Archive for May 3rd, 2008

A close acquaintance of mine has had post-traumatic stress syndrome (PTSD) for the better part of a decade. Recently, this person referred to their condition to a relative, only to receive the reply, “Aren’t you over that yet?”

The response highlights one of the many misunderstandings of this condition. In fact, from its origins to its symptoms, treatment, and long term prospects, probably no other mental condition is so misunderstood. Nor is understanding encouraged by the fact that the words “trauma” and “stress” are bandied about by people to refer to normal reactions to daily events or merely mild upsets.

So what is PTSD? Contrary to popular perceptions, it is almost never the anxiety caused by financial or romantic concerns, or by grief. All these circumstances can be stressful, but do not result in PTSD unless other factors are at play as well.

Nor is PTSD simply a reaction to physical trauma, such as combat or rape. Many people go through both and do not develop PTSD, while some people develop it because of psychological sufferings, such as interactions with unsympathetic authorities or the suicide or random deaths of people around them.

Just as importantly, there is no way of predicting what will cause PTSD. What triggers the condition in one person may seem trivial to another, and some cases of PTSD are caused by a single episode while others are caused by a continuing sequence of events. Contrary to the way that “shell-shock” was once regarded, it is not a matter of cowardice, but of being overwhelmed and rendered powerless by events.

Similarly, while some studies suggest a genetic predisposition to PTSD, what matters is whether a person ever encounters circumstances that will cause the condition in them.

Another reason to downplay any genetic tendency is that the cause of PTSD seems primarily psychological. What all cases of PTSD seem to have in common is a loss of world-view – in particular, an individuals’ ability to control their own life.

Faced with a loss of meaning and control, those with PTSD develop what psychologists refer to as “hypervigilance” — a more or less continual condition of extreme alertness. This condition generally includes permanent physiological changes to the body, including an exaggerated startle response, and permanently higher pulse rates, and higher blood pressure. A PTSD sufferer is always far closer to fight or flight than the average person, or than what they were when they were healthy.

These physiological changes explain the images of PTSD in popular culture, in which the crazed war veteran goes berserk, or the badly stressed resort to alcoholism or drug addiction. And, in fact, sometimes those with PTSD do act in this way. However, more common symptoms are depression, loss of purpose and direction, nightmares, and a distancing from social contacts. Perhaps the most common symptom is a sense of existential angst (in fact, it may not be a coincidence that existentialist philosophy emerged out of France around the end of World War 2).

All of these symptoms may be reinforced by a person’s reluctance to disclose their problem for fear of appearing vulnerable – after all, to the hypervigilant, to appear weak means that they are risking attack.

Contrary to the response my friend received, PTSD is not something you “get over.” It makes permanent changes to the body, and probably the mind as well. It can flare up at any time, even after many years. In this respect, PTSD is similar to malaria – it is something that you learn to live with, but never move beyond.

Treatment of PTSD is two-fold. In the short term, those who suffer from it can minimize its effects by reducing the stress in their lives. Eating a balanced diet, staying physically fit, and getting rest all help. Even more importantly, those with PTSD need to develop a routine that minimizes the stress in their lives. They may need to find less stressful work, or have more flexible hours, or even work from home.

For example, the poet and novelist Robert Graves, who suffered shell-shock in World War I, eventually fled to the quiet of Majorca after over a decade of unsettled life in England. When people congratulated him on his apparent recovery, he explained that all he had done was to organize his life to deal with his problems.

In the longer term, the most successful coping mechanism seems to be to find a way to reaffirm the world view and values that PTSD have shattered. A classic example is the Canadian general Romeo D’Allaire, who suffered PTSD from what he perceived as his failure to do his duty as a soldier and stop the genocide in Ruanda while he commanded United Nation forces there. After a period of adjustment in which he was often drunk, D’Allaire managed to re-assert his ethics by becoming a strong advocate for peacekeeping by both Canada and the United Nations. He has also spoken frequently about PTSD and become something of an advocate for Canadian soldiers who suffer from his condition.

This sort of compensation can mean that, despite their condition, many people with PTSD can lead highly purposeful and accomplished lives. The catch is that they generally have to continue their accomplishments in order to reassert their world view against the trauma that has physically and mentally transformed them.

Finally, perhaps the most important point to make is that PTSD is not a mental illness in the sense that schizophrenia is. Instead, it is more accurate to compare it to an injury such as breaking a leg that permanently changes regular functioning. A person with PTSD is sane by any legal or common sense definition, but, like someone in whom an injury has left one leg shorter than the other, they have some troubles with ordinary functioning.

The next time you see someone with PTSD, try to keep these points in mind. And remember – the only reason that you haven’t suffered from the same condition may be that you have been lucky.

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