The idea of Post traumatic stress disorder is that there is a direct and causal effect between the trauma and the psychological symptoms it causes. This has often been challenged, as the current criteria for PTSD can include almost any symptom from depression to anxiety to substance abuse to aggression, including psychosis. There is a risk that either (a) the PTSD diagnosis means that people ignore other syndromes, such as depression or (b) that people do not consider that people with anxiety, mood or depressive disorders cannot have trauma: instead, the converse applies. People with mental illness have more trauma.
The Canadians have given us a service by surveying the Canadian Forces and the General population using basically the same tools. The found an association with deployment trauma and suicidal ideation, particularly in those who had childhood trauma. Their definition of childhood trauma was fairly broad and included everything from being attacked to being spanked more than thrice in one session. They conclude
Approximately half of military personnel in Canada begin their service with a history of child abuse exposure, a proportion that is higher than among civilians. However, the association between child abuse exposure and suicide-related outcomes was often significantly weaker in military personnel relative to civilians. The higher prevalence and the broad negative effects of child abuse exposure make this finding an important public health concern in the military, as in civilians. Deployment-related trauma was associated with past-year suicide-related outcomes, but the association was attenuated when adjusting for child abuse exposure. In addition, when deployment-related trauma was experienced with child abuse exposure, the effect on past-year suicidal ideation and suicide plans were additive among Regular Forces personnel. Child abuse exposure, however, was associated with all suicide-related outcomes, even when adjusting for deployment-related trauma. Therefore, prevention efforts targeting child abuse exposure or mediators in the relationship between child abuse exposure and suicide-related outcomes may help reduce suicide-related outcomes.
The associated editorial puts it this way.
From a scientific standpoint, research on mental health (eg, posttraumatic stress disorder) and suicide risk among active duty personnel and veterans tends to focus on military-incurred traumas. However, an absolute focus on service-related exposures does not provide a complete picture. The complete picture of any individual contains pixels from the past; some colors fade, others wax and wane, and some burn for a lifetime. Childhood abuse has clear and consistent ramifications on adult health,6 which is why the results found by Afifi et al are so compelling. Specifically, that (1) deployment-related events were not significantly associated with recent suicidal ideation after controlling for childhood abuse, and (2) the effect sizes of childhood abuse had a greater magnitude of association than deployment-related events with recent suicidal ideation and suicide planning. Although unable to assess temporality, deployment-related events most likely occurred after childhood abuse and, thus, are the more recent exposures. Yet, it was childhood abuse that showed the stronger and more consistent associations with suicidal ideation and planning. Consequently, it makes one wonder if some soldiers had been on a battlefield long before they ever enlisted in the military.
It may be that PTSD, as a paradigm, is not that useful. Suicidal behaviour is complex. Recovery from trauma is also complex, and the kind of person you were “before the battlefield” will affect how you are afterwards. In general, the more functional before are more functional afterwards. The assumption in the paradigm — that we should look for recent trauma — may be wrong, and Freud, to our horror, may he right: it could be that early life matters far more.
We cannot undo childhood. What we can do is consider what factors can increase resilience. How to structure society so people recover from trauma, and do not define their lives as post traumatic. We may need to abandon the idea of triggering and talk instead about coping. And we may neet to consider, again, what factors protect childer: two that no one seems to want to talk about are having an involved father, and a religious faith.
PTSD is unique in psychiatry in that a cause is assumed. All other diagnoses are syndromic: they are based on clusters of symptoms that lead to patterns of behaviour over time. We may have been premature in our enthusiasm to find a cause, and fallen into error.
Hoping to see more on this. I’ve noticed that my former employer seems to have been a “last stop” on the career path for a few of the guys I worked with, and my almost reflexive thought was “looks like people don’t necessarily bounce back.” So to be fair to the employer, was it the a**hole VP who abused people (myself included–the review he did for me was pure fiction), or was it that the employer was somehow selecting abused people, whether intentionally or unintentionally?
Like you said, it’s complicated, but I’d like to learn more.
My dad grew up in Yugoslavia during WWII. He was 9 years old when Belgrade was bombed and had to walk 40 miles with my grandmother to their family farm to wait it out. Grandpa closed up the cobblers shop he owned and caught up with them later.
During the war, my father recalls hiding in the cellar while battles came through their farm. The next day, cleaning up the dead bodies and playing with their rifles until they ran out of ammo was normal for him.
One time, an officer fell off his horse in the woods and died, totally by accident. A handful of men in the village were rounded up and hung in the main square of town to make an example–“if one of our soldiers dies, this is what happens” sort of thing.
On another occasion, some of the occupying soldiers were harassing an old man and told him run so they could get target practice. He ran off and after he was a distance away, they shot him.
As an adult, my dad was put in prison for speaking out against the Tito regime–three times. He was tortured and beaten.
He then escaped and came America.
No PTSD. No suicidal or parasuicidal behaviors.
Yep. Or consider that most WWII NZ forces (on the front line 1940 — 1945) do not have PTSD. Nor to most soldiers. And consider that the Israelis predict reliably who has PTSD from intake psychometric interviews. It is not purely trauma. and trauma is not the correct paradigm.
Long ago, a professional told me that PTSD had a physical component – a consequence of the level of fear/pain/torture that affected the heart muscle. Was this untrue? Is this a case of words being used unscientifically? She was referring to someone who she had diagnosed with PTSD because of extensive childhood trauma, not someone who had been on the battlefield.
Long ago, a professional told me that PTSD had a physical component – a consequence of the level of fear/pain/torture that affected the heart muscle. Was this untrue? Is this a case of words being used unscientifically? She was referring to someone who she had diagnosed with PTSD because of extensive childhood trauma, not someone who had been on the battlefield.
This is the hypothalamic-pituitary-adrenal axis in it’s disordered state. This Wikipedia article actually does a pretty good job of explaining it.
https://en.wikipedia.org/wiki/Hypothalamic%E2%80%93pituitary%E2%80%93adrenal_axis
What is much more interesting is what stress hormones, particularly cortisol, do to synapses, and how this affects neural networks. But I don’t think that has hit wikipedia. Yet.
I thought about leaving a bunch of links to journal articles, but probably not the place. 🙂
Although looking back over your comment, I am not sure what she meant by heart muscle. There is some stuff out there about heart rate variability (HRV) and anxiety, some say its voodoo.
It is not voodoo. Anxiety has physical symptoms, and is a risk factor for Cardiovascular disease (google the World Mental Health papers on physical co-morbidities anxiety and depression: Kate Scott, a Professor in my department was a prime mover in writing most of them).
Anxiety. Not purely PTSD.
I’m actually convinced. I also think there is a genetic component to it. As I mentioned my dads story, it is interesting to note that my HRV when hooked up to the machine gives readings right down the middle of the range that protects me from anxiety. I didn’t really do any work to make that happen. Its totally subconscious.
I was originally going to comment, but then I thought it’d get to technical so I stopped. (Before any comments showed up.) But since we got technical…
PSTD is functionally caused by blowing up the Stress Response System in the body. (Think “blowing out your knee”, but at the cellular level.) As both Scott & Chris have gone over, it’s what state the nervous & endocrine systems are in when they *get* to the event, far more than the event itself. (It can also depend on how the person is on that day.)
There’s at least one other disorder that I know is directly caused by a collapse of the stress system (Fibromyalgia), but there might be a few more. It happens in the body a lot more than we realize: a set of systems is simply overcome by long-duration degradation and short-duration events.
Well, yes, we are technical. This is completely “in my wheelhouse”: one of my research interests is anxiety disorders.
Good analogy.
But from a phenomenological point of view, most if not all PTSD symptoms could be described elsewhere: as compulsive thoughts, depressed mood, or impulse control issues. Adverse events would be seen as a risk and not causal. PTSD seems to encompass the entire phenomenological dictionary. And this gives people interested in nosology — the classification of diseases — hives.
Absolutely. The overlap is problematic. You cannot meet the criteria for PTSD without also meeting the criteria for MDD.
Situation: I sent myself to therapy because I was the support system for someone dealing with childhood trauma. Therapist was pretty awesome about explaining to me the physical and mental side-effects of what had been done, so what I could expect to see from my friend in the moment and going forward. It’s been 20 years since those sessions, so don’t quote me – but I do remember the professional telling me that the length of the trauma would have caused some damage to the heart muscle, as well as the differences in social development and the effects of the coping mechanisms.
Much like getting a friend to go to the doctor with you so someone who isn’t overwrought can pay attention to doctor’s instructions, my ability to remember what the therapist told both of us has come in handy over the years. (One of my friend’s coping mechanisms/lasting bit of damage is a faulty memory).
The wiki article you linked just left me with some interesting questions – I wonder if anyone has done a study to check if childhood trauma victims are more likely to develop immune system diseases later in life? I’m thinking of someone I know (someone *else* – oh wait, a couple of someone elses) who suffered and developed an adrenal system disorder… of course she (they) used some festive pharmaceuticals too, so pretty hard to use that diagnostically.
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