Over the decades that I have been practicing psychiatry, no diagnosis has been more difficult to pin down than post-traumatic stress disorder (PTSD). For some mental health professionals, making a diagnosis of PTSD has become an automatic reflex whenever someone has had a painful experience.
One of the reasons the diagnosis is confusing is that everyone defines “trauma” a little differently. That makes sense — we differ in how we experience the world and how we cope. A small challenge for one person could be a huge hurdle for another. There are some experiences, like the 9/11 tragedy or fighting in a war that seem universally traumatic. Yet even after a profound disaster, many people develop no symptoms at all. Or they develop symptoms, but the symptoms don’t fit the PTSD pattern.
The reverse is also true: Experiences not usually regarded as traumatic can be followed by characteristic symptoms of post-traumatic stress disorder.
In a study published in the British Journal of Psychiatryin 2005, more than 800 patients from a family practice answered a questionnaire comparing symptoms that follow a traumatic event — one outside the range of normal human experience — with symptoms following more common “life events” such as illness or problems in work and personal relationships.
Subjects were asked whether they had ever experienced a traumatic event — a serious accident, witnessing violence, the sudden and unexpected death of someone they loved, physical or sexual abuse, a war, or natural disaster. They were also asked whether they had ever experienced such life events as a burglary, marital conflict, study or work problems, chronic illness, or the death of a loved one that was not sudden or unexpected. Finally, they were asked about the worst event they had ever experienced and when it occurred.
Then they checked off a list of statements representing the three basic types of post-traumatic stress symptoms: reexperiencing the trauma, avoidance and emotional numbing, and excessive anxiety or arousal. They stated whether they had experienced these symptoms never, occasionally, or continuously during the previous month.
About 60% of the subjects described a non-traumatic event as the worst in their lives. Surprisingly, life events were as likely as traumatic events to cause symptoms typical of post-traumatic stress disorder. In fact, people whose worst event was not traumatic had more post-traumatic stress symptoms for a longer time than those whose worst event was traumatic. The difference was modest but statistically unmistakable.
The authors suggest that life events may increase overall psychological stress and distress, bringing on symptoms related to an earlier trauma. Traumatic events may reduce the ability to cope with other kinds of stress. Both traumatic experiences and overall distress may increase the risk of developing post-traumatic symptoms after either a traumatic experience or a non-traumatic life event.
This research also shows that there is not a direct correlation between types of stress and the reactions people have. About all we can say for certain is that there is a complicated interaction between stress and a range of individual factors: temperament, coping style, and a person’s support system, to name just a few.
How have these factors influenced your experiences during tough times? What kind of connection do you see between stressful experiences and PTSD symptoms?
Dr. Michael Millerhas been on staff of the Beth Israel Deaconess Medical Center, a large teaching hospital in Boston, for more than 25 years. He is also an Assistant Professor of Psychiatry at Harvard Medical School.
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Comments: 7
Absolutely -- I have seen the pattern you describe a lot too – developing symptoms immediately after a traumatic incident.
One of the questions that gets debated is, when do we call it PTSD and when do we see the symptoms as a difficult but natural, human reaction? Are those initial symptoms more like a bruise or cut that appears after an injury, but then diminishes or heals?
In other words, we're wired to react like this, for example: intense memories (often in the form of flashbacks or nightmares); avoiding reminders of the trauma; being easily startled; or feeling numbed by the events.
Then, those symptoms, which are quite intense in the first few weeks or months, tend to become less forceful and less frequent.
I am not diminishing the importance of these symptoms — the symptoms are painful. But what we're learning is, the intensity of the symptoms and how long they last is not always parallel to the intensity of the trauma. That's an interesting bit of science to pay attention to.
So some of the questions I ask in a given situation are, How has it played out over time? How well is a person functioning in the aftermath? Is there something the person can do to feel more resilient, manage the symptoms, or get on with life?
And those questions often take months or years to answer.