By Mark Hammel
Best Defense guest columnist
As in all human endeavors, knowledge is power. Therefore, in treating an
individual unfortunate enough to be suffering from Posttraumatic Stress
Disorder (PTSD), I begin by explaining that PTSD is neither an illness nor a
weakness, but rather, an injury. As with all injuries, it is due to exposure to
a force that undermines the integrity of a biologically adaptive system of the
body. In the case of an injury to the musculoskeletal system, the force is
typically of a kinetic nature, such as with a badly sprained ankle. In the case
of PTSD, the force is initiated by the perception of mortal danger giving rise
to a wave of neurological activity so great that the stress response system of
the brain is damaged. Think of this as a power surge.
The stress response system is one and the same as the system that responds to the perception of danger with the fight-freeze-or-flight response. I've found it useful over the years to refer to this system as the danger-monitoring-and-response system of the brain. It is the malfunctioning of this injured system that gives rise to the symptoms that we have come to know in the aggregate as PTSD.
Under normal conditions, our five senses work tirelessly in the background, monitoring the environment for any change in ambient conditions that might represent danger, such as a novel sound or smell, or perhaps movement on the periphery of our visual field. When such a change occurs the system initiates an immediate IFF, consulting its own knowledge base of previous experience, i.e. memory, and at the same time readies itself to unleash the fight-freeze-or-flight response should our memory turn up a match for something that could do us harm.
When the system is impaired, as in the case of PTSD, it enters a sort of safe mode, where the danger-monitoring-and-response function supersedes all other normal functioning. The victim becomes preoccupied with danger, accompanied by an impaired ability to muster the attention and motivation to engage in the myriad of biopsychosocially adaptive activities that uninjured humans accomplish with relative ease.
I hope this explanation makes it easier to grasp the source of two major groups of PTSD symptoms: hyperarousal (e.g. hypervigilance, exaggerated startle response, sleep disturbance, etc.), and avoidance and numbing.
A third group, reexperiencing symptoms, among them so-called flashbacks, is perhaps less easy to grasp, but surely the most salient to victim and clinicians. Normally, when we experience something it brings about a change in the brain that results in the formation of a memory. When we recall it, it is clearly in the realm of having occurred in the past, the there-and-then. In the case of a traumatic experience, the transformation into a memory is incomplete. It exists in a kind of limbo where it is maddeningly reexperienced as occurring in the here-and-now.
For those of you who are still with me, I will close by stating that in my view it is the salience of re-experiencing symptoms that has led to a massive misallocation of therapeutic resources towards trying to reduce these symptoms: the endless hashing and re-hashing of traumatic experiences.
I began my VA internship 30 years ago, which included weekly visits to the Queens, NY Vietnam Veterans Outreach Center, "Help without Hassles." The service under which these community-based counseling centers is still administered is the Readjustment Counseling Service. Perhaps it was this rubric that helped me understand that my focus as a clinician should be on helping PTSD victims overcome avoidance and numbing by re-engaging with everyday life via mastery of symptoms of hyperarousal.
This is what helps them move into the here-and-now with re-experiencing
symptoms becoming transformed into memories of their own accord. They come back
Mark Hammel, Ph.D., is a counseling psychologist in private practice. With 30 years of experience in the treatment and rehabilitation of seriously injured patients, both veterans and non-veterans, he is an exemplar of the virtues of government investment in education and training.
Thomas E. Ricks covered the U.S. military for the Washington Post from 2000 through 2008.