importance of traumatic stress as a public health issue. They further examine the relative importance of the traumatic event itself in contrast to vulnerability or prediposing factors. They conclude that issues of predisposition and vulnerability may be most relevant to understanding recovery from acute symptomatology and the individual's long term resilience, rather than acute patterns of response to a stressor. Vulnerability factors may also define the patterns of comorbidity which play an important role in chronic post traumatic stress disorder. Critical in these considerations is the emergence of chronic patterns of adaptation, in which lack of involvement in current reality, rather than preoccupation with the past, are the most pathological features.

The next chapter, on the complex nature of adaptation to trauma, examines the intricate ways in which psychological and biological processes interact with development to produce a range of problems with self-regulation, attention, the ways people view themselves, and the ways they make their way in the world. Chronic trauma is associated with dissociative disorders, somatization and a host of self destructive behaviours such as suicide attempts, self mutilation and eating disorders. In addition, trauma at different developmental levels has different effects on further personality development. This theme of complexity of adaptation continues in the next chapter: "the Body Keeps the score", which examines the biology of PTSD, including both hormonal and autononic nervous system dimensions: the unusual patterns of cortisol, noradrenalin and dopamine metabolite excretion, the role of the serotonergic and opioid systems, and receptor modification by processes such as kindling. This chapter also examines the involvement of central pathways involved in the integration of perception, memory and arousal, as well as the impact of these central pathways on patterns of information processing in PTSD.

This Section concludes with a chapter on Research Methodology which discusses the currently available diagnostic and assessment tools that are helpful in both clinical and research settings. There often is conflict between the clinical realities and reseach paradigms in PTSD. Because of forensic as well as research issues, the problem of a valid and reliable diagnosis is of paramount importance. This question is given further relevance by the fact that a number of studies demonstrate low rates of PTSD diagnosis in exposed populations. While strict standards of diagnosis for post traumatic stress disorder are essential for good research, broader definitions may be helpful in clinical settings to assess the full extent of disability. Over time some people's PTSD may become subclinical and yet continue to influence their level of functioning.

SECTION 4. Memory: Mechanism and Processes

Because it would be unethical to conduct laboratory experiments that are so overwhelming as to cause subjects to develop PTSD, research on the nature of traumatic memories needs to rely on reports of traumatized individuals, on challenge studies, and on inferences from animal investigations. Unfortunately, it has become common for experimental psychologists to make undue inferences from memories of ordinary events in the laboratory to the nature of memories of rapes, assaults and murder. In recent years, research with traumatized individuals has been able to show how traumatic memories are qualitatively different from memories of ordinary events, that amnesia co-exists with vivid recollections, and brain imaging technologies have made it possible to gain insights into the ways traumatic memories may be organised in the central nervous system. In the next chapter, on Information processing and dissociation in PTSD, we examine how trauma affects the individual's ability to perceive and integrate the overwhelming experience. Arousal and dissociative responses during the trauma lead to fragmentation of the experience. This chapter focuses both on the dissociative responses during traumatic experiences and on the continuing role of dissociation in subsequent adaptation, including the organization of experience in dissociated fragments of the self, such as occurs in Dissociative Identity Disorder.

SECTION 5. Social, Developmental and Cultural Issues

A. Trauma and the life cycle. Trauma in childhood can disrupt normal developmental maturation. Because of their dependence on their caregivers, their incomplete biological development, and their immature concepts of themselves and their surroundings, children have unique patterns of reaction and needs for intervention. This chapter adresses the fluidity of children's schemata and the role of their care givers in modifying the trauma response. On the other end of the life cycle, in the elderly, trauma has its own long term impact: recent research has shown that as external and internal resources diminish, trauma may renew its hold over people's psychology. Long term studies of traumatized individuals show that while they may suffer from sub clinical PTSD in middle age, in senesence, memories of the trauma once again come to dominate their lives. This chapter discusses adjustment in old age after an earlier trauma, such as concentration camp incarceration, or being a war veteran, as well as the issue of lack of flexibility or capacity to repair damage with increasing age.

B. Social and Cultural Issues: The history of post traumatic stress disorder has been intimately entwined with the way that legal systems have dealt with disability and pension entitlements. Legal systems have played a major role in adjudicating the linkage between traumatic events and psychiatric symptomatology. This chapter deals with the ways in which legal systems in North America, Europe and Asia have approached these questions. In the next chapter, we explore the possible role of cultural and social issues in post traumatic stress disorder. While this is an area that has received very little attention, the cultural context of the trauma is an important dimension because the meaning of trauma as well as the social and religious rituals surrounding loss and disaster have an important healing role in both individual and community trauma. This chapter also discusses the specific functions of social supports in minimizing the impact of trauma and the protective role of attachment.

SECTION 6. Treatment

Well-controlled treatment studies are difficult to do, since there always are more variables that impact on outcome than be controlled. Nevertheless, PTSD research has provided some excellent treatment outcome studies using widely divergent theoretical orientations: cognitive-behavioral, psychodynamic, psychopharmacological and eye movement desensitization and reprocessing (EMDR). In actual practice, most clinicians use an eclectic approach, in which healthcare providers need to constantly re-evaluate what is being accomplished. This includes a continuous need to evaluate what particular interventions are most effective for which trauma-related problems. For example: core PTSD symptoms (intrusions, numbing and hyperarousal), occupational disabilities, dissociative phenomena, or interpersonal problems and alienation all may need to different approaches. Therefore, the treatment must, in large part, be derived from clinical judgment and draw from the available knowledge about the etiology and longitudinal course of this condition.

The aim of therapy with traumatized patients is to help them move from being haunted by the past and interpreting subsequent emotionally arousing stimuli as a return of the trauma, to being present in the here and now, capable of responding to current exigencies to their fullest potential. In order to do that, people need to regain control over their emotional responses and place the trauma in the larger perspective of their lives, as an historical event, or series of events, that occurred at a particular time, and in a particular place, and that can be expected to not recur if the traumatized individual takes charge of his or her life. The key element of the psychotherapy of people with PTSD is the integration of the alien, the unacceptable, the terrifying, the incomprehensible: the trauma must come to be "personalized" as an integrated aspect of one's personal history.

The therapeutic relationship with these patients often is the cornerstone of effective treatment; it tends to be extraordinarily complex, particularly since the interpersonal aspects of the trauma, such as mistrust, betrayal, dependency, love and hate tend to be replayed within the therapeutic dyad. Dealing with trauma confronts all participants with intense emotional experiences: ranging from helplessness to intense feelings of revenge, from vicarious traumatization to vicarious thrills.

In this section we examine therapeutic responses, starting with preventive strategies. The military and other emergency services have learned that it is possible to modify people's behavior during extremely stressful situations in such a way as to optimize their survival behaviors. The possibilities for preventing severe post-traumatic reactions has become a major focus in the last decade. Critical incident debriefing has been proposed as a major vehicle for modifying the stress reactions of emergency service workers. Despite the strength of the advocacy about the need for these services, there has been little systematic research examining their value. Much of the treatment literature about post traumatic stress disorder has focused on the management of acute patterns of distress or very chronic patterns of adjustment such as Vietnam Veterans. However, the increasing recognition of traumatic stress has led patients to present within weeks of the development of acute symptomatology. The absence of stable symptom patterns and extreme degree of physiological hyperarousal at this stage mean that there are unique probelms that need special attention in the treatment of acute reactions.

Of the various proposed therapies the effects of cognitive - behavioral treatments have been most thoroughly examined. There is a growing body of systematic research demonstrating the ability of such treatment to assist in the broad range of PTSD symptoms. However, because uncontrolled exposure may have negative consequences, and since traumatized people with very high levels of avoidance are often most reluctant to expose themselves to their traumatic memories, there remain important questions about the technical skills necessary, and the timing of these forms of treatment.

Psychodynamic treatment has made important contributions to the treatment of traumatized patients. Its most important contribution has been its focus on the understanding the subjective meaning to the traumatic event, and the process and barriers to the integration of the experience with pre- existing attitudes, beliefs and psychological constructs. The hyperarousal, sleep disturbances and embeddedness in the trauma in patients with PTSD makes effectve pharmacological treatment essential. During the last five years there have been a number of controlled trials which have shown that some antidepressants and serotonin reuptake inhibitors ca be quite helpful in providing symptomatic relief. The multiplicity of PTSD symptoms suggests that psychopharmacological interventions need to be targeted at specific subsets of symptoms.

This multidimensional nature of PTSD means that in clinical reality, a variety of different approaches are required and an integration of a range of methods is often needed. Dealing with very traumatized people often requires a staged process of treatment that is responsive to how much the victims can tolerate. The chronicity and severity of post traumatic stress disorder and reluctance of many victims to involve themselves in the treatment process means that a range of approaches need to be explored to manage this condition. The specific nature of the therapeutic relationship often is a critical variable in outcome. New treatments of PTSD are regularly proposed and these deserve careful clinical trials to test their efficacy.

SECTION 7. Conclusions and Future Directions

This section integrates the common themes of the book and attempts to signal the future issues and directions of clinical care, service delivery and research in the area of trauma. More than most areas of psychiatry the field of trauma has been a reflection not only of established knowledge base of the discipline, but also of a diverse range of social and political factors. The way that victims of trauma are dealt with is often an indicator of society's general attitude to promoting the general welfare of its citizens. Much remains to be learned about how trauma affects people's capacity to regulate bodily homeostasis, how, years after the trauma has ceased, memories continue to dominate people's perceptions, and how victims can best be helped to re-establish control over their lives.

Many questions that have been explored in this book continue to be challenges for the future: How do the biological effects of trauma continue to affect people's capacity to think and make sense out of current experience ? To what degree can psychological interventions reverse a disorder with such strong biological underpinnings ? Do patients benefit from getting compensation payments, or does it impair their recovery ? What is the role of predisposition, and what are the implications of pre-existing vulnerabilities for treatment? To what degree is the essence of trauma the external reality or the internal processing of that event ? Should treatment focus primarily on the trauma itself, on secondary adaptations, or on learning to pay attention to the here-and-now ? Finally, possibly the most important question that deserves intense study is: what are the natural mechanisms that allow some individuals to face horrendous experiences and to go on? What can we learn from them to help others do the same ?

The past has shown how fragile existing knowledge can be, and the degree to which psychiatry is prone to follow fashions, where we tend to become trapped in prevailing paradigms without being able to see their shortcomings. These are the unknown unknows that are the worst enemies of knowledge. This book is a body of work to be criticised and reacted against - only a critical reading will help us further define what we do not know, and determine the scope of future exploration.

The editors

Reference

Kardiner, A. & Spiegel, H. (1947). War Stress and Neurotic Illness. New York: Paul B. Hoeber.

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