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Psychological consequences of traumatic experiences:
Psychological, Biological and Social Aspects of PTSD (1995)

Bessel A. van der Kolk *

* Prof. Dr. med. Bessel A. van der Kolk is Director of the HRI Trauma Center and Professor of Psychiatry at Harvard Medical School, 227 Babcock Street, Brookline, Mass. 02114, USA.
** A preliminary to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) was published in 1928 to meet the need expressed by state psychiatric institutions in the United States to standardize the nomenclature of mental illnesses and syndromes. DSM I was published in 1952, DSM II in 1968 and DSM III in 1980. An important revision of the third edition (DSM III-R) appeared in 1987. DSM III and DSM III-R are also available in German translation: Diagnostic and Statistical Manual of Mental Disorders (DSM III). Translated by K. Köhler and others Weinheim: Beltz 1984 (or 1989 for DSM III-R). (Editor's note)
At this point, Dr. Michael Macpherson, many thanks for having obtained this article for these WWW pages. I would also like to thank the translator Stefan Scholz (Berlin) and the International Physicians for the Prevention of Nuclear War (IPPNW) for the necessary funding.

Horrific events, which suddenly break through our feeling of security and invulnerability, can profoundly affect the way we deal with our own feelings and the environment. War trauma, physical and sexual assaults, accidents and other natural or man-made disasters can trigger the syndrome called PTSD (Post Traumatic Stress Disorder). The helplessness and anger that usually accompany such experiences can have a lasting effect on a person's handling of stress, impair their self-esteem and severely disrupt the perception of the world as an essentially safe and reliable place.

A certain feeling of security and reliability is a basic requirement for goal-oriented individual action. Humans seem to be emotionally unable to accept arbitrariness and senseless destruction. They look for an explanation to understand a disaster they have experienced - usually by finding someone to blame: themselves or a perpetrator.

Helplessness and anger are closely related. In recent years it has become clear that the intensity of the first somatic response to a potentially traumatizing experience is the most important predictor of its long-term consequences. If the stressful situation is overwhelming enough, the resulting trauma conditions an emotional reaction in which the body falls into a readiness to fight, flee or freeze at the slightest stimulus: The everyday life of traumatized people is under the sign of the trauma, against which they remain constantly alert. Even after consciously processing the trauma, many traumatized people continue to feel fear and increased physical excitement in situations reminiscent of the trauma or even just loud noises. They react with a willingness to fight or flee, often without knowing the origin of such extreme reactions.


1. The symptomatology of PTSD

Although Homer and Shakespeare already knew about post-traumatic stress in their poems, its existence was not generally recognized by psychiatry until 1980, when PTSD was included in the DSM III **. Table 1 (see below) shows the diagnostic criteria for a "simple PTSD". Since then, an increasing amount of literature has emerged that has documented post-traumatic symptoms (overexcitation and overreactions to stimuli reminiscent of the trauma, avoidance behavior and emotional self-anesthesia) on the basis of numerous samples of traumatized people: war veterans, physically and sexually abused children, abused and raped women, survivors of natural disasters, refugees and political prisoners.

Regardless of the cause of fear, the central nervous system (CNS) responds to overwhelming, terrifying, and uncontrollable experiences with conditioned emotional reactions. Victims of rape, for example, may react to conditioned stimuli, such as the approach of an unknown man, with panic, as if they were being raped again.

Autonomous over-excitability and intense reliving

While people with PTSD tend to be emotionally inhibited about their environment, their bodies react to certain physical and emotional stimuli as if the threat of annihilation were still present. A large number of samples have shown that trauma-associated stimuli cause conditioned autonomic arousal. This has the vital function of making the organism aware of potential dangers. However, the reduced trigger threshold for somatic stress reactions also means that people with PTSD can no longer trust their body sensations as a measure of impending danger. In this way, the sensations lose their function as warning signals in order to prepare the organism for appropriate action.

Emotional overreactions and sleep problems

The loss of neuromodulation, which is at the center of the PTSD, leads to a loss of affect regulation. Traumatized people go directly from stimulus to reaction without first realizing what arouses them. Even with minor stimuli, they tend to have violent feelings of fear, anxiety, anger, or panic. This makes them either overreact and intimidate others or close themselves up and freeze.

Both children and adults with such hyperexcitability often suffer from sleep problems. Either they are unable to relax before going to sleep or they are afraid of having nightmares. Many traumatized people report "dream termination insomnia": as soon as they start dreaming, they wake up - for fear that the dream will develop into a traumatic nightmare. They also tend to be overly alert, jumpy and restless.

Learning disabilities

Physiological overexcitation interferes with the ability to focus and learn from experience. In addition to amnesias related to aspects of trauma, traumatized people also have difficulty remembering ordinary events. Easily put into a state of overexcitation by trauma-related stimuli and plagued by difficulty concentrating, they can develop symptoms of pathologically reduced attention. After a traumatic experience, many of them lose developmental skills and regress to previous forms of stress management. In children, skills that have already been learned can disappear again, for example when it comes to eating or personal hygiene; in adults, it is more likely to be expressed in excessive dependence and the loss of the ability to make informed and autonomous decisions.

Memory disorders and dissociation

The increased autonomic excitability not only affects psychological well-being. The accompanying fear can also directly awaken memories of even earlier traumatic experiences. The administration of lactate, which stimulates the physiological arousal system, triggers flashbacks and panic attacks in people with PTSD. Injection of yohimbine (which stimulates the release of norepinephrine from the locus coeruleus) was able to induce flashbacks in Vietnam veterans with PTSD. Any exciting situation can trigger memories of long ago traumatic experiences and provoke reactions that are inappropriate in the present.

In addition to overexcitation and intrusive memories, chronically traumatized people, especially children, can develop amnesia syndromes related to the traumatic event. If children are victims of severe trauma in a phase of life during which they try out different identities in their daily play according to their stage of development, they can sometimes split off entire parts of their personality in order to cope with the traumatic experiences. In the long term, this can lead to multiple identity disorder, which can be observed in around 4% of inpatient psychiatric treatment in the USA. Patients who have learned to dissociate in the face of trauma are likely to continue to use dissociative defenses once they are exposed to new stresses. In some experiences they develop amnesia and tend to react to the feeling of threat with fight or flight, all of which cannot be consciously remembered later. People suffering from dissociative disorders are a clinical challenge that includes helping them develop a sense of responsibility. Forensically, they're a nightmare.

Aggression and autoaggression

Numerous studies have shown that traumatized children, like adults, tend to turn their aggression against others or themselves. Childhood abuse significantly increases the likelihood of delinquency and criminal behavior later on. In a survey of 87 patients in outpatient psychiatric treatment, we found that patients who had mutilated themselves invariably had a difficult childhood of abuse, abuse and / or neglect. There is some evidence that there is a connection between the propensity for self-mutilation and changes in the release of endogenous opioid peptides in the CNS as a result of early trauma. Problems with foreign aggression are particularly well documented in war veterans, traumatized children, and inmates with early trauma.

Numb psychological reactivity

Since traumatized people are aware of their difficulty in keeping their emotions under control, they seem to spend their energies more on avoiding tormenting inner feelings than on the demands of their environment. In addition, they lose pleasure in things that used to give them a sense of satisfaction, and they can feel like they are "lost in the world". This emotional numbness can manifest itself as depression, listlessness and lack of drive, in psychosomatic reactions and dissociative states. In contrast to the noticeable PTSD symptoms that can be observed as a reaction to external stimuli, numbness is part of the basic behavior of these patients. Such stunning mechanisms have been seen among school children attacked by a sniper and among victims of physical and sexual abuse. These children are less involved in playful social interaction and often withdraw and become isolated.

After trauma, many people cease to enjoy exploring their surroundings or participating in activities. You feel like you are "just walking through" the ups and downs of daily life. Emotional numbness also influences the processing of trauma in psychotherapy: patients give up on themselves and their healing, unable to think about the future. In them the essential mental function that Freud called "thinking as trial action" fails: fantasizing about possibilities and mentally exploring ways in which wishes can be fulfilled and instincts satisfied. Psychosomatic Responses Chronic anxiety and emotional numbness also hinder learning to identify and articulate feelings and desires. People traumatized in their childhood often suffer from alexithymia - an inability to translate somatic sensations into basic emotions such as anger, joy, or fear. This inability to put body sensations into words and symbols means that they experience emotions only as physical problems. This causes devastating damage, especially in intimate and familiar interpersonal communication. Such people suffer from psychosomatic disorders and are connected to the world primarily through their bodies: communication takes place through body organs rather than through emotional ties. Risky Behavior One of the most troubling aspects of emotional numbness is that people who suffer from it, especially adolescents, need very high levels of external stimulation to feel like they are "alive at all." Perhaps this contributes to so many adopting risky behaviors, engaging in violence against themselves and others, or being susceptible to drug abuse.


2. Dependence of the psychological and biological reaction to the trauma on the level of development

Over the past thirty years, modern psychiatry has gradually begun to determine the different consequences of trauma for different ages. So one has rethought how a lack of affection or traumatic separation experiences can disturb the organism in its development. Bowlby emphasized that attachment behavior first and foremost has a vital biological function that is equally indispensable for reproduction and survival. A rapidly growing body of research has shown that disrupted attachments in childhood can have long-term neurophysiological consequences. A spectrum of studies on disorders of affect regulation in animals and humans has shown that abuse, neglect and separation in childhood can have far-reaching biopsychosocial consequences. These include persistent biological changes that can lead to impaired emotional modulation, difficulties in developing new processing strategies, reduced immune competence, and the reduced ability to form meaningful social relationships.

Thanks to the work on animals, an extensive research literature on the consequences of abuse and sexual abuse, and thanks to the field tests for the DSM IV, it became clear that there are critical developmental phases of the CNS during which children are particularly susceptible to the development of permanent disorders as a result of abuse, neglect and separation are. Given that trauma at an early age has profound effects on affect regulation and states of consciousness and affects how experiences are organized at the somatic level and how the personality adapts to the chronic experience of danger and fear, the PTSD Advisory Committee has An expanded definition of PTSD is recommended as part of the preparation for DSM IV. So far, only the ICD-10 (the international diagnostic glossary of the WHO), but not the DSM classification, has recognized the persistent consequences of trauma on all personality functions of a person. Table 2 (see below) shows the individual elements of the definition of "severe PTSD" proposed for the DSM IV.

While the biological basis of response to trauma is extremely complex, research in humans and other mammals over the past forty years has shown that early trauma, in particular, has long-term effects on the neurochemical stress response, including the extent to which catecholamines are released Duration and extent of cortisol release and on a number of other biological systems, such as the regulation of serotonin and endogenous opioid peptides. Here is a brief overview of some of these traumatic, biological changes:

Stress response and the psychobiology of PTSD

I. Activation and reaction to danger signals: The body reacts to increased physical or psychological demands by releasing noradrenaline from the locus coeruleus and corticotropin (ACTH) from the anterior pituitary gland. Although many details of the interaction between the hormones of the hypothalamus-pituitary-adrenal cortex axis and the catecholamines in the stress response have not yet been fully understood, these different hormones help the body to generate the energy it needs to respond to stressors mobilize; this ranges from increasing the release of glucose to stimulating the immune system. In a well-functioning organism, stress leads to rapid and pronounced hormonal reactions. Chronic persistent stress, however, reduces the effectiveness of the stress reaction and leads to desensitization.

It is therefore not surprising that a variety of abnormalities in stress hormone regulation have been observed in patients with PTSD. In war veterans, for example, an increased release of noradrenaline and adrenaline or an increased cortisol level in the urine were observed on a 24-hour average. The sustained activation of the stress response is not only dependent on the stress hormones themselves, but also on the ability of the organism to modulate excitation. Serotonergic input into the medial hippocampus reduces the relative strength of the noradrenergic input, which enables the hazard reactions to be modulated.In a recent study, we were able to show that fluoxetine, which blocks the reuptake of serotonin at presynaptic membranes, has a particularly positive effect on the ability to modulate excitation in PTSD patients. The clinical trials with serotonin reuptake blockers indicate that they are currently by far the best pharmacological treatment option for PTSD.

II. Anesthesia: At present, research is oriented in three directions in order to explain the biological basis for the anesthesia of psychological reactivity observed in PTSD: A. Damping of the noradrenergic system and the HHN axis. After excessive noradrenergic stimulation, humans show decreased adrenergic receptor activity. B. Opioid-mediated stress-induced analgesia (SIA) has been described in stressed animals and in humans with PTSD. C. The serotonin system: There is fairly certain evidence of reduced serotonin activity in PTSD, which disrupts the functioning of the hippocampus and which could be one of the reasons for this, since incoming sensory impressions are interpreted as threatening rather than neutral stimuli. This disturbs the attention to incoming impressions, they are not recognized as requirements that have to be met, but instead viewed as traumatic stimuli that are to be avoided.

III. Psychosocial consequences: Distressing memories of the trauma, feelings of guilt and shame because of (supposed) personal guilt for what happened, anger over being abandoned and the changed biological stress reaction all work together and lead to a complex impairment of people's ability to have family and professional relationships to your satisfaction. The majority of traumatized people suffer 1.) from the persistent feeling of depression and helplessness, 2.) from a low affect tolerance, tends to be impulsive and a primarily somatic experience of emotions, 3.) from the compulsive tendency to repeatedly find oneself in dangerous situations to give up, 4.) to helplessness and the loss of personal initiative with the result that the dependence on society and / or the family increases; also 5.) the lack of affect tolerance can lead to traumatized people turning away from complex and differentiated interpersonal relationships and throwing themselves into excessive work instead.

The lack of emotional involvement in concrete relationships makes life meaningless after the trauma and thus continues its central role in the life of those affected: They can sink into a state of generalized hopelessness or simply have difficulty distinguishing justified demands from unjustified ones. Unable to correctly assess their own role and the role of others in interpersonal conflicts, they often find themselves victimized again in many social contacts. Since they tend to experience later stressful situations primarily as body sensations rather than as well-defined problems that require specific solutions, they are often unable to act effectively. They fail to understand the cause of the intensity of their responses, which is disproportionate to the severity of current stressors, and are therefore unable to rationally consider what to do.

Only when the violent somatic reactions have been brought under control thanks to a secure relationship, through psychotropic drugs, meditation and / or hypnosis, will they gradually be able to structure their experience linguistically and differentiate between past memories and current stress. For many traumatized people, dealing with the trauma at the expense of other experiences remains a central part of their lives. This can take on the socially and psychologically useful form of assistance to other victims or "witness". Other trauma victims, on the other hand, are forced to reproduce the trauma in some way for themselves or for others. War veterans who are recruited as mercenaries, incest victims who become prostitutes, child victims of abuse who mutilate themselves as adolescents.

Implications for Treatment

Even after people have suffered terrible trauma, they somehow need to incorporate those blows into this as part of their lives. Traumatized people are torn between excessive preoccupation with the past and feeling emotionally numb to their present environment. The defense mechanisms initially created by the mental apparatus as protection in an emergency must gradually loosen their access to the psyche so that fragments of the experience do not trickle through again and again and threaten to retraumatize the victim. Trying to simply forget about the trauma is seldom a helpful psychological strategy for managing it in the long term. In general, we agree with Freud when he suggests that a person trying to avoid significant aspects of his life "is compelled to repeat what has been repressed as a present experience rather than as an experience Piece of the past to remember. " As has been shown, the ability to verbalize many details of what has been experienced after an acute trauma is very effective in preventing the development of PTSD. However, at a later stage, these people tend to feel numb and bored if they are not engaged in activities related to the trauma. In chronically traumatized people, it is essential to actively focus on the effect of trauma on current functions. Otherwise, psychotherapy can sometimes reinforce the excessive preoccupation with what has been experienced and the fixation on the trauma. The decisive factor in trauma lies in a loss of security and in a solidification of psychological and physiological reactions to danger. A primary task of interventions is therefore to make the patient's life safe and predictable. It is therefore particularly important that the helper supports the victim physically, socially and emotionally and helps and consciously avoids the spontaneous tendency to "blame the victim". Appropriate psychopharmacological support can drastically reduce autonomic overexcitability, emotional numbness and extremely intense recall. In the face of unspeakable tragedies, helper responses tend to be problematic. You can alleviate the impact of trauma on the victim; but you can also enlarge it and expose yourself to unnecessary risks. They can blame the victim or, conversely, degrade the victim by infantilizing or falsely romanticizing them.

After a trauma has completely confronted a person with his existential helplessness and vulnerability, life can never be exactly the same as before: the traumatic experience becomes part of a person's existence in any case. Understanding exactly what happened and sharing and comparing your reactions with those of other victims has proven immensely helpful: putting into words the feelings and events associated with the trauma is critical to treatment post-traumatic reactions. After the patient's vigorous efforts to stave off reliving the trauma, the therapist cannot wait for the resistances to remembering to melt under his sympathetic efforts. The trauma can only be worked through when a secure bond is established with another person; this can help hold the psyche together when the threat of physical disintegration is relived.

If the material associated with the trauma is not processed, this gradually leads to an intensification of the emotions and physical states associated with it, which in turn can lead to an increased somatic, visual or behavioral reliving. Once the traumatic experiences have been localized spatially and temporally, a person can begin to differentiate between current stressful situations and the past trauma and thus reduce the significance of the trauma for the current experience.

However, it is not enough just to talk about the trauma: trauma survivors need actions that symbolize triumph over helplessness and despair. The Yad Vashem Holocaust Memorial in Jerusalem and the Vietnam Memorial in Washington D.C. are good examples of symbols for victims who mourn the dead and give historical and cultural meaning to traumatic events. Above all, they can make the survivors aware of the help that common memory can be. The same goes for other survivors, although they may not be able to erect equally visible monuments and common symbols to gather around them, to mourn and to express their shame at their own defenselessness. This can take many forms, from writing a book, from political action, from helping other victims, or from any of the myriad creative solutions people can find to overcome even the most desperate tribulations.

literature

Herman, J.L .: Trauma and Recovery. New York: Basic Books 1992.

van der Kolk, B. A, McFarlane AC: Traumatic Stress: Human Adaptations to Overwhelming Experience. Guilford Press 1995.

van der Kolk BA: The Black Hole of Trauma: Memory, Trauma, and the Integration of Experience. New York, Guilford Press, 1996.

Table 1

Simple PTSD (DSM IV)

A.
1. Life-threatening experience followed by
2. intense subjective distress.

B. Reliving the trauma:
1. Recurring haunting memories or repetition in the game;
2. recurring nightmares;
3. Sudden behavior or sensation as if the traumatic event is repeating itself;
4. intense emotional distress caused by repeated confrontation with events that recall the trauma;
5. Physiological reactions when confronted again.

C. Persistent avoidance behavior or general responsiveness numbness:
1. strained avoidance of thoughts or feelings associated with the trauma;
2. strenuous avoidance of activities;
3. psychogenic amnesia;
4. Decreased interest in previously important activities;
5. feelings of detachment and alienation;
6. Feeling of a distorted future.

D. Persistent symptoms of increased excitability:
1. Difficulty falling asleep and / or staying asleep;
2. irritability or outbursts of anger;
3. Difficulty concentrating;
4. Over-vigilance;
5. Excessive jumpiness.

Table 2

Complicated PTSD

I. Impaired regulation of affects and impulses:
A. Affect regulation
B. Modulation of anger
C. Self-destruction
D. Thoughts of suicide
E. Difficulty modulating sexual activity
F. Excessive risk behavior

II. Disturbances in attention or impaired consciousness:
A. Amnesia
B. Transient dissociative episodes and depersonalization

III. Somatizations:
A. Indigestion
B. Chronic pain
C. cardiopulmonary symptoms
D. Conversion Symptoms
E. Disturbed sexuality

IV. Disorders of self-perception:
A. Helplessness
B. permanent damage
C. Guilt and Accountability
D. Shame
E. Feeling incomprehensible
F. Disparagement of oneself

V. Disturbed perception of the attacker:
A. Incorporation of twisted views
B. Idealization of the attacker
C. Excessive preoccupation with revenge fantasies

VI. Disturbed relationships with the environment:
A. Inability to trust
B. Become a victim again
C. Sacrifice others

VII. Disturbed motivation and orientation:
A. Despair and hopelessness
B. Loss of previous personality stabilizing beliefs