Recently, I had the profound fortune of attending a lecture with Dr. Bessel van der Kolk on trauma, during which he compared the impact of 9/11 to Hurricane Katrina. Dr. van der Kolk is one of the world’s leading research experts in the field of PTSD. He is particularly known for his work with the consequences of trauma and stress – both from a neurological standpoint and a psychological one – and has written numerous books on this topic.

Dr. van der Kolk was showing us a photograph of people on the Brooklyn Bridge on that fateful day in 2001. The burning twin towers were in the backgrounds, and all of these people were running away from them, toward their homes in Brooklyn. He pointed out that naturally, they were running in the direction of the places they perceived as safe: their own neighborhoods, where they had family, friends, and community to comfort them. We all remember 9/11 vividly. Three-quarters of Americans donated to the 9/11relief effort. Our country rallied together to support those affected by this horrible tragedy. As the media described, community and municipal departments acted quickly to provide healing resources to 9/11 survivors post-event.

In 2003 – two years after 9/11 happened – New York Magazine reported that “probably half the city’s firefighters have gone into therapy-6,100 uniformed people have received counseling through the department. The department now has 60 full-time counselors instead of the 9 it employed before September 11.” Victims of Katrina, in contrast, tended to be low-income and minority civilians without access to supportive counseling and other such resources as they tried to psychologically cope with the epic disaster they had witnessed. Governmental and FEMA resources were focused on crowd control, housing, and tangible issues.

Dr. van der Kolk talked about how, as a result of Hurricane Katrina, victims were forced to flee their homes, some of them permanently. Refugees from New Orleans numbered in the thousands. Many were displaced to other cities and even states as everything they perceived as familiar was eaten alive by the hurricane and its aftermath. And this was only if they could get out. During Katrina, those who did not or could not escape fast enough were trapped in a drowning city, without the ability to run for refuge. Their fight/flight/freeze responses were presumably on high alert for a prolonged period of time. Emergency airlifts strapped down many trapped New Orleans residents and carried them out of the city, stacking them like cordwood to fly them to safety in new and unfamiliar places. In many cases, victims never saw their homes and communities again. Additionally, while those who experienced 9/11 in New York were painted as national heroes in the press, the victims of Hurricane Katrina were labeled as just that: victims. (Of course, one has to consider the fact that one situation was a terrorist attack, the other, a natural disaster.)

Not everyone who experiences trauma will go on to suffer from PTSD. There are many factors that determine whether a trauma victim will develop PTSD, including their level of coping skills, resiliency, exposure, and the severity of any prior trauma. However, what has not been much talked about is the importance of community support in an individual’s mental recovery from a natural disaster or terrorist event. Access to external resources, the support of others -both moral and logistical – and the media portrayal of a situation are all components on the road to healing. We rely not just on our loved ones and our immediate family, but our entire community and culture, when recovering from a major traumatic social event. The likelihood of a survivor experiencing PTSD as a result of a trigger event depends not just on the event itself, but on the ensuing circumstances and the cultural reaction to the event.

I recently attended a 9/11 memorial ceremony here in California. As an imported 65-pound piece of the Twin Towers was put in place in front of our own fire department, the message “We are standing here as a unit” was the predominant theme. Survivors were remembered, and their pain was acknowledged, sending the message to all of the victims that they were are are not alone. I thought of the endless stories of my own clients who only wanted — despite their personal trauma — to have their emotional pain acknowledged. What if our community acknowledged and felt that it was a part of the solution? What if we had more such ceremonies and gave the message “you are not alone”?
Citations:

http://en.wikipedia.org/wiki/Bessel_van_der_Kolk

http://nymag.com/nymetro/news/sept11/2003/n_9189/index1.html

“Why are some people afraid to succeed but not to fail? Why are some more afraid of failure? How can one learn to embrace these two fears? What is the difference between them?”

A young Canadian woman wrote to me recently with these inquiries. I thought they were excellent questions, and decided to share my thoughts and findings here.

We are all so complex, and the way we react to situations and anticipate results is based on many physiological and psychological factors. So many, in fact, that it can be difficult to generalize why different personality types might handle success versus failure in such drastically polarized ways.

As a psychologist specializing in trauma and PTSD (Post Traumatic Stress Disorder) I’ve had firsthand experience coaching clients whose past experience feeds their current fear of success. For them, the excitement of success feels uncomfortably close to the feeling of arousal they experienced when subjected to a traumatic event or multiple events. (This feeling of arousal can be linked to sexuality, in certain cases where trauma has been experienced in that realm, but that is not always the case.) People who have experienced trauma may associate the excitement of success with the same physiological reactions as trauma. They avoid subjecting themselves to excitement-inducing circumstances, which causes them to be almost phobic about success.

There is another layer to the fear of success. Many of us have been conditioned to believe that the road to success involves risks such as “getting one’s hopes up” — which threatens to lead to disappointment. And many of us—especially if we’ve been subject to verbal abuse—have been told we were losers our whole lives, in one way or another. We have internalized that feedback and feel that we don’t deserve success. Even those of us who were not abused or otherwise traumatized often associate success with uncomfortable things such as competition and its evil twin, envy.

In order to have a healthy relationship with success (and it’s flip side, failure, or disappointment), the first step is to learn to differentiate between feelings of excitement and a “trauma reaction.” Here is an easy exercise:

1.    Recall an event where you were successful or excited when you were younger, and notice what you are feeling and sensing in your memory. Stay with the sensation of for 5 minutes.

2.    Recall an event where you were successful and excited recently in your life, and notice what you are feeling and sensing. Stay with this sensation of for 5 minutes.

3.    Now tap into the sensation of a memory of an overwhelming situation. I suggest not to start with a truly traumatic event, at least not without a therapist’s support. Start with something only moderately disturbing to you.

4.    Now, go back to visualizing your success story. Do you notice a difference?

While corresponding with the young Canadian woman, I asked her to do look up bodily response to fear and excitement and let me know what she found. This is what she wrote back:
“I was looking up how the body responds to fear, and it said that when we sense fear the brain transmits signals and our nervous system kicks, in causing our breathing to quicken, our heart race to increase… we become sweaty, and we run on instinct. When we get excited or enthusiastic, doesn’t our nervous system work the same way?”

I assured her that, yes, the physical reactions to stress and to excitement are very similar. So, when we experience a traumatic event—such as a car accident or a school bullying incident— our body associates the fear we experience with the same physiological feelings we get while excited. Once we have been through enough trauma, we start to avoid those types of situations that trigger memories of fear. For this reason, trauma victims can tend to avoid excitement, and that can lead them to avoid success.

I work with trauma victims to get past their fears and associations and help them embrace and follow the path to success and healthy recovery.

Postpartum PTSD is very different from Postpartum Depression. The former occurs as a result of trauma (or perceived trauma) during delivery, while the latter happens because of hormonal changes in a woman’s body as a natural result of giving birth. Nevertheless, these two conditions are linked together in some cases, and can certainly exacerbate one another. It’s important to distinguish between the two so that you can seek the most effective means of treatment.

Postpartum PTSD happens most often when mothers give premature birth to infants who begin their lives in critical condition. According to a new study from the Stanford University School of Medicine **, “… over half the parents whose babies were in the NICU for an extended period of time either had Post Traumatic Stress Disorder (PTSD), or were at high risk for developing it.”

Along with parenting premature babies who must endure Neonatal Intensive Care, PSI* also lists the following types of childbirth trauma that could potentially lead to PTSD:

·     Prolapsed cord
·     Unplanned C-section
·     Use of vacuum extractor or forceps to deliver the baby

Feelings of powerlessness, poor communication and/or lack of support and reassurance during the delivery can also contribute to Postpartum PTSD.
In 1993 The Journal of Obstetric, Gynecologic, & Neonatal Nursing printed the results of a study conducted to conclude how mothers of premature infants were affected by PTSD.***  Out of thirty mothers who had given birth to premature at-risk infants, sixteen of them showed symptoms of PTSD and a whopping 24 reported “re-experiencing” and “avoidance” characteristics. These reactions were still happening six months after the expected birth date.

The trick is to distinguish PTSD symptoms from those of postpartum depression and regular healthy recovery from childbirth. PTSD symptoms are generally grouped into three categories: re-experiencing, avoidance, and increased arousal.

Here are some of the signals to look out for:
·     Intrusive re-experiencing of a past traumatic event (which in this case may have been the childbirth itself)
·     Flashbacks or nightmares about the childbirth experience
·     Avoidance of stimuli that remind the mother of the childbirth experience—including thoughts, feelings, people, places and details of the event
·     Persistent increased arousal (irritability, difficulty sleeping, hypervigilance, exaggerated startle response)
·     Anxiety and panic attacks
·     Feeling a sense of unreality and detachment

The good news is that Postpartum PTSD is treatable and temporary. The key is to get competent professional help as early as you can.  It’s important to treat PTSD before it begins to manifest as something harder to treat—such as an eating disorder, addiction, compulsive behavior, chronic panic disorder, or suicidal tendencies. If in doubt, contact your health care provider for advice right away.

More information:
Solaceformothers.org does a nice job of differentiating between “normal” biological postpartum depression and birth-related PTSD, and provides more detailed information, a breakdown of PTSD symptoms, and a helpline for those in need: http://www.solaceformothers.org/PTSD_info.html

SOURCES:
* http://www.postpartum.net/Get-the-Facts/Postpartum-Post-Traumatic-Stress-Disorder.aspx
** http://ksmu.org/content/view/6578/66/
*** http://onlinelibrary.wiley.com/doi/10.1177/0884217503252035/abstract

Victims of a mugging incident may experience any of the classic symptoms of PTSD:

• Reoccurring, terrifying flashbacks or nightmares
• Avoidance of situations that remind one of the incident
• Irritability or anger
• Emotional numbness
• Trouble concentrating
• Withdrawal from friends and family
• Physical anxiety symptoms
• Problems eating or sleeping

Victims express their distress in varying ways, and it’s not always obvious that someone is struggling with the aftereffects of experiencing trauma.

According to the National Institutes of Health*:

PTSD symptoms seem to be worse if they were triggered deliberately by another person, as in a mugging or rape. Most PTSD sufferers repeatedly relive the trauma in their thoughts during the day and in nightmares when they sleep. These are called flashbacks. Flashbacks may consist of images, sounds, smells, or feelings. They are often triggered by ordinary occurrences, such as a door slamming, a car backfiring, or being in a place that looks like where the trauma took place. A person having a flashback is likely to feel the emotions and physical feelings that occurred when the incident happened despite no longer being in danger.

There is a scientific, physical reason why trauma impacts us so strongly, and it can be traced to the amygdala—a very small nugget of our brain lodged deep inside the temporal lobe, it processes memory and emotion. Unlike conscious memories that we are aware of—for instance, a victim returning to the scene of a mugging would recognize the environment and perhaps remember details about what happened—the amygdala is in charge of deeper, unconscious emotion that can develop into PTSD. The amygdala is also responsible for the Fight/Flight/Freeze response. **

When we experience an “emotionally arousing event” such as a mugging, the amygdala is activated and it then produces a protein in the neurons of the hippocampus. This protein helps the nervous symptom to convert immediate memories into permanent ones.  ***

Because of the unique way the brain processes traumatic memories, they can actually become more vivid and intrusive over time, rather than fading away like most memories do naturally. Any memory associated with a life-threatening event has this capacity to grow and transform into PTSD.

According to NYU’s Le Doux Laboratory (Center for Neural Science):

Neuroanatomists have shown that the pathways that connect the emotional processing system of fear, the amygdala, with the thinking brain, the neocortex, are not symmetrical—the connections from the cortex to the amygdala are considerably weaker than those from the amygdala to the cortex. This may explain why, once an emotion is aroused, it is so hard for us to turn it off at will.

This is not to say that PTSD and anxiety disorders cannot be solved. Somatic Psychology has been particularly effective in treating the symptoms (and the root neurological cause) of PTSD. Recovering from the trauma of a sudden violent attack like a mugging requires a re-wiring of the brain’s fear response associated with memories of the event. With patience, we work with a victim to heal themselves.

* Citation: NIH Medline Plus Magazine http://www.nlm.nih.gov/medlineplus/magazine/issues/winter09/articles/winter09pg10-14.html

** Citation: NYU’s Le Doux Laboratory (Center for Neural Science)

** Citation: Medical News Today http://www.medicalnewstoday.com/articles/28124.php

Sexual abuse is a particularly sinister type of trauma because of the shame it instills in the victim. With childhood sexual abuse, victims are often too young to know how to express what is happening and seek out help. When not properly treated, this can result in a lifetime of PTSD, depression and anxiety.

The trauma that results from sexual abuse is a syndrome that affects not just the victim and their family, but all of our society. Because sexual abuse, molestation and rape are such shame-filled concepts, our culture tends to suppress information about them.

In the U.S (according to childtrauma.org), one out of three females and one out of five males have been victims of sexual abuse before the age of 18 years. And according to the American Academy of Experts in Traumatic Stress (AAETS), 30% of all male children are molested in some way, compared to 40% of females.

One of the most startling statistics unearthed during research into sexual abuse are that children are three times as likely to be victims of rape than adults. Stranger abuse constitutes by far the minority of cases. It is more likely for a child to experience sexual abuse at the hands of a family member or another supposedly trustworthy adult.

Sexual abuse is a truly democratic issue. It affects children and adults across ethnic, socioeconomic, educational, religious, and regional lines.

Exactly what constitutes “sexual abuse” when it comes to children?

The Incest Survivors Resource Network states that “the erotic use of a child, whether physically or emotionally, is sexual exploitation in the fullest meaning of the term, even if no bodily contact is ever made.” It’s important to notice this clause about “no sexual contact.” Often, victims of sexual abuse will try to downplay their experience by saying that it “wasn’t that bad.” It’s vital to recognize that abuse comes in many shapes, colors and sizes, and that all abuse is bad.

Outcomes of sexual abuse

The most common effect of sexual abuse is Post Traumatic Stress Disorder. Symptoms can extend far into adulthood and can include withdrawn behavior, reenactment of the traumatic event, avoidance of circumstances that remind one of the event, and physiological hyper-reactivity.

Another legacy of sexual abuse is that children abused at any early age often become hyper-sexualized or sexually reactive. Issues with promiscuity and poor self-esteem are unfortunately common reactions to early sexual abuse.

Substance abuse is a common outcome of sexual abuse. In fact, according to the AAETS, “specialists in the addiction field (alcohol, drugs, and eating disorders) estimate that up to 90 percent of their patients have a known history of some form of abuse.”

Specific symptoms of sexual abuse:
(citation, the American Academy of Experts in Traumatic Stress)

• Withdrawal and mistrust of adults
• Suicidality
• Difficulty relating to others except in sexual or seductive ways
• Unusual interest in or avoidance of all things sexual or physical
• Sleep problems, nightmares, fears of going to bed
• Frequent accidents or self-injurious behaviors
• Refusal to go to school, or to the doctor, or home
• Secretiveness or unusual aggressiveness
• Sexual components to drawings and games
• Neurotic reactions (obsessions, compulsiveness, phobias)
• Habit disorders (biting, rocking)
• Unusual sexual knowledge or behavior
• Prostitution
• Forcing sexual acts on other children
• Extreme fear of being touched
• Unwillingness to submit to physical examination

Studies have shown that children who experience sexual abuse tend to recover quicker and with better results if they have a supportive, caring adult (ideally a parent) consistently in their life.

Because most child sexual abusers were once abused themselves, it’s crucial for victims of sexual abuse to seek counseling and care so that they don’t end up repeating the pattern themselves.

http://ptsd.about.com/od/glossary/g/hypervigilance.htm

Trauma has occurred when symptoms have developed and have become visible. One type of trauma results from natural disasters such as earthquakes, tornados or hurricanes, forest fires, floods, volcanic eruptions, landslides, or tsunamis. These types of experiences are particularly insidious because they tend to traumatize large populations of people at once, and can result in epidemics of Survivor Guilt along with other PTSD symptoms.

Like many causes of trauma, natural disasters can be sudden and overwhelming. The most immediate and typical reaction to a calamity is shock, which at first manifests as numbness or denial. Quickly—or eventually—shock can give way to an overemotional state that often includes high levels of anxiety, guilt or depression.

If victims have lost their loved ones or their homes, they may feel helpless. This can be exacerbated if they have to live in shelters without support from relatives or friends for extended time periods. However, living with other survivors can be a time to reconnect, talk about the event with others, and help to reframe the event. Being able to help another survivor can reduce helplessness, and may start the healing process.

Natural disasters in particular can bring victims a feeling of being betrayed by “their god,” which can result in a loss of faith.  Making peace with “the divine” might be one step toward healing and gaining faith back.

It’s hard to predict when PTSD will set in with a survivor of a traumatic natural disaster. Some victims seem at first perfectly (or even abnormally) fine, only to be beset with symptoms later on.  Survivors are recommended to seek professional guidance if they find themselves unable to regain control of their lives or if they continue to suffer from PTSD symptoms for more than a month.

Victims do not need to have experienced a disaster firsthand in order to suffer from PTSD. As an example, an emigrant from Haiti living abroad at the time of the recent earthquake could be profoundly affected by the countless hours of television coverage of the disaster, especially if they still had family living in Haiti at the time of the event who they were unable to contact or gain information about.

It’s very important with natural disaster trauma that the victim give himself time to heal and pass through an appropriate mourning process. Only by processing the experience over a realistic period of time is healing possible.

Over the next few months, I’ll touch upon the most common types of trauma and the ones I see most frequently in my practice. You can also read a longer version of this article on Examiner, Psychology Today, and Womens Radio (published 3/3/10).

One unfortunate side effect of a calamity such as the recent earthquake in Haiti is a phenomenon known as Survivor Guilt. Obviously, Survivor Guilt affects those who are fortunate enough to survive a traumatic event such as a natural disaster.

The phenomenon of Survivor Guilt is especially insidious because those who are afflicted with it are under the impression that they have done something wrong, and that their own survival is somehow responsible for the death, injury or trauma of others.

Interestingly, The DSM-IV (The Diagnostic and Statistic Manual of Mental Disorders—the professionals’ guide to mental illness and diagnosis) lists Survivor Guilt as a symptom of Post Traumatic Stress Disorder, and not as a malady in its own right. Like other symptoms of PTSD, Survivor’s Guilt is a distorted reaction to a traumatizing experience.

What Survivor Guilt Looks Like

Survivor Guilt is defined by a pattern of symptoms such as anxiety, depression, social withdrawal, sleep disturbance, nightmares/flashbacks, and emotional lability (instability). As we know, PTSD can also manifest as physical symptoms, which is the body’s way of expressing pent up stress.

Proactive Reactions to Disaster

Those of us who live in earthquake-prone places such as the Bay Area find it easy to feel empathy for those who are suffering in Haiti. After all, it could easily be us. And we can derive lessons from this tragedy.

Dr. Peter Levine, a well-known trauma therapist, offers the following suggestions, which he calls “Emotional First Aid” for trauma. (You can read the expanded version of this list here. http://www.summerjoy.com/September112001/levinepeter.html)

Fortunately, many of these suggestions are inherently practical in the wake of a natural disaster—such as an earthquake—that affects an entire community and displaces people from their homes.

1. Get together with family and friends for support.

2. Organize and meet in community/neighborhood groups.

3. Don’t be isolated.

4. Try to get the information about your loved ones ASAP… without getting hooked on traumatic images on the TV.

5. Refocus on your resources and support systems, and keep your mind occupied.

6. Stay active, volunteer, and help.

7. Encourage people and yourself not to tell their stories in a repetitive way which ultimately deepens the trauma.

Therapy for Survivor Guilt

Once Survivor Guilt has been diagnosed, therapy is of course the most appropriate form of action.

A therapist working with a traumatized victim of a natural disaster will help the patient to formulate alternative and more positive views on the situation and will also help the patient consciously recognize how their own trauma is affecting their behavior. It’s important for the afflicted person to understand that their own actions did not cause or exacerbate the situation, and that they in fact were a victim.

The next and most important step for conquering Survivor Guilt is to pass through an appropriate mourning process. Only then can the patient continue on with their life.