Part I: Anxiety in PTSD
The Nature of PTSD
Post-Traumatic Stress Disorder is a fairly straightforward mental health disorder. The origin of PTSD is the natural protective response to life threats in the environment. In PTSD, the person takes those threats out of the direct context and applies them in another context where they may not represent and actual threat to life/existence. PTSD responses are usually more about the meaning of a traumatic experience than simply the event itself. For instance, we might understand that a parent who lost their brother to drowning as a child might not let their children go to the pool or go boating with friends. But if that parent believes, because of the trauma, that they did not keep their brother safe, they may react to that meaning in ways that are not directly related to swimming. They may rage at a missed curfew or even rage at a chore their child did not complete. In one instance, they may see their child as ‘deliberately’ doing dangerous things or staying out of touch—not allowing the parent to protect them. In the other instance, the parent is upset with the child who ignores their directions, which can lead to life and death situations. In this situation, it only leads to a bed not being made or a garbage can that is not emptied. To the child or the other parent, the response is unreasonable and out of proportion. At the moment, the parent with PTSD is merely reacting to cues connected to the meaning of their trauma (I can't keep people safe). It is even possible that after some time, the parent with PTSD will agree with the idea that their reaction was inappropriate and find ways to connect their overreaction to their belief that they cannot keep people safe. Their PTSD responses and belief about themselves are subtly reinforced. We call these beliefs ‘maladaptive' because they are working against the person, as opposed to an ‘adaptive' belief which would better help us cope. Many times, a maladaptive belief grows out of a belief that kept us safe in the past but now works against us.
Hypervigilance is at the core of PTSD. We will address how hypervigilance can feed into the other symptoms of PTSD, but first, we must understand the role of anxiety and even what anxiety is when we are talking about PTSD.
How Anxiety Relates to PTSD
In the Diagnostic and Statistical Manual of Mental Disorders (DSM) fourth edition, you would find PTSD under anxiety disorders. As we will see from a good definition of anxiety, it IS an anxiety disorder. However, PTSD is differentiated from all else by the presence of a life/existence-threatening trauma and the duration of the meaning of that trauma. Therefore, the DSM fifth edition (DSM 5) developers created a separate diagnostic category for those disorders which are centered around trauma and stress responses. However, the issue of anxiety is critical to understanding PTSD.
A Definition of Anxiety
There are many definitions of anxiety. I might agree that it is an overused word, or that we need a way to discriminate between different degrees of anxiety. Anxiety is not stress and it is not simply worry. When I hear people define anxiety, they do a pretty good job of introducing the idea of uncertainty. In studying the work of Harry Stack Sullivan and Karen Horney in the 1930s and 1940s, I arrived at a simple working definition of anxiety:
Anxiety is the fear of a non-present danger.
Ok, what is the fear of a present danger? Well, that is simply – fear. In PTSD the non-present dangers are those traumatic events and traumatic experiences (events and meanings) from the past. The danger actually existed at some point. The mind and body processed the patterns present in those events/meanings and are now on the lookout for cues that those events are about to happen again. When we discuss hypervigilance, we will see how this works day today. To experience anxiety is to feel overwhelmed. Humans will usually act to reduce anxiety where possible.
Thus, anxiety is based on ‘triggers’ or the cues that signal the mind and body that a life-threatening / existence-threatening event is unfolding or will unfold. But the dangers that the triggers are pointing to, in the case of PTSD, are usually not present. Some of what the body has stored as cues/triggers might have had no real relevance to the traumatic event, for instance, the color of someone's clothes may be a trigger but not related to the trauma except by coincidence.
Life and Death Anxiety
In the example above, the parent experiences the children not honoring their directions to do their chores. In reality, not cleaning their room is not life-threatening. However, the parent who may have ignored their own parents’ warnings about taking their brother swimming, believes that they are not able to keep their kids safe. They may even believe that the drowning accident was their fault. At this moment, children ignoring their parents' instructions could mean that the parent is unable to keep them safe and reacts to the life and death fear that is triggered in the moment. The life and death anxiety of PTSD.
One of the difficult issues in treating PTSD is that the clients are often unaware of their triggers. They are not connected to the life and death meaning of their trauma and the triggers. They feel the anxiety in their bodies and react to the anxiety or seek to curb the anxiety through medication, substance abuse, or behaviors that are calming (but can also be maladaptive). They may feel the anxiety comes “out of the blue” because they are not connected to the triggers. One symptom of PTSD is to ignore or forget parts of the original pain and trauma itself because it creates pain within the body. Thus, often, the PTSD client is literally out of touch with their reactions as trauma responses. They believe that the feelings they have are inappropriate. However, given their trauma, the feelings would be appropriate if the danger were actually present as it was in the past.
Anxiety, the Original Emotion?
Harry Stack Sullivan thought that anxiety might be one of the first emotions we experience. Within the womb we are experiencing the world through our mothers, but indirectly. We may hear a voice or feel a movement and then experience the mother’s physical reaction – heartbeat, breathing, expression, etc. When we are born, we are thrust into a new, strange world where everything may appear dangerous because we do not know what it is. We are overwhelmed and possibly in danger. A human baby suffers constantly from the threat of annihilation and, thus, anxiety. We assess our world by looking back to our mothers and gauge her reaction to situations to know what is appropriate. Think of the baby who runs and falls and then looks at mother for a reaction. If mother is shocked, the baby reacts with fear and shock, if mother takes it in stride so, usually, does the baby.
In PTSD, an actual threat is experienced in one situation. However, the client carried the context over to another situation where it is not a threat. Their response to triggers causes them to feel that they are again in the original situation. The police officer who loses a brother in a swimming accident and blames himself, arrives at an accident where a young child, the same age as his daughter is killed. The officer is too late to save her and somehow believes that he should have arrived earlier. Later he goes home and drinks to fall asleep because he believes that he will eventually lose his own daughter that he cannot protect. Perhaps he begins to distance himself from her because he knows he will only lose her, or she might be safer if she is not around him. While the loss of his brother and the other child are real, his future loss of his own daughter is not. He is faced with his anxiety, not an actual danger.
His very real fear of a non-present danger is based on life and death experiences. His reaction is out of place because the danger is not present, however, the anxiety is real. How will he relieve this anxiety? He could get a prescription, self-medicate, take risks and use the adrenaline and endorphins that the body will produce. He could seek out other relationships where he does not need to get close. Or, he could challenge his maladaptive beliefs in therapy, identify the origins and sources of his beliefs, and learn to accept and cope with some levels of anxiety, knowing them for what they are. Only one solution can actually resolve his maladaptive beliefs and increase his resilience in future situations.
Copyright © 2019 Shared Expectations PLLC/Michael Bryan Allison LMFT