Posttraumatic Symptoms and the Complexity of Responses to Trauma

Several articles in this issue of THE JOURNAL highlight the increasing appreciation of the complexity, ubiquity, and inescapability of both personal and indirect exposure to trauma and violence.^{1 - 5} Trauma, variously defined, is an integral part of the human condition. Most of the world has already known this, in many cases firsthand. Whatever illusions of a tranquil life the more fortunate segments of US society may have had prior to the 1995 Oklahoma City bombing and the September 11 terrorist attacks, a different awareness of individual and collective vulnerability has been instilled in the US consciousness. This awareness has been expanded to consider the psychological consequences of the "routine" violence that occurs daily in less dramatic form—routine and less dramatic, that is, except for those most immediately affected.

Several articles in this theme issue of THE JOURNAL examine responses to different forms of exposure to trauma; what they share is recognition of the long-term consequences of experiences of violence in terms of individual morbidity and social cost. Two articles report the effects of political violence and forced emigration of Central American refugees, one group in Chiapas, Mexico,¹ and the other group in the United States.² Two other studies examine the circumstances of children exposed to violence, one study reporting on a school intervention program to reduce the effects of ongoing neighborhood violence on sixth-grade children in Los Angeles, Calif,³ and the other study reporting a brief screening instrument to assess risk of development of psychological sequelae (posttraumatic stress symptoms) from the effects of motor vehicle crashes on the children injured.⁴ A fifth study reports the results of a telephone survey of the effects of 19 months of terrorism on a nationally representative sample of Israeli citizens.⁵ All 5 studies used careful design, data gathering, and analysis, and they represent considerable theoretical and field effort to measure and control for the enormous complexities of human experiences and responses.

The violence and genocide and the uprooting and resettlement of whole populations throughout the world in the 20th and 21st centuries increasingly shown as they happen by the news media; the high-profile domestic exposure of childhood abuse in its various forms; and the awareness of the psychological effects of the Vietnam War on all exposed to it have made posttraumatic stress disorder (PTSD) a familiar concept. This familiarity has had both beneficial and deleterious effects for health care professionals and the general public. The benefits are those exemplified in 5 articles in this issue of THE JOURNAL,^{1 - 5} namely, recognition that the effects of trauma do not disappear just because broken bones are mended, that children are deeply affected by exposure to violence, that collections of peoples and their cultures are irrevocably altered by exposure to violence and subsequent uprooting, and that the consequences of all types of trauma constitute important arenas for health care assessment and intervention.

On the other hand, PTSD, like many other constructs, has been incorporated into social awareness in a simplified and exploitative manner that claims too expanded a territory and too broadened an explanatory principle. Not every ill that befalls a person is, or results in, PTSD and, conversely, many of the ills and sufferings that do befall persons cause much more than PTSD.

Cultural Influences on PTSD. The notion of PTSD as a timeless, fundamentally biological response to adversity that occurs independently of culture is a naive and essentialist idea.⁶ The response to trauma and fright is hardwired into human biology, as exemplified by the neuroendocrine aspects of PTSD.⁷ Nevertheless, the particular psychological reactions to trauma are influenced by cultural norms of how individuals are expected to respond to threat, injury, and loss.⁸ Intrusive imagery and flashbacks are typically considered the quintessential and dominant features of PTSD.⁹ Yet a recent study of UK servicemen from 1854 onward who had been awarded war pensions for postcombat disorders found that flashbacks were conspicuously absent in former servicemen from the Boer War and World War I and II. Body pains, palpitations, feeling faint, and fatigue were the prominent symptoms of postcombat disorders.¹⁰ The increase of multiple personality diagnoses and "recovered memory syndrome" cases a decade ago in the United States and Canada should convince even the most skeptical that flashbacks as memory-driven imagery are susceptible to general cultural conditions and focused suggestions.^{11 - 12}

Relationship of Trauma Dose to Development of PTSD. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision states, in regard to PTSD: "The severity, duration, and proximity of an individual's exposure to the traumatic event are the most important factors affecting the likelihood of developing this disorder."^{13 (p466)} This position overstates the contribution of trauma variables relative to other risk factors, such as pretrauma variables, lack of posttrauma social support, and posttrauma life stress.¹⁴ Many empirical studies of PTSD have found that the development and severity of PTSD symptoms are not directly related to proximity of exposure or severity of the trauma.¹⁵ Three studies^{16 - 18} examining possible predictors of PTSD found that acute stress response at the time of trauma was associated with the development of PTSD in the ensuing months, but that there was no association between the severity of the injury or trauma and the severity of posttraumatic stress symptoms. In line with this, the study by Bleich et al⁵ of Israeli reactions to terrorism found no association between exposure and posttraumatic response, and the study by Sabin et al¹ of Guatemalan refugees found no association between the number of trauma events reported and symptoms of PTSD. Furthermore, studies demonstrating changes in recall of trauma events several years after the trauma raise questions about research findings linking severity of exposure and development of PTSD.¹⁹

If exposure to trauma alone does not shape posttraumatic stress responses, what are the other major influences? By definition, trauma is a necessary cause of PTSD,¹³ but apparently not a sufficient one by itself under most circumstances. A public health model is applicable in considering the development of stress response syndromes. The relevant trauma is the "disease agent"; host factors include vulnerability based on constitutional and experiential conditions, and environmental factors include cultural and other contingent factors. Many studies have demonstrated that preexisting psychiatric conditions, especially depressive and anxiety disorders, and a prior history of traumatic experiences are associated with severity of posttraumatic stress responses.²⁰ Individual differences in personality and temperament, to a large extent based on genetic factors,²¹ also account for much of the variance in posttraumatic responses. But to emphasize factors within the individual rather than purely exposure to trauma as major determinants of who develops PTSD sounds suspiciously like blaming that individual for his or her troubles. Advocacy groups have taken the position that PTSD is a condition with only a single risk factor, the trauma.^{22 - 23} However, to ignore individual vulnerabilities and contextual circumstances is to ignore the scientific evidence.^{24 - 25}

Breadth of Trauma Experiences. Part of the problem in accounting for disparities between levels of exposure and response are the incommensurability of various trauma events (eg, witnessing assault vs being assaulted) and the variety of context in which traumatic experiences may occur. The term trauma may be used to describe a motor vehicle crash, a rape or other assault, the war/conflict-related experiences of soldiers and civilians, the violence due to exposure to terrorist attacks, and injuries to persons harmed by technological and natural disasters, such as train wrecks, industrial spills, tornadoes, floods, and famine. In regard to trauma experienced by refugee groups, as Hollifield et al point out, "No empirically developed instruments assess the complete range of trauma experiences in refugees." Nor is it clear that the symptoms currently defined in Western terms as constituting PTSD are the most appropriate constructs for traumatized refugees.²⁶

Definitions of trauma have been expanded to include hearing about trauma, direct exposure to the aftereffects of trauma (such as in rescue workers),²⁷ indirect exposure to the effects of trauma (such as in mental health counselors and court workers), and even observation at a safe distance from the trauma (as in the television coverage of the terrorist attacks of September 11).²⁸ In addition, PTSD diagnostic terms have been applied inappropriately to survey participants whose self-reported mental health symptoms have been assessed with instruments not validated for use in specific cultures, or to those who report experiencing trauma-related stress symptoms but not enough to warrant a clinical diagnosis of PTSD.

In line with this problem of assessing what is PTSD and who has it, one of the pieces of information that is frequently missing in studies of PTSD is whether litigation or other forms of benefits or compensation are at stake in the presentation and duration of symptoms of PTSD.²⁹ The effects of compensation-seeking in confounding the presentation of PTSD symptoms by military veterans is well recognized.³⁰ The increased use of a PTSD diagnosis in civil tort cases with the attendant need to rehearse and repeat the trauma stories often appear to have a deleterious effect on the plaintiff.³¹ Refugees, who are not interested in litigation as such but in reaching a safe haven, understand that their survival and welfare and that of their families often depend on their ability to convey a convincing narrative of their persecutions to their assailants as well as their custodians.

Demoralization, Depression, and PTSD Among Refugee Populations. A growing body of literature addresses the mental and physical health of refugee groups who have experienced violence and trauma in their country of origin, during their flight to "safety," and while living in refugee camps. Although these experiences are all dreadful, there are important distinctions between the specific experiences and health outcomes of refugees from different countries, cultures, wars, conflicts, and disasters. Moreover, the commingling of PTSD and depressive symptoms developed by these different refugee groups reflects the differences in the type and duration of their traumatic experiences.³²

With the passage of time, the process of PTSD subsides for some, and depression and other mental health symptoms become more prominent. Depression is often overshadowed by the dramatic symptoms of PTSD, yet 3 studies of chronic stress situations included in this issue of THE JOURNAL report higher levels of depressive symptoms than of posttraumatic stress symptoms. In the study in Los Angeles of Latinos exposed to political violence in their country of origin, Eisenman et al² found that 36% had symptoms of depression and 18% had symptoms of PTSD. In the study of Guatemalan refugees who had lived for 20 years in refugee camps in Chiapas, Mexico, Sabin et al¹ found that 54% had anxiety symptoms, 39% had depression symptoms, and 12% had PTSD symptoms. In the study of Israeli life under the threat of terrorism, Bleich et al⁵ report that 58.6% responded positively to the statement "I feel depressed or gloomy" compared with only 9.4% who met full symptom criteria for PTSD.

In addition, refugees who have successfully immigrated may continue to have psychological distress and difficulty adapting and adjusting years later. For example, many Southeast Asian patients, other than those with schizophrenia and bipolar disorders, who continue to seek mental health care years after entry into the United States have not made successful adjustments when they compare themselves with their neighbors.³³ Many of these refugees may not have learned English, may not have found jobs, may be dependent on government welfare that is increasingly shrinking, and, worst of all, may be in despair that their children, once their hope for the future, are delinquent, dropping out of school, and disrespectful to them.³⁴ The situation is analogous to that of the Guatemalan refugees described by Sabin et al.¹ It must have been difficult for these refugees to have hope for the future or believe that there was anything they could do to improve their lives. Consequently, many of these refugees experienced profound demoralization. Demoralization is often labeled depressive disorder by physicians because the formal diagnosis helps patients in Western countries obtain benefits that accompany disability status. But the depressive disorder label medicalizes a social problem that calls for a social solution at least as much as a medical one.³⁵

In a series of studies conducted in the 1960s and 1970s, Dohrenwend et al³⁶ pointed out that demoralization underlies much of the clinical picture of what is called depression. In their analysis of many psychiatric screening instruments used in World War II and subsequent decades, demoralization was a common factor underlying a variety of problems including severe physical illness, especially chronic illnesses, stressful life events, psychiatric disorders, and social marginality.³⁷ The most recent revision of the Minnesota Multiphasic Personality Inventory (MMPI) includes a new subscale for demoralization, constructed by extracting the general complaint or malaise factor from each of the clinical scales. The shared demoralization items are not core depression markers but reflect general unhappiness and account for the high correlation between the traditional MMPI depression, anxiety, and somatization clinical scales.³⁸

PTSD and the Moral Emotions. There is another dimension to the experience of trauma and the long-term process of posttraumatic stress responses that cannot be encompassed by the simplistic formula of "survivor guilt," an overworked construct that conceals more than enlightens. It is part of the human condition continually to assess experiences from a moral framework, to process what philosophy refers to as the moral emotions, which include guilt, shame, regret, and remorse.^{39 - 40} The PTSD components of traumatic experiences are descriptively clear; however, there are a number of personal and cultural/religious meanings of the traumas and subsequent responses that determine their long-term impact.

These moral emotions might appear peripheral in light of the larger losses that befall the refugee families, including loss of loved ones and their entire way of life. But as time passes, the nagging remorse seems to grow stronger, shifting the focus away from the immediacy of the intrusive imagery to a repetitive anguish about the role of one's own actions and choices in the tragedy. It is the remorse that "if only I had acted differently, all else might be different," which stems from the belief that there is a moral cost to one's actions or failures to act.⁴¹ The observer, such as the clinician, who with hindsight sees only the inevitability of the outcome in light of the overall violence afflicting the country or an individual, tries to assuage the grieving person but finally understands that remorse is not easily relieved.

Summary. Posttraumatic stress responses are complex phenomena that resist easy formulation and categorization. Although final common pathways are inevitably mediated biologically (neuroendocrine functional alterations) and psychologically (the trio of reexperiencing, avoidance, and arousal), the long-term consequences of trauma are far-reaching. The context in which the trauma occurs, the age and stage of life of the traumatized person, the associated losses of family and cultural coherence, characteristics of the person prior to the trauma, the conditions of life after the traumatic encounter, and the symbolic and moral meanings attached to the traumatic events all affect the expression and experience of posttraumatic stress responses. The challenge for the health care professional is to approach the study and treatment of PTSD in a scientifically sound, targeted, and systematic manner, providing the basis for incorporating social and cultural components as well as traditional medical interventions into comprehensive programs. The 5 articles in this issue of THE JOURNAL on the personal and social consequences of trauma and violence provide outstanding examples of research designed to increase the understanding and treatment of PTSD as a public health problem.