AN “AFTERMATH” of VIOLENCE can include terms like: POST-TRAUMATIC STRESS (PTS), POST-TRAUMATIC STRESS DISORDER (PTSD), POST-TRAUMATIC STRESS INJURY (PTSI).
(DISCLAIMER: I am presenting my understanding of this topic to the reader, to provide information for educational purposes. I am not able to diagnose, recommend specific interventions, or treat your individual symptoms because your reading of this material, DOES NOT establish a professional relationship between us. You are, however, free to explore any of this information on your own, to share it with others, and to comment and ask questions of me, as you like. If the reader requires any individual assistance with their personal matters or their symptoms, please seek the guidance of a properly trained and licensed mental health and/or medical professional, and/or contact 911 or go directly to your nearest emergency room if you have any serious, acute or life threatening concerns.)
First of all, recovery from trauma varies from survivor to survivor. Symptoms might fade over time and/or not significantly impact daily living. Unfortunately, other times symptoms can emerge even after a traumatic event has passed, or distress can be more severe and persist for years, cause great hardship, and push those who suffer to deep despair.
The goals of this and any future posts on this topic, are to provide information about 1. PTS, PTSD, and PTSI, 2.Common Road Blocks to Recovery, 3. Recovery Considerations, and 4. the Role of Comprehensive Personal Safety and Self-Defense Training.
About the author Dr. “Jerry”
- Self-Defense Company Elite Member.
- Survivor of a violent abduction as a teen.
- Martial art and self-defense background/ Green belt in Judo, Purple belt in Hapkido, other formal martial art instruction.
- Education/ Doctoral degree with licensure in the Behavioral Sciences.
- Dissertation Research/ Historical Conceptualizations of Trauma, Treatment Modalities, and a Controlled Study to Evaluate the Efficacy of an Experimental Trauma Treatment.
- Experience/ 20 years of clinical experience at the doctoral level, 10 years prior at the master’s level. My experience includes mental health, substance abuse, and trauma treatment for civilian, law enforcement, and military populations. I completed supervised training at the Louisville VA, and was later employed in the VA system. I have also worked in community and private clinics, including private practice. At the end of my career, I retired out of the U.S. Army as a civilian Behavioral Health provider, where I had been credentialed in Behavioral medicine and Cognitive-behavioral treatments. Here I was responsible for varied evaluations, e.g. fitness for duty, clearing soldiers for specialty school assignments, medical board referrals, command directed evaluations, pre and post-deployment screenings, diagnostic assessments, and therapeutic interventions with active duty soldiers. PTS, PTSD, grief/loss, traumatic brain injury (TBI), and family challenges were common issues among our combat veterans.
- Qualified as expert witness on PTSD in the U.S. Army Military Justice System.
- Recipient of the “Hero of the Transition” Award for Exemplary Care of Warriors in Transition who were assigned to the WTB.
What are PTS, PTSD, and PTSI?
(Post Traumatic Stress, Post Traumatic Stress Disorder, Post Traumatic Stress Injury)
First of all, many non-traumatized individuals function satisfactorily in their daily lives. They go about their normal routines with a relative sense of safety and well-being. They may not think much about a violent event ever happening to them. On the other hand, police, security, and military personnel in particular, are trained to address violence and often better able to cope with it.
Still, when the unexpected happens, often suddenly, violently, ruthlessly, sometimes without any anticipation or understanding, even trained individuals can panic! Such persons can be thrust into an instant state of overwhelming terror, mental confusion, and profound helplessness. Maybe their worst fears have become reality. There may no escape, no one to protect them, nothing to save them or their friends from imminent harm, horrible injury, excruciating pain, and/or brutal death.
Witnessing horrific harm to others, or even just hearing the awful details of such events, can also be severely traumatic for some. For those who survive these trials, their life will often be changed forever. These are the precursors to PTSI, PTS, and/or PTSD.
Earlier historical terms for trauma reactions were mainly military related, including “shell shock, nostalgia, soldier’s or irritable heart, traumatic neurosis, combat stress during WW I”, and other labels, sometimes very negative like “weakness, cowardice, disorder of will, illness gain, compensation neurosis, etc.” It was not until 1980 when the first diagnosis of PTSD appeared (5 years after the end of the Vietnam War) in the DSM-III, a diagnostic manual by the American Psychiatric Association.
This diagnosis of PTSD has since been updated and revised over time to better describe updated comprehension of the clinical features. Regardless of the terms and labels, these individuals suffer “extreme fear reactions from exposure to severe and often life threatening events”. These “extreme fear reactions” are natural involuntary responses of our biological nervous system.
On one hand, FEAR often has an adaptive function to energize us to “fight or flight”, to adapt, to over-come, and to survive. But if too extreme, FEAR can overwhelm and immobilize us, shut down any rational thought and life-enhancing actions. In such cases, the result can be involuntary “freeze”, complete incapacitation, with inability to help or protect oneself or others. Afterward, intense shame, self-condemnation, and feelings of worthlessness are common.
PTS typically consists of some of the symptoms inherent in PTSD. They can be distressing, but do not constitute a complete PTSD disorder as required in Criterion F, G, and H from the DSM 5 (a diagnostic manual for mental health disorders from the American Psychiatric Association). The DSM specifies the Criteria for a full diagnosis of PTSD. PTS symptoms are “to be expected” for anyone who has had direct violent encounters, and for some who have directly witnessed a violent incident happening to others, and/or heard about specific details of a violent event, especially to someone they know. PTS symptoms can vary in intensity, last for different lengths of time, be triggered by reminders of what occurred, but commonly become less frequent and/or problematic over time. Again, PTS by itself, does not typically cause severe distress that impairs functioning. In such cases, first responders, soldiers, law enforcement, security personnel, or civilians often continue with their careers and typical routines.
The DSM 5 diagnostic criteria for PTSD (D for Disorder) are as follows:
Criterion A (one required): The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, in the following way(s):
- Direct exposure
- Witnessing the trauma
- Learning that a relative or close friend was exposed to a trauma
- Indirect exposure to aversive details of the trauma, usually in the course of professional duties (e.g., first responders, medics)
Criterion B (one required): The traumatic event is persistently re-experienced, in the following way(s):
- Unwanted upsetting memories
- Emotional distress after exposure to traumatic reminders
- Physical reactivity after exposure to traumatic reminders
Criterion C (one required): Avoidance of trauma-related stimuli after the trauma, in the following way(s):
- Trauma-related thoughts or feelings
- Trauma-related reminders
Criterion D (two required): Negative thoughts or feelings that began or worsened after the trauma, in the following way(s):
- Inability to recall key features of the trauma
- Overly negative thoughts and assumptions about oneself or the world
- Exaggerated blame of self or others for causing the trauma
- Negative affect
- Decreased interest in activities
- Feeling isolated
- Difficulty experiencing positive affect
Criterion E (two required): Trauma-related arousal and reactivity that began or worsened after the trauma, in the following way(s):
- Irritability or aggression
- Risky or destructive behavior
- Heightened startle reaction
- Difficulty concentrating
- Difficulty sleeping
Criterion F (required): Symptoms last for more than 1 month.
Criterion G (required): Symptoms create distress or functional impairment (e.g., social, occupational).
Criterion H (required): Symptoms are not due to medication, substance use, or other illness.
- Dissociative Specification. In addition to meeting criteria for diagnosis, an individual experiences high levels of either of the following in reaction to trauma-related stimuli:
- Depersonalization. Experience of being an outside observer of or detached from oneself (e.g., feeling as if “this is not happening to me” or one were in a dream).
- Derealization. Experience of unreality, distance, or distortion (e.g., “things are not real”).
- Delayed Specification. Full diagnostic criteria are not met until at least six months after the trauma(s), although onset of symptoms may occur immediately.
Note: DSM-5 introduced a preschool subtype of PTSD for children ages six years and younger.
In recent years, there has been professional discussions to modify the term PTSD to PTSI (Post-Traumatic Stress Injury). This is considered to be less stigmatizing by more accurately describing this condition as biologically based.
Especially chronic PTSD involves “chronic stress” reactions that generate problematic levels of stress chemicals, like cortisol, which are involved in the hypothalamic–pituitary–adrenal axis. This stress response in particular, involves a chain reaction between the amygdala, hypothalamus, and the prefrontal cortex that reverberates throughout the body. Excess cortisol can result in increased brain inflammation, re-wiring and aberration of neuronal pathways, with adverse modifications in normal brain cell production and function, with changes in the size of brain structures. Shrinkage has been found in the prefrontal cortex and hippocampus, with an increased size of the amygdala (making it more reactive with production of intense survival reactions). Dr. Dumas, a neuroscientist, also reported decreased thalamus size in response to excessive and/or chronic stress. Excessive cortisol can decrease the number of stem cells that would normally develop into brain neurons and damage, and even kill brain cells. Consequently, chronic stress can interfere and impair brain regions involved with attention, concentration, working and long-term memory functions, with negative impact on learning.
Chronic stress can also decrease immune system function and interfere with cell-mediated and antibody-mediated immunity responses, e.g. reduction in the body’s white blood cells, lymphocytes, phagocytes, B cells (that surround body cells to eliminate invaders) and T cells (that destroy invaders if they get inside a cell). Compromised immune function will limit our body’s capacity to protect against infection, viruses, bacteria, and other antigens. The immune system’s reaction to chronic stress, can also result in inflammation and visceral fat accumulation. Inflammation, now known as a “silent epidemic” underlies the development of numerous ill-health conditions, i.e. neurological, pulmonary, autoimmune, arthritis, diabetes, cardiovascular, and more. These conditions can have negative behavioral consequences to those who suffer from them. As a result, these persons may lack proper nutrition, sleep, stress management, etc. that can again compromise return to normal immune function.
Chronic stress can also significantly alter normal body physiology that increases risk of cardiovascular disease. Stress hormones, like Adrenalin and Cortisol speed up breathing and heart rate, narrow blood vessels and increase blood viscosity that increase blood pressure. These factors can alter normal heart rhythms, exacerbate inflammation and blood cholesterol/plaque buildups in arteries which can block blood vessels and cause heart or other body damage. As noted, chronic stress can lead to poor coping and problematic self-care behaviors which complicate and promote cardiovascular difficulties, e.g. smoking, excessive alcohol consumption, over-eating and weight gain, etc.
Ongoing stress also causes changes in normal chemistry and physiology, that underlie mood regulation and daily function. There can be disturbances in eating and sleep patterns, libido, energy levels, and concentration and memory as already noted. Such individuals can show marked irritability, elevated, blunted, and/or labile affect, and potential suicidal impulses and/or psychotic features. Behavioral changes and mood symptoms can vary among individuals, but are rooted in this underlying neurobiology. Normal brain neurotransmitter levels (especially epinephrine, norepinephrine, and serotonin) can be altered. Chronic stress can also impair the brain and mood by via inflammation which is a known factor in the development of neurological disease. Additional stressors, especially if severe and chronic, like financial hardships, relationship conflicts, medical problems, chronic pain, etc. can all potentially increase likelihood of mood disturbance.
Chronic stress affects interacting biological systems throughout the body and brain. This can involve high activation of the sympathetic nervous system (SNS) which can directly interfere with sleep and known to increase pain sensations. These pain reactions can generate more stress, and also interfere with sleep, a major stressor by itself. Autonomic arousal also predisposes people to over-eating of poor food choices, and so has been linked to weight gain and obesity which can often be factors in sleep apnea. This again exacerbates stress and inflammation.
Ongoing stress can fatigue the adrenals and may also play a role in sleep problems and migraine headache pain. Chronic inflammation can also spur plaque formations in different body regions, including the brain. Alzheimer’s disease is an example of plaque concentrations in the brain that disrupt normal neuronal function. Chronic stress is also related to shorter telomere length in white blood cells which has been predictive of cognitive decline and is linked to musculoskeletal pain and deep sleep disturbance of Fibromyalgia.
Consequently, the Canadian Public Safety departments now use the term PSTI when applicable to their safety officers who have been suffered ill-effects from traumatic events while serving and protecting the public. These officers are then able to get assistance through Stress Injury Clinics.
–The DSM-IV-TR, was the predecessor to the DSM 5. This former diagnostic manual indicated slightly higher rates for PTSD due to diagnostic changes in the DSM-5, but both found that gender rates were higher among women than men, which increased with multiple traumatic event exposures per the U.S. Dept. of Veteran Affairs/ National Center for PTSD.
The DSM-IV further indicated rates of 8% of a life prevalence of PTSD in the adult population of the U.S. Variable rates of PTSD were found in particular groups (from different types of occupations and backgrounds like fire fighters, law enforcement, etc.) who experienced specific traumatic events, while rates as high as 33% to greater than 50% were found with rape survivors, and with those with political and ethnic internments and genocide experiences, including military combat and captivity. (While there has been a slight rate reduction in diagnosable PTSD by use of the DSM 5 criteria, there are still a large number of persons “at risk”, with particular groups at higher risk.)
So numerous individuals have suffered violent trauma and became overwhelmed, bewildered, confused, and debilitated by the complexity and severity of symptoms they experience. Many civilians know the profound heartache and hopelessness of ongoing PTSD symptoms, either in themselves or among trusted friends or family members. Likewise, many of our military, combat veterans, police officers, other security personnel and their families have endured great heartache related to PTSD. There are those who suffered serious physical harm, traumatic brain injuries (TBI), wounds, burns, body deformities, severe scarring, blindness, limb amputations, chronic pain, medication reliance with limited efficacy, and substance abuse to try to relieve symptoms. It is often very difficult to adapt to mental and/or physical limitations, fears of social rejection and heartless ridicule by unsympathetic observers. Many feel anger at the short-comings and failures of health care systems designed to help. In addition, to all of these challenges, there can be increased risks of multiple disabilities, medical complexities, depression, social isolation, hopelessness, and sadly, suicide by too many. The U.S. Dept. of Veteran Affairs/ National Center for PTSD found the following statistics for those who served during the Iraq and Afghanistan wars between 2001–2007:
- Deployed Veterans had a 41% higher suicide risk compared to the general U.S. population.
- Non-deployed Veterans had a 61% higher suicide risk compared to the general U.S. population.
While I was surprised by the “deployed vs. non-deployed” difference found in this particular study, it is clear that military service comes with a great cost to many.
In conclusion of this introduction, I know well, that trauma takes a tragic toll on many. But I want to announce some GOOD NEWS: that RECOVERY is NOW MORE POSSIBLE than ever. There have been important developments in evidence-based treatments (methods and skills supported and validated by science) that are waiting for you. So I want to encourage all who suffer from these symptoms to NOT give up hope.
Yes, there is HOPE!
How do I know? I have seen many who have struggled for years, some for decades, and finally make important therapeutic progress by getting the right help. I have also personally assisted many to recover over the years “when they did their part”. Yes, you will have to do your part. Recovery requires ACTION, the RIGHT KIND of ACTION. A dear friend of mine, who returned with a severe wound and Purple Heart from Vietnam, also returned with severe, chronic, and debilitating PTSD and suffered for 4 decades because he did not trust the VA system, but has now rebuilt a new life worth living. I know he has regained the sparkle in his eyes, his sense of humor, found new love and family, and renewed his positive engagement in life. It’s been a beautiful thing to see. I have also benefited from therapy interventions, as well as martial art and self-defense training and the camaraderie and support of like minded individuals in these special circles. I am honored to be a student of Damian Ross and to hold membership in the Self Defense Company.
Finally, I like to believe “if others can do something, then so can I, and so can you.” Will you join me for my next post?
All Respect, Jerry
Please post your comments and questions below and Jerry will be more than happy to respond.