Monday, August 6, 2012


 So what exactly is Post Traumatic Stress?

We will begin our discussion today by looking at “Criteria A” for determining whether or not a person is experiencing Post Traumatic Stress.  Criteria A, along with criteria B through F, are spelled out in the DSM-IV-TR)(1), which is a diagnostic and statistical manual used by most mental health professionals.

Criteria A
    The person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others.
    The person's response involved intense fear, helplessness, or horror. Note: in children, it may be expressed instead by disorganized or agitated behavior.

There are also Criteria B through F which we will look at below.

So tell me this.  How many people can you think of who not only fit criteria A, but who fit criteria A over and over again on a daily basis?  Think combat soldiers, perhaps soldiers period, policeman, fireman, EMT folks (like ambulance personnel), emergency room folks, surgeons,  nurses.  And let’s not forget folks who work and live in gang and or crime-infested neighborhoods.

And, of course, there are many people throughout the world who live daily with the threat of terrorism, political upheaval, or who live in countries where war is non-stop.  Yes, they experience Criteria A daily.  (Sometime, watch the movie, Harrison’s Flowers.)

And if we want to become all inclusive, there are the folks, even in our own country, who are the object of hate, and who must live under the fear of being attacked.  For example, there are the people we refer to as the “derelicts.”  And as much as we don’t want to admit it, people, in this country, can still be attacked for the color of their skin and their sexual orientation.  So yes, the list can be quite extensive.  And my point?  Simple.  There are plenty of human beings experiencing Criteria A all the time, plenty of folks subject to Post Traumatic Stress.  They are not some rare minority who don’t have what it takes to face the realities of life.

So is Post Traumatic Stress the same as the acronym PTSD?  Well, the big difference is that letter “D” which stands for DISORDER.  M-m-m.  How did Post Traumatic Stress become a disorder?  Wow!  That’s an interesting question.  You think?

So what is with that?  And what are the implications and the ramifications to categorizing Post Traumatic Stress as a disorder?  Don’t you just love those words?  Implications and ramifications!   Well, it is more than an implication.  According to the DSM-IV-TR)(1), you are considered “disordered” if you have experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others, and then you responded with intense fear, helplessness, or horror.

Really?  How come?  Well, none of us like saying the obvious out loud, but apparently, the bottom line here is money.   Yes, insurance companies are not in the business of subsidizing or supporting therapeutic services for healthy folks.  Absolutely not.  When I bill your insurance company for the therapy services I provide you, I have to “give” you a diagnosis, which means you fall into one of the many “disorders” that qualify for insurance reimbursement.    Ugh!  This is how the system is set up.  At least in mental health treatment, you get to use your insurance benefits when you are “disordered” and “sick,” not healthy or well.

So with respect to Post Traumatic Stress, adding the D implies that a normal person, a healthy person, an “ordered” person (in constrast to disordered), will not experience Post Traumatic Stress, which is just a huge huge CROCK!  We just listed above a large large number of ordinary human beings who are subject to Post Traumatic Stress on a daily basis.

So today, I want us to consider that perhaps Post Traumatic Stress is a normal response to actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others.   Adding the letter D, disorder, pathologizes a normal neurological response to trauma.  The ramifications of adding that letter D may just be what keeps so many people, like soldiers, policeman, fireman, EMT folks, from seeking the support they deserve to debrief the at times daily occurrences of Post Traumatic Stress.  They have to pretend that they are not having a normal response to trauma because they do not want to be seen as weak and disordered.

As indicated in two previous blogs (The Gift of Post Traumatic Stress, PART ONE  and PART TWO) from my perspective as a therapist in practice for 30 years, Post Traumatic Stress is a gift, the brain’s gift to those of us who again experience actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others.

Criteria B through F further attempt to pathologize normal responses to the extraordinary.

Criterion B: intrusive recollection....Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions....Recurrent distressing dreams of the event.... Acting or feeling as if the traumatic event were recurring....Intense psychological and physiological distress and reactivity at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

Criterion C: avoidant/numbing....Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by at least three of the following:
    Efforts to avoid thoughts, feelings, or conversations associated with the trauma
    Efforts to avoid activities, places, or people that arouse recollections of the trauma
    Inability to recall an important aspect of the trauma
    Markedly diminished interest or participation in significant activities
    Feeling of detachment or estrangement from others
    Restricted range of affect (e.g., unable to have loving feelings)
    Sense of foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

Criterion D: hyper-arousal....Persistent symptoms of increasing arousal (not present before the trauma), indicated by at least two of the following:
    Difficulty falling or staying asleep
    Irritability or outbursts of anger
    Difficulty concentrating
    Exaggerated startle response

Criterion E: duration....Duration of the disturbance (symptoms in B, C, and D) is more than one month.
Criterion F: functional significance....The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

One does not have to be weak, disordered, or less than to experience any one or all of Criteria B through F.  Again they are the brain's normal response to trauma, as well as the brain's way of protecting us from having a head-on collision with the trauma and experiencing the trauma all at once.  Criteria B through F are also part of the gift of Post Traumatic Stress.  How?

First of all, experiencing these Criteria lets you know that what you experienced was, in fact, over-the-top.  Be wary of anyone, even yourself, saying things like, “Hey, it was no big deal....all in a day’s’s what we do as a policeman, soldier....”

  Of course, it IS what you do and what you do is to face trauma every day of your life and sometimes, several times a day and that is the point of this article.  The experience of Criteria B through F confirms for you that you faced trauma, and that you continue to face trauma.  And to suggest that some combat soldiers or some EMT folks or some firemen or some surgeons or some policeman do not experience criteria B through F is ludicrous.

Does anyone believe that there are some folks who will feel no pain when they undergo surgery, and therefore do not require any local or general anesthesia?  Does anyone believe that?  Of course not.  So too, when we experience an over-the-top event, trauma, we will experience Criteria B through F, not because we are disordered or weak, but because our brain is designed to save our ass from the full impact of the trauma at the moment it is occurring.

So know, whenever you face an over-the-top event, whether it is once in your lifetime or on a daily basis, God has given you a brain, a wonderfully designed brain that keeps you from being “wiped out” by over-the-top events.  And also know, that now that your ass has been saved, you have a little work to do to get your brain back into balance.  AND also know, it is not something you can do alone.  You need and deserve safe safe people to accompany you on this journey.

So our next blog will focus on that journey, BRINGING OUR THINKING AND FEELING BRAIN BACK ON LINE.  Watch for it.  It will be posted soon.  Then we will take a look at all the traumatic or over-the- top events in the news.


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