John, a survivor of a cardiac arrest, has nightmares of dying, numbness, and hyperarousal symptoms.

Susan, a battered wife, has had difficulty falling asleep and frequent suicidal ideas, and has lost all interest in work and other parts of her life for the past three months.

Ira, a victim of the war in Iraq, swears at the nurses caring for him, has difficulty trusting authority figures and public institutions, and sees no future for himself.

Janet, a rape victim, resists recounting the details of her attack and reports numbing of emotions and persistent symptoms of sleeplessness and irritability for more than a month.

What does each of these people have in common? They are victims of Post Traumatic Stress Disorder (PTSD). This condition was once associated mainly with the survivors of wars, but today it is used to describe a wide range of trauma survivors — rape, crime, and torture victims; survivors of natural catastrophes, vehicular accidents, and technological disasters; and abused women and children. Also at high risk for PTSD are rescue squad workers, police officers, firefighters, and nursing personnel who witnessed or experienced a traumatic or life-threatening event that had the potential for bodily harm.^1,2 Even people who have had a miscarriage or experienced job loss may suffer from PTSD.²

At first glance, combat veterans, hurricane survivors, and nurses seem a very divergent group. What makes them similar? They all have at least one common experience: They have all been rendered helpless in a situation of great danger. While each survivor is unique in history and coping strategies, they share a similar and fairly predictable set of psychological and physiological reactions that define PTSD.

Common reactions, uncommon causes

Primary symptoms of those who suffer PTSD include insomnia, substance abuse, nightmares, anxiety, depression, and anger and fear that the horror will return. War-related flashbacks have been glamorized in movies and newspapers. Less publicized are the agonizing self-doubts and fears of nightmares, flashbacks, and/or impending death. Less well-known are the reactions of battered wives and abused children: sleep disturbances, flashbacks, addiction, chronic anxiety, and low-grade depression.² Avoidance strategies, acting out, tuning out, imagining themselves somewhere else, and temporarily being unable to move, speak, or feel are also possible.

Investigations have shown that given sufficient stress, PTSD can develop. Other factors, such as an individual’s previous psychological state or mental stability, are unreliable in predicting its occurrence.³ During World War II, for example, some soldiers with sterling records of mental health and family stability developed the disorder, while others who had preexisting psychological or low socioeconomic status did not. Likewise, women may not have a disposition toward PTSD, but sexually motivated violence can lead to a higher prevalence of the condition. The critical variable was the degree of stress to which the survivor was exposed.^4,5

Because emotional distress can be overlooked in injured patients, researchers in a recent study of injured and uninjured soldiers caution caregivers to pay more attention to psychological aspects of a patient’s condition in general and to the early symptoms of PTSD in particular, both during hospitalization and after discharge.⁶

PTSD does not develop because of some inherent weakness in the personality. Trauma changes personality, not the other way around. Although pretrauma personality does affect the interpretation of and the reactions to a traumatic occurrence, the intensity and duration of the stressful event are more significant factors in assessing the problem.

PTSD is not the only reaction to trauma. If the condition is of short duration — occurring within four weeks of the traumatic event and lasting a minimum of two days and a maximum of a month — it is called acute posttraumatic stress disorder. Some survivors may react with psychosomatic problems or panic attacks.

Physiological changes

When trauma occurs, it affects the whole being — not just the mind or emotions, but also the body. Central nervous system changes include catecholamine reactions and depletion of neurotransmitters. Physiologically, trauma can give rise to a host of “hyperarousal” bodily changes, including heightened heart rate, blood sugar, and muscle tension. Perspiration increases, pupils dilate, and rapid, shallow breathing ensues. The individual may exhibit signs of hyperventilation: irregular heart rate, choking sensations, shortness of breath, and confusion or inability to concentrate.⁷

Many emotionally distressing symptoms of PTSD also have a physiological basis.⁸ For example, John, the combat veteran mentioned above, has nightmares nearly every night of the firefight that cost him his leg. He has tried to rid himself of the nightmares, but has been unsuccessful. If physiological research is correct, his recurring nightmares are beyond his control: The situation he lived through was severe enough to profoundly alter his thinking, his emotions, and even his physical reactions.

It need not take hours, months, or years to create such lifelong reactions. A single life-or-death incident that lasts only a few seconds can traumatize an individual. For example, Monica Seles, a one-time No.1 female tennis player, was stabbed in the back at a major European tennis tournament. Despite her work with a psychologist and the complete physical healing of her wound, she was too afraid to return to playing competitive tennis for more than two years. In those few moments when the individual is experiencing the traumatic event, emotions, identity, and sense of the world as an orderly, secure place can be severely shaken and even shattered. Trauma can lead to a profound rupture in the individual’s sense of self-worth and trust in the world as a safe place.

The dynamics of PTSD

The diagnosis of PTSD can only be made if the individual meets all of six symptomatic criteria stipulated by the American Psychiatric Association. Generally, a person who suffers from the disorder experiences a cycle of intrusive recall of the trauma, accompanied by reexperiencing physiological hyperarousal and psychological symptoms. This is usually followed by a repression of memories, called numbing, and in some cases, partial or total amnesia of the event.

Symptoms are sometimes directly related to the type of trauma. For example, survivors of family abuse — one of the most common causes of PTSD — often share special profiles that are characterized by four oppositional stances or “polarities.”⁹

1. Naiveté vs. cynicism or suspiciousness. The survivor may hold a joyful “all will be well” view of the world or an extremely negative one. The naive optimism reflects the survivor’s denial of the abuse and the wish it had never happened. Cynicism or suspiciousness reflects the victim’s recognition of the abuse and generalization of cruelty and manipulativeness of the abuser to others and to the world in general.
2. Worthlessness vs. specialness. Victims may feel worthless due to humiliation from their abusers, who sometimes relegate them to subhuman status. However, survivors may also feel important, as if they had been chosen for special, if horrible, treatment.
3. Self-punitive vs. self-indulgent behavior. This polarity mimics the abuser’s pattern of first punishing, then indulging the victim. It may also reflect survivor self-hatred and feelings that the abuse was deserved. Alternately, or at the same time, victims may reward themselves because they feel deprived or self-pitying.
4. Intense dependency vs. excessive caretaking. Abusers often foster the victim’s dependency through forced isolation and appeals to the victim for sympathy. Ironically, victims often continue to function as the emotional, physical, and sometimes financial or sexual caretakers of their abusers.

The terms epiphenomena, masked presentation, and secondary elaborations all refer to the secondary symptoms or psychological syndromes that evolve to allow survivors to cope with the trauma. The longer individuals have suffered from trauma without assistance and the more severe the experience, the more likely that secondary symptoms — alcoholism or drug abuse, eating or panic disorders, or phobias — occur. This can happen when survivors are in the numbing stages of PTSD, have difficulty remembering, or are amnesic.²

Following the trail of PTSD

After a traumatic event has been identified, a knowledgeable nurse can use three categories of questions — presence of intrusive thoughts, avoidance reactions, and physical symptoms — to assess the extent to which an adult survivor is suffering from PTSD.⁹ When a therapeutic relationship has already been established and the individual is ready to discuss the event, questions can be phrased in a direct, personal manner. When a person is in the early stages of PTSD or extremely anxious, and/or a therapeutic relationship is just being established, questions need to be less obtrusive. Questions that are less direct and nonspecific allow the survivor more control over the amount of sharing that will occur. The answers to these questions can then be compared to the criteria published in the DSM-IV by the American Psychiatric Association.

l. To assess the presence of intrusive thoughts:

• Are you bothered by upsetting thoughts and nightmares of the trauma (for example, rape, fire, crash, or war)? OR Tell me about your sleeping patterns.
• Do you often feel as though you are actually reliving the trauma? OR What are your feelings about the trauma?
• Does it upset you to be exposed to anything that reminds you of the traumatic experience? OR What are your feelings when you are reminded of the trauma?

2. To assess the presence of avoidance reactions:

• Do you find yourself trying to avoid thinking about the trauma? OR What have you been thinking about since the trauma?
• Do you stay away from situations that remind you of the trauma? OR Tell me about your experiences with situations that remind you of the trauma.
• Do you have trouble recalling exactly what happened to you? OR How has your memory been since the event?
• Do you feel detached or cut off from other people? OR How have things been between you and other people since the event?
• Do you feel numb emotionally? OR Tell me about your feelings.

3. To assess the presence of physical symptoms:

• Are you having trouble sleeping?
• Have you felt irritable or had outbursts of anger?
• Have you had trouble concentrating?
• Do you feel jumpy or become easily startled?
• What kind of physical reactions do you have when you are exposed to anything that reminds you of the trauma?
• Does your heart ever beat too fast without exertion (palpitations)?
• Do you sweat too much without exertion (diaphoresis)?
• Do you have headaches, tight shoulders, or other signs of muscle tension?

The process of healing

Individuals who have experienced trauma progress through three stages of recovery — victim, survivor, and thriver.⁸ As with many “stage theories,” the lines of demarcation may not be clear-cut: They may overlap, not occur in all individuals, or reappear at a later date.

There is a tendency for the least traumatic memories to emerge first and the most traumatic ones to appear later in the healing process. With each new revelation, the survivor may regress temporarily to the victim stage, exhibiting thoughts, feelings, and behaviors characteristic of that stage. None of the stages may uniformly characterize an individual. For example, a patient may be in the thriver stage at work, the victim stage regarding intimate relationships, and in the survivor stage when dealing with family relationships.

• The victim stage consists of three phases: prediscovery of the trauma, early awareness, and discovery. Symptoms of PTSD may appear in prediscovery with little understanding of why they are occurring. Patients can feel inner chaos, which may be reflected in personal relationships. They often suffer from poor recall, and sometimes total amnesia, of parts or all of the traumatic event. Individuals may suffer from low self-esteem or feel physically, emotionally, or financially vulnerable from the effects of a trauma of which they are fully conscious. They may engage in escapist activities — substance abuse, or a change of job, residence, or relationship — in a search for relief. As the awareness phase begins, victims have a vague sense that they have been affected by trauma. This awareness leads to heightened anxiety, along with depression, irritability, and dissatisfaction with themselves and others. As in any crisis, when survivors finally face their traumatic experiences, reactions vary from initial disbelief and shock, vacillation between denying and admitting fragmented facts of the trauma, to a surge in PTSD symptoms, such as flashbacks and nightmares.
• Because the essence of being a victim is being out of control,² entering the survivor stage means taking control of one’s environment and inner self. A commitment to therapy or some other effort to be healed must be made. The trauma is confronted and the intense feelings associated with it begin to emerge from repression to find constructive expression. With healing, repressed memories and feelings no longer control the individual’s inner life, relationships, and external behavior because they have lost their power.²
• In the thriver stage, personal goals replace the trauma as central organizing principles for life. Survivors pursue new education, work, and life goals. They improve their relationships. Emotional upheavals are fewer and less bothersome, and greater periods of peace and serenity emerge. Symptoms that may persist become fewer and less intense. Survivors learn to manage their symptoms with less anxiety and panic.

Factors that enhance recovery

If the stressor is sufficiently great, almost anyone can develop PTSD, but the impact of the trauma is not uniform. Some individuals suffer long-term impairment, while others are able to overcome the event in a short time. PTSD is complex and subject to the effects of personal and social factors. Good health and the absence of physical disfigurement due to the trauma enhances recovery. Those who are able to return to some, or all, pretrauma roles have a better chance of overcoming PTSD. Finally, the encouragement of significant others and the support of adequate finances and healthcare services contribute to a better prognosis.²

Nurses can identify and encourage those who have experienced significant trauma to seek therapy and build a network of support. Clinical specialists and nurse practitioners in psychiatric/mental health are good referral sources for treating these patients. Part II of this series will explore the role of nurses in the therapeutic process of PTSD.