Types of PTSD

The Scream by Edvard Munch

Posted: 23 April 2011

Updated: 27 June 2012

The types of PTSD as defined by the American Psychiatric Association are classified differently here, because I think that they should be categorized by the physiological responses of the patient. I do this to emphasize the fact that the brain is a physiological and anatomical organ that houses the “mind” and all behavioral responses are programmed in the brain, either dynamically, or before birth. The symptoms shown by a person having PTSD will differ primarily based upon important aspects of brain development, simply because all we ever experience in life is stored in the brain, accessed by centers in the brain, regardless of whether or not we consciously remember the details, or even the fact of the event having occurred. This observation has been demonstrated  in countless experiments and surveys in neurological research.

This post is based on my thinking about my own symptoms and their effects on my life.  However, I also bring in ideas proposed by others (in radio programs, journals and books) and can comment on the symptoms that other people have had due to PTSD.  I hope to explain not only the types of symptoms (which can range greatly) but also the kinds of behavior that can betray the presence of PTSD.

Introduction

The American Psychiatric Association has defined PTSD (Post-Traumatic Stress Disorder) as a severe anxiety disorder that develops after exposure to at least one traumatic event that exposes the patient to risk of death or bodily/emotional injury, or the patient witnesses the event that threatens someone else in the same way. Other criteria include the following symptoms of the patient:

• has intense fear, helplessness or horror
• persistent re-living the traumatic event
• persistent avoidance of any circumstance that is similar to the traumatic event
• feelings of numbness (emotional)
• persistently increased vigilance
• all symptoms last for more than one month
• symptoms cause clinically significant distress or prevent the person from functioning socially, at work, or other important aspects of life

See Post Traumatic Stress Disorder DSM IV Criteria  for more detailed information.

Mary Jo Barrett spoke on the topic, “Rethinking PTSD: Blueprint to Test Complex Trauma” in the NICABM Treating Trauma teleseminar on 29 June 2011.  She said that the DSM-IV describes two types of PTSD. A person can have a simple response of the characteristics mentioned above, when undergoing a single traumatic event (most commonly happening in what I feel are random events, but can occur when physically, emotionally or sexually attacked by either strangers or people they know). The DSM (Diagnostic and Statistical Manual of Mental Disorders) describes this as Type I PTSD. Type II PTSD is defined as the same set of symptoms that are suffered chronically as a result of continued attack. It is characterized by more complex behaviors/physical symptoms in more complex scenarios. In other words, the categories are based primarily upon symptoms with some regard to the situation of the patient in a general sense.

I have defined PTSD differently, based upon the physiological responses of the victim toward their attacker. The type of attacker seems to predict the physiological responses because of the strong effects of family on the physiology of a social animal, as humans are.  PTSD is notable for often showing panic attacks. The DSM-V has revised its definition of panic attacks and recognizes two types. One type results from unexpected triggers, the other happens because of expected triggers (e.g. fear of flying, New Diagnostic Criteria for Panic Disorders). I suggest that, based upon some other criteria, there are essentially three main types of PTSD, which come from:

I. interactions with people the sufferer knows
II. interactions with people the sufferer doesn’t know
III. totally random events

The single characteristic that these three types have in common are that they are life-threatening to the person experiencing them.  Now others may not think they are life-threatening when they hear the full story, but we have to remember that the distinction is based upon how old the victim is at the time.  A sexual assault by an adult on a child is life-threatening to the child, every time the same predator does it, and the memory of that fear is recalled with every assault.

Another quality of these three types of PTSD is that the person relives some aspect of the original event every time they recall conscious or unconscious memories of the first time and each subsequent time.  Thus these sufferers carry that memory with them for the rest of their lives, with profound effects. The life becomes a series of memories of memories of memories….

I theorize here that the critical aspect of memory for this purpose, is that memory is stored in multiple places, depending upon its sensory qualities.  When we recall an event, we reinterpret all the sensory information again, often in new ways.  Thus, those who claim memory is not trustworthy are wrong.  It is trustworthy, if you tap into all of the places that each aspect of an event is stored.  However, recalling the components of a memory stored in all of these places is not necessarily in our interest, since it would lead us to experience delusion, as we clearly think we are reliving the entire event all over again. Our memory becomes too real. Thus our brains block the recall of most of the sensory information associated with an event and allow only what we need at the time, to maintain some distance from the event.

Every person who experiences a terror leading to PTSD will display each of these behaviors:

• withdrawal from contact with people
• blocking of the ability to speak
• inability to live the life they used to live

They may show these behaviors in different ways, depending upon the type of PTSD they have, but the basic characteristics mentioned will always be visible to observers. I will explain the behavioral, emotional and physiological implications of each of these three characteristics in other posts at this site. I will also describe the kind of behaviors associated with each type of PTSD concerning interactions with people and changes in lifestyle and discuss the problem of inability to speak in a separate section, Language and Speech, below.

Type I PTSD

The behaviors of people with each of the types of PTSD will be different.  The person with type I PTSD could be someone who has been sexually assaulted because the predator usually has to gain the trust of the person they eventually assault.  The victims may suffer from

• child or adult sexual abuse,
• rape or abuse by a known person, like a relative,
• child abuse or child neglect

Nervous Face, from Barry Langdon-Lassagne at Wikimedia

Trust has been broken in the type I PTSD sufferer.  Depending upon the age of the individual, that ability to trust may be broken forever when it comes to a specific person or when dealing with anyone.  As such, trust is at the root of every behavior expressed by a sufferer of type I PTSD. This sufferer will not be able to form close relationships with new people after the event, but may be able to maintain those formed before the event.

The world of the Type I PTSD sufferer will be smaller than that of normal people. They have to work very hard to build trust in their co-workers and classmates.  Usually they are unmotivated to do so because they will never believe that these people will come to their aid when requested. They will make either poor decisions or no decision at all precisely because they feel they have no one at their back, so that any consequence from that decision will have devastating effects on them. They will pay a much higher price for any decision than kids who were not rejected by their mothers.  In extreme cases, they will never have a home where they feel safe and protected.  They will often seem like they cannot “settle down”, having to move to a new city if they think they cannot stay where they are originally. Often they never feel accepted by the culture surrounding them. For the extreme cases, the small stage is the only stage they can handle. The big stage is terror for them.  Thus they avoid all circumstances where they must be judged by people they do not know personally.

They will not be able to respond normally to any person who is responsible for the terror ever again, because just seeing, hearing, or sensing the presence of that person is enough to alter the victim’s behavior.  This is much like any small animal who has just escaped predation by a particular predator.  When they sense a similar predator in any way they will zig and zag in their fleeing often very much more erratically than ever before.  So will the human being.

These victims will avoid all possible contact with the predator in the future. They will sooner stay home than go to a place where they might possibly be seen by that predator.  They will avoid any friends or relatives who are in any way associated with that predator. Tell-tale signs of both children and adults are seen when they turn down an invitation by someone with whom they are close, but who are not predators, to do something that they clearly enjoyed doing before. However, they may be very willing to do this thing alone if they can, as long as it is unlikely that their predator will be there (e.g. going to a park when they know that the predator is at work).

The avoidance behavior is based not only on wanting to avoid the possibility of being attacked again, but also on not wanting to even sense their predator again, because the sensation triggers a lot of undesirable physiological responses in the person. Often the victim doesn’t understand these sensations, or they are impaired physically when the body is carrying out these responses. Someone may ask them why they are having difficulty standing up, or they cannot move fast enough out of the way when other dangers are imminent. They feel frozen in time and space, almost paralyzed.  I describe the physiological responses and what causes them in a another post.

Lying is not uncommon in this victim, but generally in those cases where they feel someone is trying to get too close to them or may find out about their shame. I speak of this problem more extensively in my posting Special Case of Type I PTSD–Sexual Abuse.

Rejected Face, from Barry Langdon-Lassagne at Wikimedia

Another case where this type of PTSD applies is to the child in foster care who never gets adopted, who “ages” out of foster care.  They are generally on their own at 18.  I commented on a report on a new novel written by a foster mother about a foster child who cannot develop trust in anyone (“Speaking Of Foster Care In ‘The Language Of Flowers” reported on Weekend Edition Saturday 27 Aug 2011.)

My comment at that site was as follows:
“Vanessa Diffenbaugh mentioned how foster care kids often cannot trust people, especially those who cannot get adopted before they reach the age of 18 and lose their foster parents. Children rejected by their mothers will not trust anyone either. The common denominator to both children is the lack of the mother-infant bond which has to be formed within 3 years after birth. The only difference is that the mother keeps the child in the latter group, but both suffer from chronic PTSD, since the mother repeatedly rejects the child even when the child is still living with her, and the foster child is repeatedly “rejected” by potential adoptive parents. She also mentions the feelings of unworthiness by these foster care kids, who share those feelings with kids who still live with the mothers who rejected them. The lack of acceptance so early in life is critical to both children. It is extremely difficult to make it possible for the full development of self-esteem in either child because the baseline of support is not there, no matter how much foster parents love them. There is a “death sentence” hanging over the foster child who cannot be adopted, since he will lose his foster parents at 18. The rejected child has already lost his mother. It takes rewiring the brain and clear sensitivity toward what each individual child needs to achieve any real success with these kids.”

“There are children who reject one of their parents, generally because of the trauma associated with divorce when one parent wins the affection of the child and the other parent loses. {See Pilla & Bernet 2011 for more on this aspect). Usually they reject one parent regardless of the affection they had for each other before the divorce. Bitter divorces often force the child to choose one parent over the other, leaving them confused, but forced to reject one parent. The child does not understand the bond between parents and thinks it is the same for them as his/hers is to each parent. Thus divorce is usually much harder on the child than on the parents.”

“See Special Case of Type I PTSD: Rejected Children.

See Special Case of Type I PTSD: Sexual Abuse.”

Type II PTSD

These people will suffer from PTSD as a result of physical or sexual attack by someone unknown to them.  The attack may appear to be totally random as a result. It would not have been quite so random if the attacker were known to the victim.

Examples of people that can cause this type of PTSD are

• burglars,
• terrorists,
• hijackers,
• enemies in war
• torturers

Type II PTSD sufferers will not be totally isolated from people because they will turn to people they know for help.  In fact they will display the need for help even for things that shouldn’t need help.  Neediness will not be expressed for everything, but will be apparent only in activities that the sufferer thinks are related to the attack or to feelings they had at the same time as the attack. Thus if a young girl going to a prom is attacked (physically or sexually) in the parking lot, she will need help afterward every time she is planning on getting dressed up. If she was thinking about her pet dog at the time, she will need to be with it after the attack.

In all cases of this type of PTSD, the sufferer will not tend to remain as isolated as the type I PTSD sufferer.  In fact they will readily seek out friends even for activities that they used to do alone.  However, that need for these friends at every step quickly ends over the course of time.  They will still carefully avoid any chance of being attacked however, choosing the least risky route or activity, rather than trying to avoid one particular person.  Some will avoid contact with people who look like their attacker, and still feel fearful when they see them for years after the attack.  All will be happiest when they are with people they know and love around them.

Trust is also broken in this person, but generally it is trust in themselves, becoming expressed when they need other people around them when wanting to do certain things.  Men will be particularly affected by feelings of helplessness. They are physiologically and behaviorally programmed to not show such feelings and instead, to feel that they are essential for achieving a conclusion or final result.  Random attacks cast doubt on their ability to respond fast enough, and thus trigger feelings of helplessness. However, their feelings of helplessness will never be as great as for those suffering from Type I PTSD.

Afraid Face, from Barry Langdon-Lassagne at Wikimedia

A special case of Type II PTSD is the victim of torture.  Dr. Ruth Buczynski of NICABM has written recently in her blog that there is evidence that some people who have suffered from torture will also suffer from PTSD (she cites a study by de Jong 2001).  She writes about Survivors International,

“According to Survivors International, some of the most common signs include:

• Fear and anxiety in formal setting
• Sleeplessness at night as a result of the anxiety of late night torture experiences
• Forgetfulness in performing regular chores and keeping appointments
• Flashbacks that hinder the ability of victims of torture to adapt to new circumstances and impede their capacity to function normally”

I consider most of these symptoms a bit too vague.  With the use of MRT (see my post, Using MRT: Removing Toxins and Emotional Trauma and below, under Treatment) and mindfulness techniques, a care giver can help the victim determine, not only what is happening when he/she suddenly feels uncomfortable (recognizing panic attacks), but also what exactly is causing the symptoms.

Furthermore, if the torturer is also known to the victim before the victim was tortured, this victim will almost certainly suffer from Type I PTSD as well, showing all the symptoms listed under that category.

Type III PTSD

Since this type of PTSD happens when a person suffers from a totally random event not involving people or not caused by one or more persons, it rules out war. Even if a soldier is hit by a roadside bomb, in his/her mind, the bomb was set by a person, the enemy, and was not totally random.  Included in the events that cause this type of PTSD are

• earthquakes,
• volcanic eruptions,
• hurricanes,
• tornadoes,
• mine explosions,
• tsunamis,
• avalanches,
• fires,
• interactions with animals

Other events which can cause PTSD include accidents happening while:

• driving,
• skiing,
• hiking,
• climbing,
• boating,
• playing sports,
• work-related accidents (fires, logging, shop work, digging), etc.
• hospital treatments or surgery (see below)

The person suffering from this type of PTSD will show the same symptoms as the type II PTSD person.  However, they will often need to be alone, but never completely alone for long.  They too, will suffer from a lack of trust in their own abilities to survive on their own, or to do the activity involved with the terror.

Type III PTSD appears to also be associated with hospital treatment for ovarian cancer (Gonçalves, V.  et al 2011) and surgery (Aaron, D.L. et al 2011, Davydow, D.S.et al 2008).  I strongly suspect that at least some of this type of PTSD could have been prevented with thorough mental preparation of the patient with a lot of information about the treatment procedures and/or surgery–I mean detailed, describing the structures in the body that are involved with photos of the cells or tissues (that not covered in blood, nor of the surgery directly).  The patient may not understand everything, but his/her unconscious brain will use this information to find what will be changed by the surgery/treatment and the expected outcome.  This is critical for the unconscious brain to determine what physiological responses are necessary for the life of the patient. Otherwise, surgery of any kind and some treatments (like chemotherapy/radiation) become random events causing physical trauma to the body. The intensive care cases (Davydow, D.S. et al 2008) may have been due to the incident that brought them into the hospital to begin with, as would be the ovarian cancer patient (Gonçalves, Vânia et al 2011) who is suddenly faced with a diagnosis requiring immediate treatment. In both cases, the circumstances may fall within Type III PTSD.

Another reason for talking about details, and showing pictures (charts will do to some extent) to the patient has to do with the emotional aspects of undergoing these major physical changes in the body (see Emotional Representation in the Brain, and Physiological Responses to Terror, especially when referring to Emotional Terror Attacks)

See Behavior and Emotional Responses to Terror for more information on this topic.

Language and Speech

As stated previously, speech is blocked during or immediately after the event.  Many sufferers express frustration later over the fact that they cannot say “NO”, that they struggled to push the predator away or to scream for help. This frustration is not only a symptom of what happens physiologically to the sufferer but is also a source of more emotional trauma, as they remember that time of total speechlessness.

Another aspect of speechlessness is that it may take years to be able to talk about the events or anything else associated with those events in the mind of the victim.  Thus a victim who was eating an apple at the time he/she was terrorized, cannot now eat, look at or even talk about an apple afterward.  When under severe duress, the victim may even concoct all sorts of elaborate stories to mislead the listener away from the truth about the event. If talking to the police, the victim may not be ready to talk about the event but the police need information NOW, causing a huge conflict within the victim, not just about the terror attack, but about any interaction with people.  Again, this condition may last for years without treatment.

I suspect that these symptoms reveal a very important aspect of the anatomy of nervous control of speech.  I theorize that there are many centers associated with speech and that they are hard-wired in the brain, as Noam Chomsky (1968 Language and Mind) has suggested in one of his lectures in that book, and developed in many publications afterward.  However I think that the speech centers are found in all parts of the brain, not just the neocortex as most linguist theorests propose.  I will be posting a separate discussion about language at another time. For this blog posting, I will describe the most useable aspects for understanding this “blocked speech” behavior.

Language and speech involve both conscious and unconscious aspects. Our brains regulate our responses to both internal and external environmental changes. In both types of change our brains want our physiology to change in response, and the unconscious brain is called into action.  There are centers that handle all aspects of our physiology from cellular, to tissue, to organ level in the body.  In addition there are centers responsible for analyzing the information coming in from cells all over the body, interpreting them and organizing a physiological response.  Critical to the actions of the unconscious brain are emotions and behavioral responses. Behavioral responses include changes in body position or action.  These changes in the body can be attributed to communicative functions along with others: changes in facial expression, actions of the jaws, arms, legs, and in humans, speech.

All vertebrates have the same basic concepts represented in the brain that are important for survival.  In the case of the social human, those concepts include trust, home, safety, protection, and communication to another person when help is needed, among others. Even though speech and language in humans have many functions that involve a lot of “higher thought”, they have the same physiological function as any other type of communication that a vertebrate will display.

We have to understand that the basic functions of the language/speech system that are found in the unconscious brain will be different from those found in the conscious brain.  These unconscious process must precede any activity in the conscious brain. Our body’s physiological responses depend upon the careful organization of proper functioning of the physical support system (muscles, bones, tendons, ligaments, aponeuroses, fascia, fat, skin) and the vegetative support system (gut, kidney, liver, spleen, some glands).  However the unconscious brain also controls associated systems that complement or link the body with the mind–those involving the beginnings of communication, whether with our whole bodies or parts of it (e.g. larynx).

Severe emotional trauma doesn’t “bruise our egos” (in the words of some researchers), as if the mind is some “vapor” hanging over our heads.  It does true damage to neurons in the brain. Our brains spend a lot of time repairing itself from these damages when we sleep. Whenever we suffer from emotional trauma, physical damage is done to all of the centers of the brain associated with emotion, including both conscious and unconscious centers. When emotional centers are damaged, their contribution to the organized physiological response to the trauma affects speech because the unconscious brain associates the emotion with communication. Emotion will always trigger communication, but if emotion centers are damaged, the next link in the chain will not work. In order to protect us from more damage, very often the brain shuts down language centers. Thus a child, after trauma, may not speak for months, and even years.  Older children and adults whose brains have developed elaborate mechanisms of communication that depend upon speech will have only parts of their language centers blocked to prevent more damage, and they won’t be able to talk at all about the traumatic events, but will about other things.

To those who have never gone through the pain of rejection by a mother or sexual abuse by a father, you have never felt that kind of pain–it is absolutely crippling.  The brain will not let you talk because talking about it, even thinking about it, is so traumatic, and just thinking about talking about the event causes the same level of pain. It does not go away with the passage of time, either. Any pain that comes from family life will not diminish or disappear with time. Because this type of emotional pain is so debilitating, it probably causes severe damage to circuits in the brain involved with emotion. This is why it is so difficult to treat.  There are the millions of lifelong therapy patients to prove this statement.  Thus lying (behaviorally and/or verbally) about it or anything in any way related to it (in the victim’s brain, but not necessarily to any outside observer), is the only way the victim can handle this kind of damage.  The brain will block any attempt to speak directly about it.  The brain might even block postures and behaviors that exhibit shame or fear under certain non-threatening circumstances (when directly confronted by an unbiased person wanting to know more about it).

Treatment

Treating a patient with any type of PTSD is an active, ongoing field, especially with the return of soldiers from the 3 Wars in which the US is now engaged (Afghanistan, Iraq, and Libya, as of 27 May 2011).  I will not present here all the ways that are being used right now*.  I have mentioned how I developed methods using mind-body medicine (Mindfulness, Muscle Response/Reflex Testing or Applied Kinesiology ) in Using MRT: Removing Toxins and Emotional Trauma.

Some regions of the brain known to be affected by PTSD and stress, National Institutes of Health, PD

Clearly Type I PTSD can be the most traumatic. If it is due to being rejected as a child by a parent, often the child has no idea that this is the cause of the problems he/she has in life. Sometimes they know that they have been mistreated by the parent, but still have no idea how pathological the parent’s behavior is. Perry et al. (1995) tells us that early childhood trauma changes the course of the entire lifetime of that child, and as a result treatment may have to be extensive. We do not know what in the brain was damaged by that trauma. Perry (1997) offers some general suggestions involving the ratio of responses between cortical, subcortical and brainstem regions. I think we can guess, using mind-body medicine techniques, such as muscle reflex/response testing. The figure above shows some of the anatomical regions found in research to be associated with PTSD.

One of the problems for victims of any type of attack when the police should be called is that the victim has blocked out language. With a great deal of struggle they can answer some questions. However, rarely is the victim’s information at this time going to be as helpful as it would be if someone else were there who was neither attacker nor victim. Both spoken and written language will be blocked. One thing that can be done with the victim is to ask questions to which the victim can answer with a pre-arranged signal for “yes” and “no”, e.g. nod or shake of the head among most Americans or Europeans (these signal something else among East Asians). This allows the victim to bypass the language blocks that would otherwise occur. The type of question asked by the police must change drastically, and follow a formula that allows them to get to more detailed questions about specifics with only a “yes” or “no” answer required.

This process is completely antithetical to normal police procedure, since they assume that they must hear the words used by the victim.  They need to change their rules so that the victim, after treatment aimed specifically at removing the emotional links to their memory, and training them to use unconscious memory circuits as well (Using MRT: Removing Toxins and Emotional Trauma), can then give a complete statement about what they saw, heard, and felt about the attacker in their own words. The same procedure can be used for interviewing very young children who have not fully developed their language ability.  These children do recognize the meaning of “yes” or “no” long before they develop the capability of uttering complete sentences or phrases.

The single-most important understanding we should have about PTSD is that it changes the entire life of the victim.  Getting rid of it changes the entire life of the victim again.  Thus, any treatment cannot be attempted half-heartedly by people who do not understand it.

 

References

American Psychiatric Association. 1994. Diagnostic and statistical manual of mental disorders: DSM-IV. Washington, DC: American Psychiatric Association. ISBN 0890420610.

American Psychiatric Association. 2013. Diagnostic and Statistical Manual of Mental Disorders: DSM-V. Washington, DC: American Psychiatric Association. ISBN 978-0-89042-554-1

For a complete bibliography of Noam Chomsky’s works, see Wikipedia–Noam Chomsky Bibliography.

Aaron, D. L., Fadale, P. D., Harrington, C. J. & Born, C. T. (2011). Posttraumatic stress disorders in civilian orthopaedics. Journal of the American Academy of Orthopedic Surgery, 19(5), 245-250.

Davydow, D. S., Gifford, J. M., Desai, S. V., Needham, D. M., & Bienvenu, O. J. (2008). Posttraumatic stress disorder in general intensive care unit survivors: A systematic review. General Hospital Psychiatry, 30(5), 421-434.

de Jong, J. T. V. M., Komproe, I. H., Van Ommeren, M., El Masri, M., Araya, M., Khaled, N., … Somasundaram, D. (2001). Lifetime events and posttraumatic stress disorder in 4 postconflict settings. Journal of the American Medical Association, 286(5), 555-562.

Gonçalves, V., Jayson, G., & Tarrier, N. (2011). A longitudinal investigation of posttraumatic stress disorder in patients with ovarian cancer. Journal of Psychomatic Research, 70(5), 422-431.

Perry, B. D., Pollard, R. A., Blakley, T. L., Baker, W. L., & Vigilante, D. (1995). Childhood trauma, the neurobiology of adaptation, and use-dependent development of the brain: How states become traits. Infant Mental Health Journal, 16(4), 271-291.

Perry, B. D. (1997). Incubated in terror: Neurodevelopmental factors in the “cycle of violence.” pp. 124-149 in Children in a violent society, Osofsky, J. D., Ed. New York, N. Y.: Guilford Press. [Freely available version is at The Child Trauma Academy].

Pilla,  J. M. & Bernet, W. (2011). Letter to the Editor: Ursula A. Kelly, PhD, ANP-BC, PMHNP-BC, Guest Editor. Journal of the American Psychiatric Nurses Association, 17(2), 189. (Available only by subscription [Sage Journals sometimes has free access to Psychiatric Journals if registered] or at libraries).

*However, my readers might want to visit the NICABM web page to sign up for free (or subscribed Gold Standard) teleseminars that often cover this subject. I also suggest looking at Dr. Ruth Buczynski’s blog for May 26, 2011 where she announces a teleseminar on Treatment of Trauma.  Many teleseminars are available for purchase after the completion date, as well.  See her blog for May 29, 2011 concerning torture.

Survivors International Publications and Research

Survivors International Additional Resources

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