PTSD The Approach/Avoidance Disorder

PTSD The Approach/Avoidance Disorder

As I look at each symptom of PTSD in this section I will repeatedly bring that symptom back the varying attachment dynamics that can be precursors to the approach/avoidance strategy.

B-1) Recurring distressing recollections of the traumatic event or events.

This symptom is more inclusively stated by saying; having an over-powering need to talk to someone about an intrusive, distressing memory, along with the seemingly intuitive sense it will be painful to relive it.  This need to tell gets stronger over time if not expressed, with a felt sense of attunement from the listener.  The sufferer believes the memories will get less intense over time.  This phenomenon has some components similar to a frog not noticing the difference in temperature increases in a pan of water until they boil to death.  If you drop frogs into boiling water they jump out so fast their skin hardly gets scalded.  As the person fights off the memories it is hard to notice they are getting more emotionally intense.  It seems natural and intuitive to expect them to lessen.  This “hallmark” symptom of re-experiencing thoughts and feelings of the traumatic event may also seem to stand alone to the sufferer.  When he or she finds out this symptom has lend to the rest of the symptoms it is a great relief for most people.

I use the example of how compelled you feel to tell anyone you can find about the big fish you have caught.  The compulsive need to tell about experience outside the usual range of human experience is natural.  We seek out people who are likely to attune to our feelings, either by knowing us or knowing what it is like to catch a big fish. After about the twelfth telling the need to tell the story has diminished.    Now drop yourself in the middle of a desert where you don't know anyone and they have almost no experience with fish.  The compulsion to tell someone may not get satisfied.  Without the telling it is likely, and healthy to continue have the need to tell “the big fish story” no matter how long you are in the desert.

The need to tell is somewhat centered in our body-based sense of ourselves.  Developmentally it is the child rushing into the living room saying to her parents, "Look at me! Look at me!"  Healthy parents make sure the child knows they attended to her.  She goes away from that experience knowing it is natural to express feelings stronger than usual.  If instead the parents ignore her she eventually bottles up the need to tell someone her feelings.  If these two girls go through the same traumatic event their probability of seeking soothing from outside themselves is very different.  In one of them the need to tell about the trauma resurfaces and is expressed until it is relatively exhausted.  With the other girl the need to tell only shows up when she can't stop the compulsion to tell.  Even if she does tell someone who could be attuned to her, she has learned to not look for cues of someone attuning to her.  With one girl the story of the trauma becomes integrated inside her with the felt sense of being attuned to by her support system.  With the other girl the need to tell about the trauma wars with the known fact of feeling more alone with the story if she does ever tells someone. 

Consider a 19 year old medic in Vietnam in 1967.  His training is condensed into eight months.  In his first three months he has the need to perform two tracheotomies, both of whom die.  On the second one he remembers some subtlety of his training he wasn't doing.  Even if his saves 100 soldiers through performing great tracheotomies the next nine months, the part of him that feels less than others fixates on the two deaths. 

When a person’s developing psyche comes upon an extreme life event there is a tendency to retreat to an earlier survival based coping strategy.   The younger the disturbing situation the more problematic the reactions to it can be.  The infant or toddler who learned to survive the lack of an attuned response to their affective states may develop a strategy to compensate for the lack of attunement.  When later life traumas happen the individual will likely use the same coping mechanism as they did in their youth.  There may be a short term gain to this strategy, however in the long run it is necessary to seek and find affective attunement to the disturbing feelings.  PTSD has been proven to be developed from the lack of an attuned response, rather than the effects of the trauma.

There is an accumulation of factors bringing a client into my office for distress from symptoms of PTSD.  These factors need to be observed from the perspective of representing strengths in the individual’s ability to hold their identity together.  An example would be a combat veteran who was physically abused as a very young child by their parent.  He may develop a Disorganized Attachment, because the person he needs to be soothed by is the one who is causing the distress.  Soothing means a felt sense of attunement.  Another example is the rape survivor who was ignored as a child, especially when in distress.  She may develop an Avoidant Attachment imagining she will never be attuned to.  Both examples create internal tension with no avenue for action.  For the Avoidant person they can predict their environment won’t attune to their distress.  The Disorganized person keeps finding attunement in people who feel abusive to him.  We are neurologically organized to seek out attachment.  It requires massive energy to block the need to feel soothed.

This is the "hallmark" symptom of PTSD.  The other re-experiencing symptoms can almost always be related distressing to memories and thoughts of the trauma, or distressing memories and thoughts of the other re-experiencing symptoms developed after the traumatic experience.  We know a lot about healthy expression of distress over critical life events of loss.  We call it the grieving process. Depending on the degree of attachment, suddenness of the loss and the temperament of the griever the intensity, frequency and duration of out-pourings of distress take place.  It is healthy for these out-pourings to continue with decreased frequency, intensity and duration for at least a year.  The anniversary of the loss is a particularly likely time for the feelings to re-surface.  Two years is not considered overlong to feel swept up in the feelings of a critical life event.

In the original description of PTSD the stressful event needed to be something as life threatening as a bullet hitting the wall behind your head.  Integrating the experience of being centimeters away from sure death into your self-story, requires you to relinquish fantasies of immortality and omnipotence.   Freud and I agree we all harbor these fantasies.  In a sense, those healthy parents responding to the "Look at me" are perpetuating the child's fantasy of their felt sense of importance in the world.  This healthy nugget, around which the developing psyche organizes itself, is highly challenged by the stark reality of the dangers of the world.  It takes the time and the processing of the internal tension of the felt sense of increased endangerment.  PTSD can only be diagnosed when the felt sense of endangerment remains exaggerated for a long enough time and leads to distress for the client.  Reconciling the infantile sense of being omnipotent with the mature realization of the dangers of the world is part of growing up.  Retreating to an earlier strategy for coping with distressing feelings is the opposite of maturation.  The earlier the strategy developed the less likely we are to know we are using it.  It feels intuitive to isolate and push away the distressing memories.  The fact that we blow up easily or can’t sleep does necessarily feel related.  Short-term it works better to deny the memories access to our consciousness.  Long-term we want to be able to access the memories and feelings when we want to and not be over-powered by them.  Learning when we are capable of allowing the feelings to go through us is maturity.

Another internal tension that we all carry which feeds into feeling an exaggerated sense of endangerment is "rapprochement".  This is the tension between a desire for independence and a desire for dependence.  It is exemplified in the moment the exploring toddler notices his mother walking out of the room.  Does the child respond to his internal need to explore, or the internal need to have mother caring for him.  If either he or his Mom is omnipotent he thinks he will be okay.  As the reality sets in that she can't be two places at once, or join him in all his explorations, a sort of disbelief in the parameters of his existence sets in.  This really never gets reconciled in us.  Therefore, when a traumatic event happens in life there is more fuel for this tension.  The subliminal dialog might go something like this: "I can't survive without someone taking these horrible feelings away from me", or "I have to be able to hold onto these horrible feelings by myself".

PTSD recovery is allowing the person's development to take place.  This requires the person developing a felt sense of being attuned to in their most challenged states.  The states of coming to terms with the immediate, practical dangers of the world, and the irreconcilable needs for independence and dependence are two of these ongoing challenges. If you have ever been the care giver for a child going through a tantrum you have experienced some of what a therapist needs to be able to do.  The client's emotional expression is seldom as dramatic as a childhood tantrum.  The client does need a feeling of having survived an "affect storm" in the presence of another.   This survival of self and the therapy (therapist as respecting other) is essential for the integration of memories that are outside of the parameters of what we have learned to expect from our world.