Winter 2015

Family and Relationships

Dressing Invisible Wounds

Gina Stepp

What comes to mind when you hear the term PTSD, or posttraumatic stress disorder? If you visualize the face of a soldier, you’re not alone. This is the usual image in media reports on the subject; and certainly, high percentages of military veterans do experience posttraumatic symptoms.

However, the diverse faces of PTSD sufferers tell another story. While many victims are soldiers, many more are civilians who have never seen a battlefield. That said, in 1980 when PTSD first entered the Diagnostic and Statistical Manual of Mental Disorders—the canon on which mental health assessment is based in the United States and many other countries—it did so based on the observed symptoms of returning Vietnam veterans. At the time, researchers were examining earlier combat situations, when the trauma responses of soldiers had been referred to as “shell shock” or “battle fatigue.” In those days, the brain’s response to trauma was so little understood that military officials often equated it with cowardice or moral weakness.

Vietnam vets helped researchers move mental-health care a significant step forward, despite the fact that early subjects were mostly male and their traumas seemed to have been encountered largely in battle. By the time avenues of research began opening up for those studying other types of trauma, PTSD was understood as a set of psychological reactions resulting from car accidents, combat, natural disasters, one-time physical or sexual assault, etc.

One does not have to be a combat soldier, or visit a refugee camp in Syria or the Congo to encounter trauma. Trauma happens to us, our friends, our families, and our neighbors.”

Bessel A. Van Der Kolk, M.D., The Body Keeps Score: Brain, Mind, and Body in the Healing of Trauma

It soon became clear from the research, however, that PTSD was also prevalent in a uniquely complex form in victims of childhood abuse, particularly when the abuse was repetitive and occurred in the context of family relationships during crucial developmental periods. As adults, these childhood victims, whether male or female, exhibited serious impairment in interpersonal skills. As a result they tended to collect multiple diagnoses along with PTSD, including, among others, borderline personality disorder (mostly women) and antisocial disorder (mostly men).

As clinicians began to notice these patterns, neuroscience progressed in understanding human brain development, and trauma researchers picked up clues as to why trauma experienced during childhood resulted in such complex symptoms. In the process, they shed light on questions that often come up among families and friends when a loved one is first diagnosed: Why do some trauma victims develop PTSD while others do not? Why my loved one? And what can I do to help? To answer these questions, it’s important to gain a basic understanding of how the brain reacts to trauma.

Effects of Trauma

Besides handling our needs for thinking and learning, the brain acts as a central control system for the body, regulating the release of hormones that govern various bodily functions. When we are threatened, stress hormones (which temporarily commit all resources to the fight-or-flight system) flood the brain. Growth, learning, digestion and many other operations are put on hold until the threat subsides and operations can return to normal. Generally no harm is done—unless the threat doesn’t go away. A brain that remains under prolonged stress may become stuck in fight-or-flight mode. Worse, if we are exposed to chronic stress during the brain’s key developmental periods in childhood, the effects on brain growth, attention and learning, as well as on heart rate, digestion and the immune system, can be devastating to future mental and physical health.

It’s important to note that the automatic fight-or-flight reactions in the brain are regulated by higher structures, which are shaped through emotional attunement with caregivers during infancy and well into the first three years of life. If we experience safe and nurturing relationships during these key periods, we are more likely to be resilient when we encounter traumatic experiences later in life.

On the other hand, if parents—the caregivers with whom a child typically forms the closest attachment—are abusive or even simply unresponsive during this crucial developmental period, a child’s ability to regulate the body’s automatic responses to emotional arousal and to respond effectively to stress can be severely stunted, with far-reaching effects on development. If these are not addressed by the teen years, when attachment-dependent skills such as self-regulation and prosocial behavior typically stabilize, serious harm to the ability to regulate emotions, attention and behavior and to maintain interpersonal relationships will likely result.

Genetics have also been associated with resilience, but research suggests that the social environment plays an important role in whether and how these genes are expressed throughout development. In fact, a 2014 Columbia University study, in collaboration with the University of Michigan, has pinpointed interaction between childhood adversity and a specific gene that influences whether a child will be resilient or vulnerable to later trauma. Although the study focused on soldiers, researchers observed that the same interaction occurred in the civilian control group. Depending on which of three forms of the gene was present (no matter whether the individual was a civilian or a soldier), if the victim experienced more than one type of childhood adversity, the degree of risk for trauma reactions could be predicted. These findings help explain why other studies link high military suicide rates to childhood abuse and trauma symptoms that were measureable before enlistment, naming these factors as “the real trauma” behind wartime PTSD.

The environmental influence on gene expression largely explains why not everyone who experiences trauma ends up with PTSD. Family and friends may find it reassuring to understand that their loved ones with PTSD are not suffering from a lack of courage or character, and that the support of a secure social network can make an important difference in recovery. In fact, treatment success requires a therapeutic relationship characterized by trust, which is why it’s so important to find a therapist that your loved one feels comfortable with.

It may seem obvious that people who have difficulty regulating emotional and physical responses to fear would also have difficulty handling stress. But this is a key understanding for those who hope to help their loved ones throughout treatment. The adult (or child) suffering from PTSD needs to regain basic self-regulation skills necessary for coping with stress before exploring the trauma event itself. Otherwise he or she is at risk of being destabilized or even retraumatized.

What does this mean for friends and family? First and foremost, it means those suffering from PTSD need your love, support and responsive care in order to heal. There’s no getting around the fact that it may be challenging to provide these basic human needs. PTSD symptoms are not easy to live with and require a lot of patience and understanding. Your loved one may seem to vacillate between emotional distance and angry reactivity; he or she may at turns be defiant, aggressive, needy, demanding, detached and emotionless, or indiscriminately confiding. Fortunately a little education goes a long way. Learning about common symptoms and treatment needs can give family and friends the understanding they need to keep from being overwhelmed as they support a loved one through the healing process. 

Common PTSD Symptoms

Human beings connect to one another primarily on an emotional level. Unfortunately it is on this level that PTSD is most crippling: posttraumatic reactions to extreme stress may include self-destructive tendencies, suicidal thoughts, and an inability to control anger; alterations in attention including detachment, depersonalization or amnesia; alterations in self-perception, which may include feelings of guilt, shame, ineffectiveness, the sense of having been permanently damaged, or isolation stemming from the feeling that no one else can possibly understand; alterations in relations with others, including an inability to trust, hypersensitivity, and hypervigilance to perceived threats; as well as despair, hopelessness or loss of previously important beliefs. But PTSD also profoundly affects the physical body, which retains a memory of trauma reactions even when the brain doesn’t seem to. It may manifest in the digestive system or in the form of chronic pain, cardiopulmonary symptoms or neurological symptoms, among others.

Clinicians who are familiar with borderline personality disorder (BPD) will see obvious overlap between complex PTSD symptoms and BPD symptoms. While it’s true that not all people with BPD have histories of childhood trauma, a large number do; and there are unique features when BPD and PTSD occur together.

Unfortunately, because of stigma attached to BPD symptoms, especially in those who are seen as manipulative or needy, child-abuse survivors may not be best served when they are treated as though they had several distinct and unrelated disorders. This is partly because treatment approaches will be fragmented but also because your loved one may be harmed by treatments he or she is not yet able to handle emotionally.

One of the most important risk factors for severe posttraumatic reaction is believed to be age at the time of the traumatic event or events, with younger children at greater risk, whether the trauma is home-based or not. However, the number of trauma types experienced and the level of betrayal by a caretaker also play significant roles. Betrayal trauma refers to victimization at the hands of those closest to the child, and the more prominent the perpetrator is in the victim’s life, the more disorganizing the trauma is likely to be. Unfortunately the vast majority of abuse occurs at the hands of parents (most often biological parents), a child’s most significant caretakers.

Working with traumatized and maltreated children has . . . made me think carefully about the nature of humankind and the difference between humankind and humanity. Not all humans are humane. A human being has to learn how to become humane.”

Bruce D. Perry, M.D., PH.D., The Boy Who Was Raised as a Dog

A child’s exposure to betrayal trauma often leads to an effect referred to as dissociation—an umbrella term covering a number of ways we mentally detach from our surroundings, and a common coping style in children who are faced with overwhelming circumstances. Although helpful for survival in the traumatic moment, dissociating disrupts the normal link between experience and awareness, a state that underlies many PTSD symptoms and can lead to extremely debilitating disorders.

In children, complex trauma symptoms differ in subtle ways from those in adults. In practical terms, the child may be disposed to frequent outbursts, fear of emotion (and an inability to describe emotion), sleep disorders, pain, aversion to touch, eating and digestive disorders, a heightened focus on perceived threats, distractibility, aggression, risk-taking, expectancy of betrayal, overidentification with the distress of others, expectancy of attachment loss, and self-destructive coping strategies such as self-harm or substance abuse. Because they have difficulty expressing their feelings verbally, these children lack appropriate response strategies and are more likely to act out.

Due to this wide array of symptoms, most of which are related to deficiencies in self-regulation, children with PTSD are often diagnosed with additional disorders such as phobias, attention-deficit/hyperactivity disorder (ADHD), and oppositional defiant disorder (ODD). In light of neuroscience’s contributions in establishing a link between infant attachment and self-regulation, it is interesting that ADHD has likewise been connected to deficits in self-regulation, suggesting that it may not be best described as a disorder of attention. Unfortunately, if clinicians focus on treating issues such as ADHD as separate problems in these children rather than as symptoms stemming from a common cause, the developmental effects of trauma may be missed. When this happens, there’s a good chance that self-regulatory skill-building or trauma recovery will not be undertaken early enough, and these children will end up in the health-care system again as adults.

We are fundamentally social creatures—our brains are wired to foster working and playing together. Trauma devastates the social-engagement system and interferes with cooperation, nurturing, and the ability to function as a productive member of the clan.”

Bessel A. Van Der Kolk, M.D., The Body Keeps Score: Brain, Mind, and Body in the Healing of Trauma

In fact, researchers note that trauma in children may be entirely missed because there are significant differences between children’s and adults’ responses to traumatic events. On the other hand, if it is detected early enough for children to receive help within 30 to 45 days of an event, and if the child has good family and social support, then the chances of long-term consequences such as PTSD are greatly diminished.

Treatment Needs

To successfully “rebuild” a traumatized brain, it appears that treatment should imitate the natural sequential development of the infant brain; that is, treatment should be phased, beginning with stabilization. This would include educating sufferers about their symptoms and teaching coping behaviors and awareness of emotional states so they can tolerate negative emotions and handle stress. Strategies may include breathing exercises, specific postures or even mindfulness training. In this phase, the relationship between therapist and patient becomes an important scaffold for building skills in self-regulation, self-soothing and interpersonal relationships, echoing the way attachment with caregivers provides a scaffold for the infant brain.

Family and friends can contribute to establishing a sense of safety during this period by asking about and being sensitive to their loved one’s particular triggers, things that remind the person of the trauma and cause flashbacks. These can include sights, sounds, smells, strong emotions or bodily sensations, even hunger or thirst. When loved ones experience a flashback or a strong sensation that they struggle to regulate, it’s not always easy to know how you can help. In some cases, your only course will be to ask what they need from you.

Although the need for support never goes away, it will change in form and intensity throughout the healing process. For instance, in the second phase, which addresses the actual trauma, your family member with PTSD may be ready to talk to you about it repeatedly. At this point, helpful support involves listening while resisting the urge to respond with any negative or judgmental emotions you may feel. Simply listening and being understanding of emotions without minimizing or discounting them will be the best way to offer support. Telling someone to “get over it” or “stop thinking about it” is profoundly unhelpful during this stage.

During the third phase, your loved one will begin moving away from a focus on the trauma and toward forming and strengthening relationships and building an identity centered on new capacities and hope for the future. One of the most devastating aspects of traumatic experiences is that they happen outside the victim’s control; so gaining back some sense of control is an important part of healing. The central focus will shift to an interest in and mastery of work, recreation and other activities. At this point you can help build a support system outside of therapy, which in this phase becomes a priority. Research also suggests that if the patient has a chosen religious affiliation—another source of connection and resilience—it will be especially helpful at this time. Not only is the potential for further human connections useful, but according to research, belief in and perceived connection to a higher power can help create an important sense of meaning that fosters resilience. In addition, meditation and prayer can exert a calming effect on the brain circuits that regulate attention and emotion, turning off the areas of the brain that focus on the self. These benefits are highly relevant to the goal of therapy in this phase, which is to help the person develop and refine a substantial identity beyond that of victim or survivor.

Some people may choose to confront their abuser during this stage, but this is by no means a necessary step. Others prefer to disclose their history to supportive family or friends. Either way, care should be taken not only in the way disclosures are made but also regarding potential outcomes, since poor patterns of relating to one another within the family may not be easy to break, even considering the survivor’s new capabilities. However, if at least some family members are aware of the need to support change and are committed to providing emotional support for their loved one with PTSD, there is great hope for recovery, although it is always possible some symptoms may return under stress.

What does healing look like, then?

Healing includes reaching a point where your loved one is able to manage symptoms and traumatic memories successfully, place the event in a meaningful context, and concentrate on the present and future more than the past. But more importantly, healing involves being able to enjoy positive relationships and build strong bonds within personal networks as well as in the community. Trauma isolates. Whether or not it is overtly interpersonal in nature, the sense that no one else can understand their experience separates survivors from the human connection that is so crucial to mental and physical health. Without social support and secure interpersonal ties, trauma recovery cannot even begin.

As a friend or relative of a person with PTSD, this means committing to understanding trauma so you can provide the support your loved one needs. But doing so may also make you vulnerable. You, too, may need support to keep up with the demand for your love, compassion and persistence along what may often be a very bumpy road because, as trauma researcher Judith Herman writes, “to study psychological trauma is to come face to face both with human vulnerability in the natural world and with the capacity for evil in human nature.” 

Now God makes his home with people. . . . And God himself will be with them and be their God. He will wipe away every tear from their eyes. There will be no more death or sadness. There will be no more crying or pain. Things are no longer the way they used to be.”

Revelation 21:3–4, New International Reader’s Version

Helping a loved one through the healing process may well take an emotional toll, but it can be very rewarding in the end. Family and friends—first-hand witnesses to trauma recovery—have a front-row seat to experiencing pain and tears turn to gratitude and hope. And in the process, we gain some small insight into love’s tremendous power to overcome evil.