POST-TRAUMATIC STRESS: CONSCIOUSNESS AND OTHER CORRELATES IN THE ASSESSMENT AND TREATMENT OF POSTTRAUMATIC STRESS DISORDER
M. Allan Cooperstein, Ph.D.
begins with diagnosis, the process of identifying or determining the nature and
cause of a disease or injury through a critical analysis of a patient’s
history, examination, and the evaluation of observed and/or measured data. One
of the most vexing diagnostic issues to be encountered in psychology is the
clinical and forensic identification of Posttraumatic Stress Disorder (PTSD).
The Diagnostic and Statistical Manual of
Mental Disorders IV (DSM IV, 1994) lists PTSD (309.81) under anxiety
disorders, stating that it may result from direct or indirect exposure to
trauma. Generally, its essential syndromal features include intrusive
(invasive) and avoidance symptoms, and
hyperarousal for greater than 1 month,
causing clinically significant distress or impairment in important life areas.
Indirect traumata may include observing the serious injury or death of another
person through violence, accident, war, or disaster or the chance encountering
of a corpse or body parts. Although Adjustment Disorder and PTSD both require
psychosocial stressors, PTSD is elicited by extreme stressors and specific
symptoms, while Adjustment Disorder may be triggered by a stressor of any
severity and can involve a wide range of symptoms.
Forensic mental health experts are occasionally required to assess emotional damages--including PTSD--claimed by a victim or family within the context of life histories. These include preexisting mental conditions and prior experiences that dispose the victim toward greater vulnerability to trauma. It is assumed that, in their assessment, they would also consider the possibility of feigning, dissimulating, malingering, or exaggerating symptoms. Assessments of this type are valuable in establishing treatment plans/goals and in helping juries evaluate the victim’s credibility and degree of existent damage.
Although an ever-growing body of literature and research information on PTSD is extant, the goal of this writing is to provide a brief overview of this complex syndrome, its antecedents and precipitants, components of the experience and treatment implications, adding the need to consider PTSD from a systems of consciousness model. Subsequent writings will examine these aspects in greater depth.
associated with the PTSD Syndrome: the mandate for comprehensive assessment
Experimental (e.g., Moradi, A. R., Taghavi, M. R., Neshat Doost, H. T., Yule, W., & Dalgleish, T., 1999) and clinical research has shown that at least 7 factors are associated with PTSD as antecedents, precipitants, or collateral events and/or features of PTSD.
The pretraumatic state, the
immediate social environment, the nature of the trauma, the dynamics of the
traumatic episode, and the nature of the posttraumatic state.
Recent life events, chronic
strains, and social supports
Negative life events during the
year before the trauma, health problems during the previous ten years, and a
personality trait characterized by high emotional reactivity (Tjemsland, Soreide,
& Malt, 1998).
The degree of trauma and its
The sum of the above factors, including implications of an alteration in philosophy and worldview, introduces a novel concept into our understanding of PTSD: the need to apply information from studies of human consciousness and the application of systems of consciousness to appraise and treat the syndrome.
Typically, consciousness has been defined as “the state of being aware, or perceiving physical facts or mental concepts; a state of general wakefulness and responsiveness to environment; a functioning sensorium” (Stedman’s Medical Dictionary, 1996). In a broader sense, however, it means a sense of one's personal or collective identity, especially as a complex of attitudes, beliefs, and sensitivities held by or considered characteristic of an individual (The American Heritage Dictionary of the English Language, 1996). Reflecting on the evolution of psychology, Webb (1997) says “Throughout the development of clinical and industrial psychology, the conscious states of persons in terms of their current feelings and thoughts were of obvious importance. The role of consciousness, however, was often de-emphasized in favor of unconscious needs and motivations. Trends can be seen, however, toward a new emphasis on the nature of states of consciousness.” In agreement, Melvyn Hammarberg, psychologist and anthropologist at the University of Pennsylvania and author of Penn Inventory for Posttraumatic Stress Disorder Test (1992) agrees that the issue of consciousness and the impact of trauma has been seriously overlooked in addressing PTSD and requires more research attention (Personal communication, March 3, 1999).
and nonordinary consciousness
A leader and pioneer in consciousness research, psychologist Charles T. Tart (1975) refers to ordinary consciousness as a patterned construct resulting from the interaction of attention/awareness with cognitive structures shaped by physical, personal (e.g., genetic), and interpersonal (social, cultural) factors that reinforce certain potentials while suppressing others in the formation of an individual's world view. He (Tart, 1977) describes "ordinary" consciousness as a culturally-defined discrete state of consciousness delineated by a high level of ratiocinative processing (executive functioning) and a lower level of imaging (nonrational) ability Following a review of research Cooperstein (1990) offered the following observations on consciousness: “Ordinary" consciousness is a culturally-relative construct that refers to a relatively stabilized set of cognitive processes applied to everyday subsistence, or survival, operations.
Western culture ordinary consciousness
is distinguished from nonordinary
consciousness by the following features:
contrast, nonordinary consciousness (defined by Ludwig, 1972) includes:
a result of the combined effects of the above, the individual’s ordinary
configuration of consciousness is altered.
we look at consciousness closely, we see that it can be analyzed into many
parts. Yet these parts function together
in a pattern: they form a system While the components of consciousness can be
studied in isolation, they exist as parts of a complex system, consciousness,
and can be fully understood only when we see this function in the overall
system. Similarly, understanding the complexity of consciousness requires
seeing it as a system and understanding the parts (p.3, italics added).
Spiegel (1992) evaluated PTSD in relation to consciousness, applying a model of
consciousness based on the behavior of certain neural networks during and after
trauma as instrumental in promoting dissociative dysfunctions of consciousness.
They present them within a conceptual framework as seen in 2 dissociative
disorders: (formerly) Multiple Personality Disorder (MPD) and PTSD.
In terms of
the neural network model, ordinary consciousness is approximated by the
succession of more or less continuous, stable states through which a net alters
in response to changing environmental demands and constraints. In contrast, dissociation is a relatively discontinuous leap (Author’s note: We
should also add involuntary) from one
state to another, each with its own dimensions of reality and self.
Persistent traumatic schemata and their easy reactivation along with
dissociative features found in PTSD can be modeled via parallel distributed
Li and Spiegel’s data suggest that the fundamental processes involved in the PTSD experience consist of (1) an initial subconscious activation of a preparatory set triggered by situational and/or internal cues (2) intensified by the victim’s attention, physiology, and cognitive processes and (3) shaped by their personal attitudes and system of beliefs. This results in (4) an ascendance of ordinarily subconscious primary processes, producing nonordinary modifications in time and space orientation, meanings, emotional responsiveness, and motor activity that contribute towards (5) a global alteration in one's perception of the environment and sense of self as part of an ontological change marked by an increased, uncritical acceptance of past realities. The latter may be interpreted as an “existential shift” (Ehrenwald, 1978), an alteration in the Generalized Reality Orientation or “the structured frame of reference in the background of attention which supports, interprets, and gives meaning to all experiences” (Shor, 1972, p. 242).
PTSD: PTSD Behaviors and Reactions
upon existing research, the PTSD victim would be expected to manifest overt
signs such as avoidance activities and a clinically significant level of
impairment in an occupational or educational setting. Particularly dramatic are
episodes in which "flashbacks" occur: victims may demonstrate visible
signs of physiological arousal, fear, and hypervigilance. During these periods,
reality markers of time, space and self no longer define the immediate situation
and the victim is thrust into an earlier, traumatic episode with many (if not
all) of the concomitant emotional and psychophysiological signs.
century ago, Pierre Janet, the French
psychologist and early investigator into hypnosis, proposed that events
or information integrated into existing mental systems and would lose their
separateness, becoming distorted by prior experience and one’s emotional state
at the time of encoding and recall (van der Kolk & van der Hart, 1991).
victims are reactive to exposure to events or people resembling or symbolizing
aspect(s) of the traumatic event(s). Symbols represent something else by
association or resemblance and are associated with subconscious operations. A
symbol is “essentially an unconscious content that is altered by becoming
conscious and being perceived, and...takes its colour from the individual
consciousness in which it happens to appear” (Jung, 1980, p.5).
definition, PTSD is accompanied by memory disturbances, consisting of
hypermnesias (exceptionally vivid and accurate memories) and amnesias. PTSD
often leads to recurrent and intrusive recollections of events triggering
painful memories. In attempting to guard against these intrusions, the
individual deliberately attempts to avoid activating thoughts or reminders in
the form of conversations, places, or symbols. This appears to establish a state
of inter and intrapersonal tension in which surfacing memories or associations
cause emotional reactions which, in turn, impact negatively upon attention,
concentration and the completion of tasks.
the PTSD victim has experienced one or more situations in which s/he felt
intensely painful emotions of fear in combination with helplessness, horror and,
at times, repugnance. The association between memories of the event(s) and the
affective reactions they trigger set the stage for either avoidance of emotions
by distracting thinking away from triggering memories and/or a form of
self-anesthesia in which they attempt to numb themselves to the painful
particularly when memories near surfacing, angry outbursts are not uncommon.
Some PTSD victims, in hardening themselves, lose touch with
"softer" sentiments, demonstrating a reduced capacity for intimacy and
affection, which are associated with making themselves emotionally vulnerable.
Beyond the conscious
control or mediation of the PTSD victim, the hypervigilance,
the exaggerated startle response, difficulty
with sleep onset and maintenance, recurrent distressing dreams and reduced
ability to feel sexuality, all lead to the inference that considerable
subconscious (or non-conscious) involvement is linked with physiological
manifestations. Intense stress results in the release of stress-responsive
neurohormones, such as cortisol, epinephrine, norepinephrine, etc. These help
the individual muster the necessary energy to deal with the stress.
Chronic and persistent stress, however, reduces the effectiveness of the stress
response and induces desensitization (Axelrod, 1984).
yet another example (in a non-forensic case), a 38 year old man presented with
insomnia and sleep maintenance difficulties at a sleep laboratory where I am
associated. History elicited
nothing remarkable. However, a few weeks after initiating contact, he revealed
that he served a tour of duty during the early years of Vietnam involvement,
almost 23 years before. During that time, he was under orders not to return
enemy fire even if fired upon, causing a sense of fear,
helplessness and vulnerability. His base camp was attacked suddenly while he
was digging a trench. He jumped into it for cover, thinking that this trench
might become his grave. Upon returning home, he realized that he would be on
active reserve and could be called back to duty at any time. Using a guided
imagery approach, a forgotten memory appeared: he recalled making a commitment
to himself not to not relax his vigilance as he could be returned to the war
zone. By doing so, he affirmed a need to remain alert or hyperalert, a
light-sleeping condition he developed while in Vietnam. This persevered
subconsciously long after his active reserve status ended and was reactivated by
what was perceived as minor stresses in his present existence.
Interaction and Social Reality
There may be a diminished
responsiveness to social reality. Individuals who arouse recollections of
traumatic situations may be avoided. If avoidance is not possible, dissociative
feelings of detachment or estrangement are possible, apparently a fear
Altered Environmental Awareness, Altered Sense of Self & Dissociation
Dissociation is described as “a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment. The disturbance may be sudden or gradual, transient or chronic” (DSM IV, 1994). Posttraumatic Stress Disorder (PTSD) may be conceptualized as part of a dissociative spectrum in which recall/re-experiencing of the trauma (flashbacks) alternates with numbing (detachment or dissociation), and avoidance (Turkus, 1992; also see Briere, Evan, Runtz, & Wall, 1988; Carlson & Rosser-Hogan, 1991; Goodwin & Reynolds, 1987; Jaschke & Spiegel, 1992; Kuch & Cox, 1992; Mellman, Randolph, Brawman-Mintzer, Flores, & Milanes,1992; Roszell, McFall, & Malas, 1991; Shalev, Schreiber, & Galai, 1993; Southwick, Yehuda, & Giller, 1993).
the PTSD victim’s response to the external environment, similar to the social
changes, there are “flashbacks,” or dissociative revivifications of intense
experiential and psychological distress during which aspects of the event are
relived. These are varying periods of dissociations or displacement in time and
space, the fundamental indices of consciousness in our relationship to the
physical world. Simultaneously, there is a diminished responsiveness to physical
reality, an obvious, altered worldview, or reality (derealization) and
hypervigilance towards threat in spite of the safety of the actual situation.
to one’s person, identity, or sense of self, there are dissociative
disruptions that may be quite brief or last for several hours or days in the
normally integrated functions of consciousness, memory, identity, or perception
of the environment. With this may be a sense of a foreshortened future. The
altered sense of personal self (depersonalization) may be associated with
feeling detached from others and appear as diminished responsiveness to the
Under ordinary conditions, many traumatized people (and animals) have a fairly good psychosocial adjustment (Green, A., 1980; Hilberman, & Munson, 1978; Kilpatrick, Veronen, & Best, 1985). When exposed to stress, however, they react differently and may feel or behave as if the trauma was recurring. Apparently, high arousal states promote retrieval of traumatic memories and/or behaviors associated with earlier traumatic experiences. Traumatized individuals regress to emergency behaviors in response to minor stresses that are not relevant to their immediate situation (e.g., a patient having lunch at his country club prior to a round of golf heard a helicopter flying low overhead and darted under the table for protection).
Spiegel, Hunt, and Dondershine (1988) examined hypnotizability in veterans with PTSD contrasted with a normal control group and four patient samples. The results demonstrated that PTSD victims show significantly higher hypnotizability scores than patients with schizophrenia, major depression, bipolar disorder-depressed, dysthymic disorder, generalized anxiety disorder, and the controls. This supports the hypothesis that dissociation effects may be used as defenses during and after traumatic experiences.
Bremner and Brett (1997) examined dissociation in premilitary, combat-related and postmilitary traumas and the presence of long-term psychopathology in Vietnam combat veterans with and without PTSD. Most interesting was the finding that PTSD victims reported higher levels of dissociation at the time of combat-related traumatic events than non-PTSD patients. These higher levels of dissociative states persisted in PTSD victims as higher levels of dissociation in response to postmilitary traumatic events. The dissociative responses to combat trauma were linked with higher, long-term dissociative symptoms as measured by the Dissociative Experience Scale and an increased number of “flashbacks” since the time of the war. The findings are congruent with earlier concepts that traumatic dissociation may be a sign of long-term psychopathology.
The impact of cognition, emotions, physiology, sleep, social interaction and social reality all blend to influence altered environmental awareness and an altered sense of self culminating in an altered state of consciousness (ASC) that is pathological and discrete from the victim’s ordinary consciousness characteristics. In combination with the victim’s personal history, personality, and other factors cited earlier in this writing, these features intermingle as is illustrated below.
& treatment considerations
is a diagnostically complex phenomenon requiring a multidimensional evaluation
including clinical interviewing, extensive background history, adequate
psychological testing, test interpretation, and psychophysiological assessment.
These are imperative for diagnosis, treatment and competent testimony (Levit,
1986). In my practice, interviewing, objective psychological testing,
malingering/exaggerating/dissimulating measures (e.g., MMPI-2 validity and PTSD
scales, Structured Interview of Reported Symptoms [SIRS; Rogers, Bagby, &
Dickens, 1992]) and physiological responses to positive, negative and neutral
stimuli are merged, attempting to sample the biopsychosocial model of PTSD as
reported by Scrignar (1988) in assessing Environment, Encephalic Events, and
to appropriately and comprehensively assess PTSD we must examine
to traumata are of such consistency across experiences that these reactions
appear to be normative reactions to overwhelming and uncontrollable experiences;
this is supported by vast, growing literature on combat trauma, crime, natural
disaster, and accidents.
trauma response typically involves hypermnesia, hyper-reactivity to stimuli and
traumatic reexperiencing that coexist with psychic numbing, avoidance, amnesia
and anhedonia. In many victims, the PTSD response diminishes with the passage of
time: in others it persists. Considerable research remains to identify which
victims are most flexibility and which are most liable.
Contrary to the symptom-specific expectations of insurance reviewers, current research demands flexibility and comprehensiveness in treating PTSD. In some instances (see Foa, Hearst-Ikeda, & Perry, 1995), brief cognitive–behavioral treatment undertaken shortly after assault reduces the reexperiencing of severe arousal symptoms as well as depression. However, a history of physical abuse in childhood has been strongly correlated with dissociative symptoms later in life as well as combat experiences in veterans (Spiegel, & Cardena, 1990). As dissociative symptoms during and soon after traumatic experience predict later PTSD, brief, symptom-focused treatment may not always be applicable.
Hypnotic procedures may be helpful because the population has been shown to be highly hypnotizable. Hypnosis provides regulated access to painful memories that may otherwise be denied access to conscious awareness. In treating PTSD victims, dissociated traumatic memories are connected with a positive restructuring of involved memories, a cognitive reorientation. Accordingly, victims are helped to confront and manage traumatic experiences by inserting them into a new context meaning or ”worldview. “ Feelings of helplessness are endorsed while experiences are interlaced with restructured memories, emphasizing positive efforts at self-protection, affection with the living and those who may have died, or the capacity to control events and the environment at other times.
use of medication use a modest, clinically meaningful effect on PTSD, in their
literature review on the effectiveness of PTSD treatments, Solomon, Gerrity, and
Muff (1992) found more robust effects for behavioral techniques involving direct
psychotherapeutic intervention in reducing PTSD intrusive symptoms. There is a
caveat, however, in that complications were reported from the use of these
techniques in victims with collateral psychiatric disorders. Cognitive therapy,
psychodynamic therapy, and hypnosis are also
promising, but further research is needed.
Psychodynamic psychotherapy focuses on helping the victim examine their reactions to the physical or emotional personal violations of the traumatic event(s). The goal is to increase awareness of intrapersonal conflicts and their resolution. The victim is guided towards developing increased self-esteem, self-control, and a regenerated sense of personal integrity and self-confidence.
therapy may help PTSD victims develop a reference group and a sense of
community, reacquiring the capacity to relate to others in a controlled,
health-inducing manner and setting.
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